Essay Healthy cities after COVID-­19 pandemic: the just ecofeminist healthy cities approach Margarita Triguero-­Mas ‍ ‍,1,2,3,4 Isabelle Anguelovski ‍ ‍,1,2,4,5 Helen V S Cole ‍ ‍1,2,4 1 Institute for Environmental ABSTRACT and environmental injustices to create more just, Science and Technology, The COVID-­19 pandemic crisis has compromised the liveable, sustainable and healthy cities for all.1 8 Universitat Autònoma de Barcelona, Bellaterra ’healthy cities’ vision, as it has unveiled the need to Care work, understood as those tasks accom- (Cerdanyola del Vallès), Spain give more prominence to caring tasks while addressing plished in order to look after ourselves, others and 2 IMIM (Hospital del Mar intersectional social inequities and environmental the environment,7 9 has been one of the material and Medical Research Institute), injustices. However, much-­needed transdisciplinary emotional dimensions most impacted and valued Barcelona, Spain during the pandemic.7 During the pandemic all of 3 Mariana Arcaya’s Research approaches to study and address post-­COVID-­19 healthy Lab, Massachusetts Institute cities challenges and agendas have been scarce so far. To us (and particularly low-­income racialised women) of Technology Department of address this gap, we propose a ’just ecofeminist healthy have experienced an increase in our responsibilities Urban Studies and Planning, cities’ research approach, which would be informed by to provide assistance, shopping or cooking for sick Cambridge, Massachusetts, USA or disabled parents, friends or relatives, checking 4 Barcelona Lab for Urban the caring city, environmental justice, just ecofeminist Environmental Justice and sustainability and the healthy cities paradigms and on neighbours, caring for pets, home schooling, Sustainability, Barcelona, Spain research fields. Our proposed approach aims to achieve and, of course, treating and attending to the health 5 Institucio Catalana de Recerca the highest standards of human health possible for the needs of COVID-­ 19-­ impacted patients and their i Estudis Avancats, Barcelona, whole population—yet putting the health of socially families.7 The exacerbation of caring tasks has Spain been to such a degree that we have been forced underprivileged residents in the centre—through preserving and/or improving the existing physical, social to re-­evaluate our ability and commitments to the Correspondence to Dr Margarita Triguero-­Mas, and political environment. Importantly, the proposed productive, reproductive, personal and political Universitat Autònoma approach recognises all spheres of daily life (productive, spheres of daily life.7 10 de Barcelona, Bellaterra reproductive, personal and political) and their The pandemic has also aggravated or created new (Cerdanyola del Vallès), connections with inequities, justice and power dynamics. contexts of intersectional social inequities.8 11 By Catalunya, Spain; Last, the just ecofeminist healthy cities approach intersectional, we refer to the multiple axes of iden- ​mtrigueromas@​gmail.​com understands human health as interconnected with the tity such as gender, race/ethnicity, class, disability, Received 27 May 2021 health of non-­human animals and the ecosystem. We sexual identity or migration status that intersect Accepted 20 September 2021 illustrate the proposed new approach focusing on the and overlap creating susceptibility to differentiated implications for women’s health and public green spaces oppressions and social (under)privileges.11 12 For example, economic and gender axes of inequalities research and propose principles and practices for its have been exacerbated by the pandemic because operationalisation. at the population level—due to high job insecu- rity and lower pay conditions—women and other marginalised gender groups have less capacity to face the COVID-­ 19-­related economic recession.6 INTRODUCTION This inequity has been exacerbated by women Apart from emerging as a public health crisis being more likely to be forced to leave their paid with significant impacts on the mental and phys- jobs due to heavier care responsibilities.6 Moreover, ical health of urban residents all over the world, the economic sectors most affected by the pandemic the COVID-­ 19 pandemic has also prompted a economic crisis (eg, retail, tourism or restaurants) social and economic crisis.1 COVID-­19 suddenly are highly feminised.1 6 Last, the workers more propelled health to the very daily centre of our exposed and infected by COVID-­19 have been the lives, making us all realise how dependent our essential service workers (eg, public transit, food health is on the health of others and also on the store or hospital workers), many professions of health of the planet.2 So the crisis has unravelled which are both heavily feminised and marked by and reaffirmed the relevance of the planetary and racial/ethnical and economic inequalities (eg, nurses, ecohealth approaches (both with public health cleaners and caregivers for the elderly).1 6 11 13 © Author(s) (or their and environmental sciences as core contributing The pandemic has also visibilised urban envi- employer(s)) 2021. No sciences)3 for safeguarding health. The pandemic ronmental injustices originating