A Conceptual Approach to Urban Wellbeing from a Human Evolution Perspective

To cope with a projected global population increase from 7.2 bn to 9.6 bn by 2050, many more cities must be built. Although there are great benefits to modern urban living, there also great costs, such as the seemingly unstoppable rise in Type 2 diabetes, obesity, coronary issues and various cancers. The new towns should be designed to contain or constrain the epidemic of those ‘Western Lifestyle Diseases’ that currently plagues today’s cities. But how might this be achieved? It is suggested here that a greater understanding of human evolution combined with the potency of the ‘Palaeolithic genome’ holds the key to our future urban wellbeing. Consequently, a new paradigm is suggested that underpins positive forward thinking on townplanning and city lifestyles to create healthier urban environments. This builds directly on the ‘Evolutionary Determinants of Health’ programme initiated at University College London (UCL). A four-stage model is proposed that integrates and develops both evolutionary-concordant personal and institutional health behaviours with appropriately reconfigured townplanning and building regulations. When integrated, these strands could deliver a healthier urban culture within greened, active townscapes by proactively constraining or eliminating some of the key underlying causes of the so-called ‘Western Lifestyle Diseases’.


INTRODUCTION
For the first time in human history, more people now live in towns than in rural communities.The continuing march of modernity has urbanisation at its core, and to cope with a projected global population increase from 7.2bn to 9.6bn by 2050, many more cities must be (and are being) built.Although there are great benefits to modern urban living, there also great costs.These include a raft of health issues such as the seemingly unstoppable rise in Type 2 diabetes, obesity, coronary issues and various cancers.The new towns of the future should be designed to contain or constrain the epidemic of those 'Western Lifestyle Diseases' that currently plagues today's cities.
But how might this be achieved?There has been considerable research on aspects of urban health, as a recent review in this journal has shown 1 .The studies discussed considered the relationships between individuals and society as well as between the natural and the built environment, and the complex web of interactions that resulted.To these were added cultural, age and wage differentials 2 to further the complexity.That issues such as building design 3 access to green space 4 air quality 5 and excessive car use 6 also have a profound impact on 1 von Szombathely et al 2017 von Szombathely, M., Albrecht, M., Antanaskovic, D., Augustin J., Augustin, M., Bechtel, urban wellbeing is increasingly evident.Poor health is often easy to identify, although effective remedies for a particular condition will depend on the complex interactions previously discussed.
But to take a step back, the Evolutionary Determinants of Health programme 7 initiated at University College London considers, not so much how, but why so many elements of urbanisation have a negative effect on our health.It then argues for proactive, upstream preventive strategies that address this challenge8 .Some of the fundamental issues considered in this project relate to our basic biology, which cannot be changed, and urban morphology, which, being an artificial creation, can be changed.

