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Nearly all cities struggle with providing good quality and affordable homes for all their citizens. In some it’s become an existential challenge, fundamentally linked to the ability to continue to succeed or even survive. Our cities often have pockets of incredibly luxurious and expensive housing, beyond the reach of even those working in relatively well paid and secure jobs. It is sadly all to frequent that you can observe fellow citizens living in doorways, parks and underpasses in close proximity to these homes for the wealthy. In all measures other than geography they live lives very distant from the urban idyll. The issue of people ending up sleeping on the streets of our cities is to be found world-wide, from Osaka to Sao Paulo, from Auckland to Stockholm. The underlying reasons that lead people to living on the streets are often multi-faceted and can be linked to particular local or regional factors. Health issues, both physical and mental are more common than in the general population. Research from the UK indicates the significant role played by alcohol and drugs. There is a strong correlation in terms of individuals who have experienced some form of significant trauma. We also cannot ignore the impact of national and municipal policies. Across the globe, policies intended to reduce government expenditure have made many millions more vulnerable to becoming homeless. 

It is true that considerable resources are directed in trying to deal with this problem. I have worked alongside at least three initiatives in England or London where the objective was to end rough sleeping. National government, city level, local authority, police, health bodies and the voluntary sector all seek to reduce the number of people on the streets or mitigate related issues. A short walk through any area of central London soon shows that despite some genuinely excellent work that is happening, there is a lot more to do.

Now one positive aspect of a problem experienced by so many cities is that there are opportunities to look at what other areas have done. International comparisons in this area are fraught and challenging due to differing definitions, politics and the pure complexity of counting those without a roof over their head. The Homeless World Cup Foundation made a helpful attempt to provide a global overview, but this does appear an area ripe for some serious academic activity. However, in terms of initiatives there are some interesting projects worth examination.

Last month a headline from Irish internet publication, The Journal, carried the headline Fix it like Finland. This highlighted the success of Finland’s approach, which as the article states now means that Helsinki doesn’t have a single rough sleeper on its streets. Here is an example where the laudable ambition of eradicating rough sleeping has been achieved. So, what was this approach that succeeded where, so few others have? Step forward Housing First. The philosophy behind Housing First is simple. Rather than go through various stages such as; moving into a hostel, seeking to address health, substance use or other issues, the priority is placed on moving an individual into their own accommodation as soon as possible. Its origins are to be found in Los Angeles and New York around 1990. Its influence has spread across the world and has been adopted by politicians of all hues. Quite something when you consider its underpinning philosophy is of housing being a human right, and that its approach of removing hurdles to individuals and bringing services to them provides it own political and resourcing challenges. One of the reasons Housing First has spread is that it has a positive evidence base, although there are also a number of critiques. So, there we are, a successful, deliverable approach to a widespread and age-old problem. Except, that in some areas it doesn’t seem to have worked. The Irish story referenced above actually compares the experience of Helsinki against the much less favourable outcomes in Dublin. The fact that not all interventions work in every location should not be a surprise or automatically detract from the validity of any given approach. Initiatives likes this exist in their own local ecology. Levels of financial and political resource will vary. Support from the community (which itself can influence political support) varies. The level of substance use or mental health problems is not uniform. Nor the quality and quantity of services to respond to these challenges. Availability of suitable housing stock is difficult, or impossible, to secure in many cities.

So, we need to ensure that we continue to improve services to help address the needs of both rough sleepers and the broader communities in which they exist. In London we are fortunate to have a Find and Treat Service which goes out to street populations and helps tackle TB, HIV, Hepatitis B and C. Pathway, a charity, is doing great work to try and provide better outcomes across a range of health issues for those living on the streets. We need to do much more to help and support rough sleepers to engage successfully with mental health and substance use services. There are real challenges in terms of human rights of individuals and communities in terms of how assertive and challenging our outreach services can, and should, be as well as what services and support we provide for our most vulnerable citizens. These are ongoing debates. But, we should not loose sight of what has been achieved and how, in Finland and elsewhere, through the Housing First approach. Let’s not leave anyone forgotten on the desolate outskirts of our cities.

Wednesday, April 01, 2020
Everything is changed. COVID-19 and responses to it have seen dramatic and fundamental changes to how life is lived around the globe. International travel has come to a near complete halt, much of the world is under some form of lock down with businesses, schools, shops, pubs and cafes shut. Our economic and social reality is now unrecognisable from that of only weeks ago.
Tuesday, March 10, 2020
Clearly the current health focus is strongly centred on Covid- 19 and related issues, as it has been for the past few weeks. It is a demanding situation for politicians, officials, and indeed all of us, especially those working in our healthcare system. One of the major challenges we face is increasing understanding and encouraging changes in behaviour, while also avoiding panic and overreaction. Trusted and accurate information is clearly essential, both for those who have a key role and for the general public. We are certainly seeing more of England’s Chief Medical Officer and Chief Scientific Adviser in the media than usual. In the current situation, politicians are not only keen to hear from experts, but also happy to let them step into the spotlight. While we still see sensationalist headlines, there are also visible benefits of this approach, with more measured and informed elements within the media coverage- though this is less evident on the outer reaches of the online universe. Before I move on to other topics, let us reflect on the significant additional pressures being placed on our frontline health providers. They deserve our gratitude and, in many instances, much improved terms and conditions. Let’s hope that when this coronavirus issue passes the staff that so many rely on are not overlooked.
Monday, February 10, 2020
Public health is front and centre of the media currently, with concerns about the coronavirus outbreak, which was first identified in the Chinese city of Wuhan, splashed across almost every front page. With confirmed cases now reported in numerous countries across the world, we face the possibility of a pandemic. As several experts and commentators have pointed out, in our modern, highly interconnected world no epidemic remains a local concern. This, of course, makes for frightening headlines- which, in turn, calls for calm and informed responses.
Wednesday, January 15, 2020
So here we are: 2020. Let me start by wishing all of you the very best for the year ahead. I have, occasionally, been accused of an inclination toward cynicism and a failure to look on the bright side of things. So, for my first blog of the year, at least, I am going to be determinedly upbeat. You can judge for yourself how long it lasts. This sense of optimism is influenced by the fact that the end of 2019 saw some positive signs in the world of substance misuse. While it was something of a mad scramble against time, we managed to pull together a high quality and well-supported pan-London Christmas alcohol campaign. I am very grateful to colleagues who delivered the key elements of this work and to everyone who supported it. Some, in fact, went well beyond the call of duty to engage with our colleagues in the blue light services. Although we will not have any data in terms of its reach and impact for some months (I will update you), what I can confidently say is that many individuals and organisations liked the messaging and tone. I like to think it is helping contribute to Londoners having a more considered and healthier relationship with alcohol, though there is a way to go yet!

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CITY HEALTH INTERNATIONAL EVENTS

CHI Melbourne 2019

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CHI Liverpool 2019

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CHI Odessa 2018

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CHI Basel 2017

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CHI London 2016

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CHI Barcelona 2015

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CHI Amsterdam 2014

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CHI Glasgow 2013

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CHI London 2012

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City Health International
Founded in 2012 City Health International is a network of individuals and organisations engaged in the study of and response to structural health issues and health behaviours in the urban environment. For the first time in history the majority of the world’s population now live in urban environments and the proportion continues to grow. As national governments struggle to deal with the pressures and demands of growing urban populations against a backdrop of financial deficits and uncertainty, it is increasingly left to those working at a city level to provide the leadership and support needed to tackle key health issues.