from the fact that commercial re-­use. See rights has also highlighted the importance of reformu- cities have been traditionally planned around the and permissions. Published lating the current ‘healthy cities’ paradigm (ie, the by BMJ. needs of groups in power (usually middle-­ class movement centred on the improvement of health white men with a full-­ time employment), (re-­ ) To cite: Triguero-­Mas M, via the social determinants of health, including— producing segregation, exclusion and new types of Anguelovski I, Cole HVS. J eg—the socioeconomic position and urban physical environmental privilege.10 13 Environmental injus- Epidemiol Community Health Epub ahead of print: [please living conditions).4 5 So the COVID-­19 pandemic tices concern the unequal exposure to environ- include Day Month Year]. has visibilised the fundamental role of care work mental risks and contamination as well as unequal doi:10.1136/jech-2021- in our societies.6 7 It has also uncovered the impor- access to environmental amenities that socially 216725 tance of addressing intersectional social inequities underprivileged groups experience.14 For example, Triguero-­Mas M, et al. J Epidemiol Community Health 2021;0:1–6. doi:10.1136/jech-2021-216725 1 Essay Figure 1 The Just Ecofeminist Healthy Cities framework. On the left side, the traditional health cities paradigm and the informing concepts we bring into our proposed framework. On the right hand, the detailed presentation of the just ecofeminist healthy city framework. during confinements in particular, urban residents—especially The just ecofeminist healthy cities approach those having to live in cramped housing conditions—struggled Our proposal to incorporate care, intersectional social to maintain their psychological health, a challenge made more inequalities and environmental justice to the healthy cities obvious since most activities from different spheres of daily approach is inspired by a diversity of complementary disci- life were taking place at home.15 In contrast, higher-­ income plines. The ‘healthy cities’ movement emphasises equity, residents were able to spend confinement time in high quality participatory governance and solidarity (ie, explicit polit- housing with access to public and/or private quality public green ical commitment, leadership and institutional change), and spaces (such as parks, riversides or urban gardens) or to escape intersectoral partnerships with public, private, voluntary to their second homes (often located in the countryside or on and community organisations. 4 However, despite that the the coast).8 16 Even in areas without strict confinement poli- healthy cities movement refers to goals such as ‘sustain- cies, factors such as school cancellations, loss of employment, able development’, ‘conservation of resources and envi- increased care responsibilities, public campaigns to ‘stay home’, ronmental health’ and ‘ecosystems that are stable now and and even work from home policies have kept many people closer sustainable in the long term’, its approach has been mainly to home. This increase of time spent closer to residence has at the local scale and focusing on the existing city popula- reinforced the value and the unequal availability of neighbour- tion.4 20 Similarly—despite that justice, equality and equity hood public and private urban spaces for accessing some level are interrelated concepts—the focus on equity in healthy of basic recreation, socialisation, physical activity or access to cities is underdeveloped and rooted in equality rather than nature and, consequently, broadening health inequities.17 These on a deeper understandings of justice. Moreover, the healthy unjust situations have not been considered or counteracted with cities movement has been tackling social determinants of the temporary top-­down solutions that some cities have imple- health but rarely using intersectional lenses or focusing on mented such as tactical urbanism or temporary street closures to care. increase pedestrian space.17 All in all, those COVID-­produced In contrast, the emerging ‘caring city’ paradigm in urban sociospatial reconfigurations have exacerbated and created new planning, especially feminist urbanism, places care of its citi- environmental injustices.18 zens and the environment at the centre while also allowing Different scientific fields have explored and hypothesised citizens to take care of themselves and others.10 Despite its how COVID-­ 19 affects their discipline since the pandemic holistic conceptualisation, the caring city, as it is presented, outbreak.7 8 17–19 However, to our knowledge, much-­needed trans- so far illustrates mostly an anthropocentric approach, disciplinary approaches to study and address post-­COVID-­19 neglecting deeper considerations of environmental aspects, healthy cities challenges and agendas have been scarce so far. We including enduring environmental injustices. refer here to knowledge from fields such as urban public health, In the environmental justice literature, some scholars environmental sciences, feminist studies, geography and urban are starting to offer a new approach for analysing and planning. In this essay, we fill this gap by proposing a new schol- promoting