NORMAL LIVES
Some 7m years ago, our human lineage began diverging from that of the chimpanzee, with whom we still share 98% of our genome and thus a common Miocene ancestor9 .For the majority of the subsequent period, our basic biology gradually evolved, as our various direct ancestors lived off the land, developing into triballybased 'hunter-gatherer-style' communities.That protracted period in our human evolution is stamped deep into our DNA as our genetic 'normal'.
Such active 'hunter-gatherer-style' cultures, robustly refined by the rigours of natural selection, are well adapted to our bi-pedal physiology, while our dentition, metabolism and digestive system are likewise well suited to a diet of fresh fruit, vegetables, roots, nuts, berries, meat and fish10 .There have been many detailed studies of the benefits afforded by 'ancestral' diets, beginning with the pioneering approach taken by Weston Price 11 , the research by Melvin Konner and S. Boyd Eaton 12 and the remarkable work by Staffan Lindeberg 13 , for example.
The human race is genetically adapted for a life of routine light to moderate activity essential for survival (walking, lifting, carrying, bending, climbing), rather than for long sedentary periods 14 .The actual tasks accomplished in a "normal" hunter-gatherer's day could vary, depending on the level of hunger, seasonality, weather or terrain.Nevertheless, it seems that the typical daily distance covered by human locomotion would be in the range of three to ten miles.The necessary daily activities would require an average energy expenditure of between 3,000 and 5,000 kj, up to five times greater than many modern sedentary adults 15 .For today's city dwellers, regular walking or cycling at least part of the way to and from work/school each day would be a modest evolutionary-concordant compromise, given an encouraging townscape to move within 16 .
In addition, the lives of hunter-gatherers were lived outdoors within a natural environment.Crucially, we are not born with a fully-functioning immune system, since this co-evolved with us over the long period of human evolution as Professor Graham Rook's ground breaking studies have shown 17 .It is now clear that it is from direct contact with plants, animals and other humans that we obtain the macro-organisms, microorganisms and microbiota that live and thrive on our skin and in the gut, managing our immune system within our own personal ecosystem.We are not born with these microbiota: initially, we derive them from our mother's birth canal but not, alas, from a Caesarean section 18 .Subsequently we absorb these organisms from the external environment, from the soil, from plants, trees and animals, from the air.Without them, we are increasingly susceptibility to allergies, autoimmunity and inflammatory bowel disease.Consequently, reduced contact with nature is bad for our physical health: we still need the microorganisms that only the natural environment can provide.Living in sterile urban areas, however, decreases our exposure to nature (and thus a less effective immune system) while urban life increases exposure to crowd infections.

DISEASES OF URBANISATION
Culturally, the human race has seen dramatic and rapid transformations.Genetically, however, our evolution has been much more gradual: anatomically we remain much as we were before extensive agriculture and urbanisation were gradually developed in the Neolithic period, some 5,000 to 10,000 years ago.Although there are major benefits in city living, there are also major costs, such as the seemingly unstoppable rise in obesity, coronary-related problems, Type 2 diabetes, Alzheimer's and various types of cancer.According to the World Health Organisation, these are all listed in the ten most common causes of death in modern, urbanised societies.Do these deaths represent that mismatch between human biology and urban culture, or are they just an inevitable result of the ageing process?
There is, in fact, compelling research that challenges the inevitability of death by 'Western Life-style Diseases' and raises the possibility that living in such artificial built environments may well be exerting an unanticipated but negative impact on modern urban wellbeing.A major long-term study by Dr Staffan Lindeberg, for example, has shown that ALL those fatal 'Western' conditions are rare or non-existent in un-urbanised communities still maintaining an 'ancestral' life-style.His detailed research, included results from a long-term study of a large community in Kitava, Papua New Guinea, where some of those people lived well into old age 19 .Archaeological research supports this assumption, following the many studies of ancient cemeteries and related research graphically showing how the transformation from ancestral practices to farming and urbanisation damaged our collective wellbeing.The domestication of plants and animals during the Neolithic period, for example, heralded major changes in the human diet and activity regimes, and thus in our wellbeing.The introduction of intensive farming saw a noted increase in dental caries, dental defects, tooth loss, trauma, metabolic and joint disease.It is also associated with the first evidence of tumours, anaemia, diffuse idiopathic skeletal hyperostosis (DISH, a proxy for obesity) and osteoporosis, as well as infections such as osteitis and periostitis of sinuses, ribs and skull.Several centuries later, the Romans not only introduced the civilising concept of urbanisation to these islands, but also scurvy, osteomalacia (rickets), Reiter's syndrome, gout, ankylosing spondylitis, rheumatoid arthritis, psoriatic arthritis, septic arthritis, tuberculosis, poliomyelitis and leprosy.None of these diseases or conditions were seen in the largely un-urbanised populations that lived here before the Roman invasion of AD 43.Arguably, urbanisation was -and often remained-a mixed blessing 20 .Certainly un-urbanised or pre-urbanised populations also suffered from problems, such as malaria, childbirth complications, predators, seasonal food or water shortages and serious accidents associated with robust active lives.But what they did NOT suffer from were many of the aliments straining our health services today: these were arguably introduced by urbanisation through its culture and its townscapes.

