Equal chances for health

To ensure health equity in Amsterdam, the city has become the first to adopt the ‘doughnut economy’ model, where every resident has the opportunity to thrive in a way that doesn’t put more pressure on the planet than it can handle

The chances for a healthy life are not equally distributed in the Netherlands, and therefore not in Amsterdam. Health inequalities are often related to social problems that last for long periods, such as low education levels, low income, stress, an unhealthy living environment and inadequate access to health care. It is unacceptable that our city has a health gap between people with more and less education. Not only has the pandemic highlighted this inequality, but it has also exacerbated it. And it will also be affected by the fast-approaching energy crisis.

These are reasons enough to embrace Kate Raworth’s ‘doughnut economy’ concept and be the first major city in the world to put that theory into action on a local level. In 2020, Amsterdam City Council boldly stated that the City of Amsterdam aims to thrive rather than to grow – to ensure that every resident has access to a good quality of life, without putting more pressure on the planet than is sustainable. This perspective gives us a much wider context of the common underlying societal and political drivers for poor health of both people and the planet. The holistic framework thus helps us with some of our most important and urgent challenges: achieving better human and planetary health.

The rainbow model

To apply this thinking to our health policy, we used the rainbow model developed by Göran Dahlgren and Margaret Whitehead. It shows that working on health equity takes a combination of political, professional, community and personal efforts. An individual cannot correct all the factors that affect their health. To promote health equity, we need to acknowledge the impact of the environment on individual choices and behaviour. We need to remove these social barriers that people encounter.

In Amsterdam, we actively apply this thinking to healthy lifestyle promotion for all generations – from the first 1,000 days until the end of life. The investment in prevention at the beginning of life pays off in long-term health benefits. Growing up as a child in a protective and loving environment and learning a healthy lifestyle mean better chances for good health later in life. Therefore, we increased our efforts to support future and young parents to create a (more) stable environment. We do this before their child is born and then after the child’s birth. Later on, our Healthy School Programme helps schools, including preschools, in fragile neighbourhoods to become healthy preschools and schools on a wide range of health topics such as socio-emotional development, food, physical exercise, screen time and sleep, addictions and sexuality.

In doing so, we make bold choices in order to achieve health equity. For us at the City, this means we do not deliver or support the same activities in every part of town in the same way or with the same intensity. We focus. For instance, we help to establish networks of (mental) health professionals and informal organisations mainly in those neighbourhoods where we know professional help is not easily found and reached out to by families. During the pandemic our Covid-19 prevention team was most active in communities and parts of the city where the number of tests and vaccinations lagged and infection rates were high.

Another type of bold choice is implementing policies that might rouse public debate or lead to resistance from certain political or societal groups. Research showed us that in Amsterdam, where one in five children is overweight or obese, 84% of the food providers in Amsterdam sell unhealthy food and drinks, and 94% of the advertising is for unhealthy food and drinks. So we joined the ‘Alliance to Stop Children’s Marketing for Unhealthy Food’, a broad collaboration of scientists and social, consumer and health organisations. Together we try to change the current national system of self-regulation that is not designed in the best interests of the child. As a municipality, we can regulate the advertising space that we tender ourselves. As a result, no children’s marketing for unhealthy food can be found in Amsterdam’s public transport, its stations and stops. We are working hard to make the existing and newly built environment more inviting to use active transport and playing outside, meaning less space for cars. We are also researching what kind of national or local laws or regulations are necessary to be able to regulate the food supply, such as refusing permits for new fast food outlets around schools. All these measures benefit both people and planet.

An adaptive approach

While we are doing this, we take an adaptive approach. We use data and evidence-informed information as our foundation, but we refrain from too much policymaking and even more in-depth research. We are building a network in the city: formal care organisations, welfare initiatives, place- and topic-based communities, research and private partners, and, of course, all connected divisions of the municipal organisation. When the whole system is in the room, we listen to the stories of the parents, children and elderly and ask ourselves ‘what can I do’ and ‘how do we best work together as a system’. Monitoring and evaluating our efforts helps us to learn while we are doing and to constantly adjust and improve.

We believe cities can play a unique role to help people thrive, in a flourishing environment, while respecting the well-being of all and the health of the whole planet. Investing unequally for equal opportunities and for a sustainable future for all of us is key. In this moment, when major challenges test our mutual solidarity, I hope more cities join us in this way of thinking and doing. Together we can be the voices of millions of citizens all around the world that want their children and grandchildren to thrive as they do and also want them to be able to live on a healthy and thriving planet.