justice in public spaces focusing on care, and the arly approach for achieving a post-­COVID healthy cities agenda emancipatory functions of public spaces with intersectional which, building on those different fields, can better incorporate lenses. This new environmental justice approach considers care, intersectional social inequalities and environmental justice. the reparative/restorative and preventive justice, considering Moreover, to depict the practical research implications of our how people understand, value, sense and live public spaces proposed approach, we finish this essay zooming in on the rela- in their everyday life. Also, this new environmental justice tionship between public green spaces and women’s health. approach pays particular attention to the possibilities and 2 Triguero-­Mas M, et al. J Epidemiol Community Health 2021;0:1–6. doi:10.1136/jech-2021-216725 Essay Table 1 Examples of how the just ecofeminist healthy cities approach may inform the different stages of research around public green spaces and women’s health: research framework and research question Research stage Putting to work the just ecofeminist healthy cities approach for research on public green spaces and women’s health Research framework 1. Develop a new framework based on those traditionally used for research on the health benefits from public green spaces27 48 to: (1) include the health and research question of human and non-­human others as outcomes, (2) incorporate interrelations with widespread threats for humans and the Earth as we know it (eg, climate change, urbanisation, biodiversity loss, increasing frequency of natural disasters) as potential pathways, (3) reflect the role of caring tasks as confounders of the potential associations, (4) exchange how sociodemographic and economic factors are included in the frameworks as monolithic characteristics of participants by an intersectional understanding of these overlapping factors, (5) include political and other contextual factors that may encompass power dynamics and may impact the factors included in the framework and the associations explored (such as historic city planning decisions, opening hours of public green spaces or city transport characteristics), (6) take into account the different spheres of daily life and different perceptions and experiences of public green spaces to determine exposure to public green spaces and potential pathways, (7) include environmental justice elements as modifying factors or reconceptualise public green spaces so they become exposures with justice elements layers (eg, including value given to, understanding of public green spaces instead). 2. Embrace the importance to have different research questions at microlevel (eg, neighbourhood, institution/organisation) and macrolevel (eg, the city and beyond).23 While microlevel research questions can, for example, more deeply investigate the different spheres of daily life and the diverse understandings of public green spaces; macrolevel research questions can focus on non-­human others such as the ecosystem. 3. Focus on socially underprivileged groups of women with an intersectional approach (eg, immigrated racialised transwomen or elderly women from low social classes living alone) that are those traditionally excluded from research on public green spaces and women’s health, and yet have some of the greatest needs for healthier and greener urban environments since they do not often have the means or time to access more remote green spaces. 4. Develop research which is consequential and transformative. That is, research that focuses on impactful public health outcomes and that seeks solutions for a transition to ways of living that protect the health of current, future generations and the Earth’s health.49 This research should question the growth-­driven model of urban development and highlight practices and experiences of community-­driven wealth creation and alternative and solidarity economies, including those emerging around urban greening and public space projects. So, just ecofeminist healthy cities research should be performed only until there is enough evidence for action. 5. Frame related research questions based on the previous points1–4 such as: 1. What are similar and differential needs, uses and perceptions in regard to public green spaces and health for women across different intersectionalities (eg, between transwomen and cisgenderwomen of different ages and classes, between women born in the neighbourhood of study and immigrated to the area from different ethnic groups and ages)? 2. What quality or characteristics of public green spaces (vegetation features; biodiversity elements) improve women’s health now while not damaging the health of others now nor in the future? What type of amenities seem to best contribute to women’s health (socialising spaces and cafés; specific sports infrastructure; benches and other resting spaces; toilets, ramps, lighting and other safety elements such as emergency buttons, etc)? credibility given to experiences and knowledge of different identity. It also acknowledges the ecological interconnection social groups. 