Defining moment
However it is measured, there is now a general consensus that the maintenance and promotion of physical and psychological wellbeing for the entire population is a precondition of a more prosperous and cohesive society.For the purposes of this report, the basic question must therefore be asked and answered: how do we define 'good health' and 'wellbeing', as well as their contrary states 'ill health' and 'ill-being'?Peace has been described as the absence of war, based on the assumption that neither of those two elements represented normality: life was ever in flux, moving inexorably from one to the other.But good health and ill health need not be seen in the same light, each being defined solely as the absence of the other.A more positive, proactive line is suggested here, that good health be considered as the expected norm and ill health the abnormal state.The constitution of the World Health Organization, as adopted in New York in June 1946, defined health not just as the absence of disease or infirmity, but as a state of complete physical, mental and social wellbeing.In 2008, it was suggested that wellbeing should also include how people feel and function 21 .Those definitions are carried forward and expanded here, accepting that our basic physiology, metabolism and mindset are all determined by our long human evolution.This shows us what we were (and still are) genetically best adapted for, and, just as crucially, what we were not best adapted for.We are well adapted, for example, to eat fresh food and take daily exercise.Our overburdened National Health Service is all too well aware of the complications that arise from an urban population that ignores these fundamental evolutionary determinants of health, as the incidence of obesity, diabetes, cardiovascular problems and several forms of cancer all too painfully prove.As Professor Marmot states, "Although our material and social environments have changed beyond recognition over the last 10,000 years … our underlying biology is essentially the same as it was in ancient Babylon" 22 .Archaeologists heartily agree with his sentiment, but would respectfully add many millennia to his chronology.
Here, wellbeing and good health (physical and mental) are defined as the product of following evolutionaryconcordant behaviours.Ill health is partially the converse, a lifestyle that deviates from that broad path and is impacted by the associated consequences, or one that is affected by trauma or by infectious or contagious diseases, a common occurrence in conurbations.
Normality in health terms is working with our Palaeolithic genome; poor health is therefore abnormal, too often the product of a lifestyle that is not evolutionary-concordant.
Good health is the consequence of adopting normal evolutionary-concordant behaviour -for example, the proxy nutritional regimes, societal systems and lifestyle-embedded activities that all correspond to and are required by that concept.
Urban wellbeing is a state of mind and body obtained by those who have adopted evolutionary-concordant behaviours within an urban environment modified on evolutionary-concordant lines23 .

ADDRESSING THE CHALLENGE
The megacities of the future should be designed to contain or constrain the epidemic of 'Western Lifestyle Diseases' that currently beset today's towns.These and a myriad of other issues have been considered at length by bodies such as the Healthy Cities Movement 24 and the World Health Organisation 25 .As a contribution to this complex and far-reaching debate, it is suggested here that the urban lifestyles and townscapes of tomorrow should simulate, or at least approximate, the diet, activity regimes and environments that our hunter-gatherer biology would respond to as 'normal'.Such a situation would create the basic conditions for normal good health and encourage urban wellbeing.A series of 'Protocols' are being developed to open the debate, providing an 'upstream' approach to containing the increase in 'Western lifestyle diseases' through cultural and behavioural change, from a human evolutionary perspective.The suggested mechanisms operate on four intergrated levels, initially with personal and institutional protocols, supported by town planning and building design protocols and then, at the next level, the political protocol