21 22 Moving further, the ‘just ecofeminist between humans and the Earth, so it considers that humans’ sustainability,’ approach is situated at the intersection of health cannot be achieved if we do not take care of human feminism, ecology, society and economy while accounting and non-­ human others (ie, humans, animals, ecosystems) for the ways that our social, economic and political practices and assure their health. are traversed by multiple intersectional axes of identity and understanding that we (humans) cannot be dissaciociated from the planet. 23 Yet, although the approaches of environ- Zooming in on the new approach: health benefits of public mental justice applied to public spaces and just ecofeminist green spaces for women’s health sustainability are broad, their implications for healthy cities To illustrate the implications of our proposal for postpandemic are unclear or incomplete. urban public health research, we propose new directions for Considering how the COVID-­1 9 pandemic has evinced research on the relationship between public green spaces and the need to redefine healthy cities incorporating caring city, women’s health. Research on how public green spaces benefit environmental justice and just ecofeminist sustainability women’s health is particularly salient in the post-­ COVID-­ 19 paradigms, we propose that research about post-­C OVID-­19 outbreak urban context. cities should be built on a ‘just ecofeminist healthy cities’ Although men have been shown to experience more severe approach (figure 1). This new approach interprets the incor- COVID-­19-­related health outcomes,24 the risk of infection, porated paradigms using planetary and eco health lenses number of cases and the consequences of the pandemic—partic- which take into account linkages between broad ecosystems ularly psychological impacts—are worse for women.1 13 25 Addi- in maintaining health for humans and all species alike.3 It tionally, the higher physical and mental burden suffered by also reinforces intersectionality, as an important concept women in general during the pandemic is particularly related existing in all the incorporated paradigms. More specifi- to the increased burden of unpaid care work, especially when cally, we define this new approach as one that focuses on caring for children, elderly people or people with disabili- maintaining and/or improving the environment (ie, physical ties.1 6 13 Moreover, as a consequence, women have experienced factors and how these are impacted by social and political increased exposure to COVID-­19 once someone in the home aspects) to reach the highest attainable standards of human becomes infected.13 health for the whole population while paying particular In this section, we focus on public green spaces as one key attention to the health of socially underprivileged resi- element of well-­designed, climate-­responsive cities, of commu- dents. To do so, the approach focuses on all the spheres nity health and of moving towards just ecofeminist healthy of daily life to recognise injustices, power and domination cities. Indeed, public green spaces play a major role in climate dynamics in cities that need to be repaired and transformed. resilience, easing biodiversity and soil loss, and decreasing lone- Consideration is also given to the different ways in which liness and prevalence of non-­communicable diseases prevalence, people understand, value, sense and live the urban environ- among other benefits for humans, animals and ecosystems.26–29 ment distinctively based on multiple axes of intersectional The importance given to and time spent in public spaces like Triguero-­Mas M, et al. J Epidemiol Community Health 2021;0:1–6. doi:10.1136/jech-2021-216725 3 Essay Table 2 Examples of how the just ecofeminist healthy cities approach may inform the different stages of research around public green spaces and women’s health: research design, methods and implementation practices; dissemination of results Research stage Putting to work the just ecofeminist healthy cities approach for research on public green spaces and women’s health Research design, (1) Incorporate (trans)feminist methodologies to research so the lives of those women experiencing intersectional health are at the centre of the research, methods and with the primary aim of improving their lives and health.23 To do so, research must be orientated towards community participation, co-­operativeness, implementation colearning and empowerment50 using approaches such as (or inspired by) participatory research, popular epidemiology or feminist participatory practices research.51 52 Such approaches may also call for the incorporation of qualitative methods such as collecting data via qualitative interviews, focus groups, ethnographic methods of observation, go-­along interviews, photovoice or participatory photo mapping52 which can help researchers understand how public green spaces are experienced, perceived, navigated, made meaningful and used by women in their different spheres of daily life (ie, the exposure to these spaces and even potential pathways of association with health), what processes and mechanisms underlying the association between public green spaces and health may differ depending on multiple axes of women’s identity and may even serve to uncover new hypotheses for further studies.53 Gender-­responsive intersectional lenses can provide gender-­specific data, actions and assessments that consider the specific responsibilities, needs, experiences, expectations, challenges and underlying health conditions of different genders accounting for the intersectionality of gender with class, place of origin and other social vulnerabilities.1 54 (2) Leverage mixed methods, (semi)experimental and qualitative data from case studies to gain a deep understanding of the relationships between public green spaces and health of women and others and use its results as tools for change. However, the just ecofeminist healthy cities approach should be mainly guided by the cause of morbidity or mortality (injustice) and less by the specific methodology used, escaping from the ideas of hierarchical evidence and embracing that a mix of different types of evidence is what is needed.49 (3) Follow feminist caring practices with the research team members and participants. That is, focus on the team and its well-­being and needs instead of individualism, performance and productivity as much as possible. To do so, dedicate time and resources to care and support in your team meetings.55 With participants, ensure they feel as comfortable as possible during all the study and that they are completely informed of their rights as participants. Also, be aware of your own power and use it carefully.55 (4) Operationalise different justice dimensions for their incorporation in the research studies, including reparative and preventive justice lenses around access to green space. For example, for reparative justice, include percentage of traditionally underprivileged residents that are satisfied with access to green spaces. For preventive justice, integrate—for example—stress related with perceived risk of displacement due to environmental gentrification.56 (5) Establish clear paths of compensation for the community and residents of study such as compensating the study participants for their time and knowledge, invite them to coauthor the research outputs and employ them when possible.52 plazas, pedestrianised areas or public green spaces has increased public green spaces has been tied to greater health benefits for with the pandemic, as open outdoor spaces are considered socially underprivileged residents—that is, those experiencing safer, with less likelihood of contracting the virus, than indoor social vulnerability such as those with lower income, who are spaces or crowded sidewalks.7 17 18 30 In fact, the closure of also more likely to be women.29 39 40 These differential patterns public green spaces during lockdowns in several cities (eg, of benefit have been explained by cultural, historical and contex- Zurich in Switzerland and Barcelona in Spain) has been linked tual factors such as limited leisure time, living in highly urban- to an increased realisation and appreciation of the importance ised neighbourhoods and lacking financial resources, that can of these spaces and their biodiversity for residents’ mental and prevent women from lower socioeconomic classes from travel- physical health, with increased contact with these spaces since ling to parks or other public green spaces far from their homes the pandemic outbreak.30 31 Recent studies have also shown the or enjoying private green spaces.41 42 increased importance of neighbourhood public green spaces for Also, the pathways that could explain how public green spaces coping with confinement and the pandemic.32–35 However, these benefit people’s health may differ between genders. In that studies—potentially strongly affected by participation bias— sense, women could benefit from public green spaces to a higher have rarely explored gender health inequities (see 27 29 for extent because of the social support systems that they have built exceptions that reported no differential associations by gender) in those spaces.26 In fact, these public spaces contribute to place and none specifically investigated caring work or intersectional attachment, community identity and overall well-­being when health inequities. caretakers use them to meet others, build relationships and build However, previous research shows that the health of different trust.14 43–46 In this direction, physical distancing associated with genders may benefit distinctively from contact with public green COVID-­19 may have also decreased the potential benefits of spaces, probably due to dissimilar uses of and perceptions about greenspaces for women’s health.21 these spaces.36 These health inequities will also be influences by In view of the growing number of scholars proposing that other social axes such as race or education. For instance, due COVID-­ 19 could help planners rethink and redesign public to gender-­specific norms in informal care work and additional spaces as vibrant spaces of health, care, community and collec- vulnerability to gender-­based violence, some studies suggest that tive activities,17 19 45 we use the intersection of public green women may prefer to use public green spaces near their home space and women’s health to exemplify how our proposed just and those perceived as safe.37 38 Moreover, exposure to nearby ecofeminist sustainable healthy