Eden Protocol
Lifestyle choices are moulded by a complex of cultural, economic and societal influences, while the associated research incorporated studies concerning physiological, metabolic and psychological factors relating to nutrition, activity regimes and social interactions.The Alameda County Study undertaken by the epidemiologist Sir Richard Doll, considered a cluster of lifestyle factors which were related over time to a higher or lower risk of death: these were termed 'positive' and negative' health behaviours 26 .In a similar vein, the evolutionary determinants of health programme has identified 'normal' evolutionary-concordant behaviours as well as 'abnormal' non-evolutionary-concordant behaviours.Despite significant achievements over the previous century, it is now evident that modern medicine on its own cannot solve all health problems: its resources are over-stretched and its limitations increasingly recognised.Significant progress is no longer solely a matter of eradicating particular diseases, but requires an improved understanding of the political, economic, cultural, social and genetic determinants of health.Improving a nation's health must now rely not just on reactive medical advances but also on positive proactive cultural change that translates directly into improved urban wellbeing.
In the past, public health officials and town planners worked together in the drive to eradicate such urban evils as cholera and typhoid 27 .One of the prime goals for the new generation of cities must be an equally concerted drive to improve urban wellbeing, as the expanding Healthy Cities movement shows 28 .The concepts underlying the evolutionary determinants of health programme could have a major role in that work, realigning policy and practice to better fit our biology.It would be far most cost effective to work with our Palaeolithic genome rather than continuing the losing battle to maintain a lifestyle that is fundamentally bad for us.Although town life is, superficially, the very antithesis of the hunter-gatherers' world, this urban paradox can be at least partially resolved.A solution lies in the adoption of proxy behaviours, environments and townscapes that mimic key elements of the nutrition, daily activity, social interaction and engagement with the natural world that our minds and bodies demand (consciously, unconsciously or subconsciously).Positive attributes of this shared evolutionary past need to be developed, while negative elements must be constrained.
The practices that such applications suggest have been brought together to form a coherent protocol applied to 21st century townscapes and urban lifestyles.This approach is the Eden Protocol, a short-hand term for the evolutionary determinants of health, social behaviour and urban wellbeing.Under its banner, a series of guidelines have been drawn up to progress this concept.Unsurprisingly, many of the elements in the Personal Protocol appear in healthy living guidance issued by public health authorities across the globe, but often in isolation and usually without the Palaeolithic perspective.A more overtly evolutionary focus on such advice, 24 Rydin, Y., Bleahu, A., Davies, M., Groce, N., Scott, I. and Wilkinson, P., 2012 'Shaping cities for health: complexity and the planning of urban environments in the 21st century', The Lancet 379(9831), 2079-2108 25 WHO 2004 The Global Burden of Disease: 2004 Update.Geneva: World Health Organization 26 Gardner, B. and Wardle, J., 2012 'The role of health behaviour', in D. French, K. Vedhara, A. Kaptein and J. Weinman (eds), Health Psychology (2nd edn).Oxford: Blackwell, pp.13-32 27 Herbert, M., 1999 'A city in good shape: town planning and public health', Town Planning Review 70(4), 433-453 28 Rydin, Y., Bleahu, A., Davies, M., Groce, N., Scott, I. and Wilkinson, P., 2012 'Shaping cities for health: complexity and the planning of urban environments in the 21st century', The Lancet 379(9831), 2079-2108 however, is apparent in lifestyle literature from, for example, the Primal movement in California 29 to academics in the United States 30 and in Europe 31 .
20 see eg Roberts, C. and Cox.M., 2003 Health and Disease in Britain, from Prehistory to the Present Day.Stroud: Suton Publishing; Hassett, B., 2017 Built on Bones:15,000 years of life and death.London.See also see Milne, G., 2017 Uncivilised Genes: human evolution and the urban paradox, 229-232 21 Abdallah, A., Steuer, N., Marks, N. and Page, N., 2008 Well-Being Evaluation Tools: A Research and Development Project ,for the Big Lottery Fund Final Report.London: New Economics Foundation, 7-8 22 Brunner, E., and Marmot, M., 2006 Social Determinants of Health.Oxford: Oxford University Press, 13