cities approach can inform a new Table 3 Examples of how the just ecofeminist healthy cities approach may inform the different stages of research around public green spaces and women’s health: research design, methods and implementation practices; dissemination of results Research stage Putting to work the just ecofeminist healthy cities approach for research on public green spaces and women’s health Dissemination of results (1) Assure free unrestricted online availability of scientific publications and research data from the studies. Purposely link findings to planning action and even involve planners in building new scientific practices. Make results fully accessible as empowering knowledge tools to feminist or women’s support organisations and collectives, apart from environmental and health associations and practitioners. (2) Produce dissemination materials that highlight both the novelty and value of the research approach and design, and—at the same time— emphasise the quality and importance of the findings. These could be in the form of newspaper articles and other mass media coverage, talks, social media report of results, visual material of the study results such as (interactive web-­)documentaries, ArcGIS story maps or critical interactive mapping, for instance. 4 Triguero-­Mas M, et al. J Epidemiol Community Health 2021;0:1–6. doi:10.1136/jech-2021-216725 Essay research agenda by framing: (1) research questions (2) research 2 Padilla Bernáldez J, Gullón Tosio P. Epidemiocracia: Nadie está a salvo si no estamos design and methods, and (3) research dissemination (tables 1–3). todos a salvo [Epidemiocracy: No one is safe if we are not all safe]. Madrid: Capitán Swing, 2020. Accordingly, we advocate for the development of a new frame- 3 Lerner H, Berg C. A comparison of three holistic approaches to health: one health, work, to consider different scopes for research questions EcoHealth, and planetary health. Front Vet Sci 2017;4:163. depending on the area of focus, to pay particular attention to 4 WHO Europe. What is a healthy city? 2010. Available: https://www.​euro.​who.​int/​en/​ those women populations that are usually excluded from studies health-​topics/​environment-​and-​health/​urban-​health/​who-​european-​healthy-​cities-​ network/​what-​is-​a-​healthy-​city [Accessed 9th March 2021]. and to develop consequential and transformative research. To do 5 WHO. Social determinants of health. A conceptual framework for action on the social so, we suggest the use of feminist methodologies for data collec- determinants of health. WHO, 2010. tion and caring practices with both participants and the research 6 Spanish Ministry of Equality. La perspectiva de género, esencial en la respuesta a la team and operationalisation and incorporation of different COVID-­19 [The gender perspective, essential in the response to COVID-­19]. Spanish justice dimensions in research studies. Finally, we point out that Government, 2020. Available: https://www.​inmujer.​gob.​es/​diseno/​novedades/​ IMPACTO_​DE_​GENERO_​DEL_​COVID_​19_%​28uv%​29.​pdf it is important to ensure availability of scientific publication for 7 Valdivia B from Col·lectiu Punt 6. Críticas y propuestas desde el urbanismo all those interested, to link research findings to practice, and feminista: ciudades cuidadoras para priorizar la vida [Criticisms and proposals to produce useful dissemination materials for the community. from feminist urbanism: caring cities to prioritize life]. In: Rabasco P, ed. Ciudad y Moreover, we acknowledge that our proposed approach should resiliencia: última llamada [City and resilience: last call]. Madrid: Ediciones Akal, 2020. be based on establishing partnerships with public, private, volun- 8 Cole HVS, Anguelovski I, Baró F, et al. The COVID-­19 pandemic: power and privilege, tary and community organisations and local residents for devel- gentrification, and urban environmental justice in the global North. Cities & Health oping the research questions, study design, data collection and 2020:1–5. dissemination tools. 9 Bates C, Imrie R, Kullman K. Configuring the Caring City: Ownership, Healing, Openness. 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Healthy cities around the world: an overview of the healthy cities movement in Funding HC is funded by a Juan de la Cierva fellowships [FJCI-­2018-­035322] the six who regions. WHO, 2003. awarded by the Spanish Ministry of Economy and Competitiveness. The research 21 Anguelovski I, Brand AL, Connolly JJT. Expanding the boundaries of justice in urban presented in this paper received funding from the European Research Council (ERC) greening scholarship: toward an Emancipatory, Antisubordination, intersectional, and under the European Union’s Horizon 2020 research and innovation program [grant relational approach. Ann Am Assoc Geogr 2020:1–27. agreement No. 678034] but the sponsor had no role in the design or analysis of 22 Low S, Iveson K. Propositions for more just urban public spaces. City 2016;20:10–31. this study. All authors contributed conceptually to the paper. MTM wrote the first 23 Gaard GC. Critical ecofeminism. Lanham: Lexington Books, 2017. draft and refined the manuscript. 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