Building Inclusion: Toward an Aging- and Disability-Friendly City

Increased longevity and urbanization demand that cities optimize “opportunities for health, participation and security in order to enhance quality of life as people age.”^1(p1) In response, the World Health Organization (WHO) established the Global Network of Age-Friendly Cities and AARP Livable Communities, which includes San Francisco, California, as of 2014.

Mainstream society upholds the myth that aging and disability are abnormal rather than part of the human diversity spectrum, perpetuating the objectification and disempowerment of the “old” and the “disabled.” In San Francisco, a city being transformed by a technology boom and rapid gentrification, the contributions of older adults and people with disabilities are often excluded. Inclusion would mean that all community members share the responsibility to draw on one another to foster equity, prosperity, and health. To this end, Aging and Disability Friendly San Francisco (ADF-SF) seeks to inspire local changes through social justice–centered public health approaches that involve older adults and people with disabilities.

THINK GLOBAL, ACT LOCAL

The disability rights movement of the 1960s is important to San Francisco’s political struggles. Building on this history, San Francisco’s disability and aging advocates have collaborated to improve dignity and independence. After five years of volunteer advocacy, ADF-SF emerged in 2011 as a workgroup of the Long Term Care Coordinating Council. This council provides guidance to the mayor and city on integrating home, community, and institutional supports and services.

To assess San Francisco’s aging and disability friendliness, ADF-SF collected data through focus groups, community meetings, stakeholder presentations, and analyses of city-level reports. Preliminary data indicated that 20% of San Franciscans are aged 60 years or older; 54% speak a primary language besides English; 16% have incomes below the federal poverty line; 12% identify as part of the lesbian, gay, bisexual, or transgender community; and 9% are homeless. Among adults with disabilities, 88% live in the community, whereas 12% live in institutional or noninstitutional group facilities, and 33% have incomes below the federal poverty line.²

With San Francisco’s median current monthly rent of $4526,³ a rising cost of living poses challenges for fixed-income residents to meet basic needs. Consequently, many older adults and people with disabilities risk eviction, displacement, or homelessness. Overall evictions in San Francisco increased 87% between 2010 and 2016, from 1269 to 2376.⁴ Official eviction statistics do not account for age and disability status of tenants, making it impossible to know precisely how many older adults and people with disabilities are affected. However, occupants age 60 or older in homeless shelters increased 82% between 2010 and 2015, from 207 to 377.² Older adults and people with disabilities may be especially vulnerable to housing insecurity because many reside in lower-rent units, which offer the highest potential for rent increases if landlords are able to vacate and re-rent them at current market value.²

From these data, ADF-SF conceptualized a framework of the material conditions and social factors affecting residents’ health and well-being.¹ WHO recognizes eight interconnected domains for age-friendly cities, and ADF-SF added technology as a ninth domain in response to San Francisco’s technology boom (Figure 1). This framework transcends medical models of health, reductive assumptions that cast older adulthood as a phase of decline or conflate aging and disability issues. ADF-SF uses this framework to identify community-led solutions that link praxis and social change.

FIGURE 1—

Social Determinants of Health for an Aging- and Disability-Friendly City

^aAge-friendly domain of technology added by Aging and Disability Friendly San Francisco (ADF-SF) to the World Health Organization (WHO) eight interconnected domains.

Note. ADL = activities of daily living; IADL = instrumental activities of daily living.

MIND THE WHOLE CITY

As public health incorporates place-based interventions to address inequalities, paradigms for urban change must “keep the whole city in mind.”⁵ Cities function as vibrant centers where diverse people converge to engage civically and propagate ideas to influence the public realm. One of the most precious human rights is “the right to remake ourselves by creating a qualitatively different kind of urban sociality.”^6(p939) As such, the ways cities are built and the citizenry empowered can politicize accessibility and play a vital role in public health. This involves working in solidarity with disenfranchised populations so that the people have power to positively affect their community. One technique includes celebrating accomplishments, such as throwing “parties to build the city and learn how to be better caretakers of our metropolis.”^7(p279) Through new and old connections, city ownership is shared, creating a feedback loop between hard work and collective joy.

Recognizing the value of such celebrations, ADF-SF hosted the first annual A Party With a Purpose! More than 200 people attended, generating excitement for an aging- and disability-friendly city movement. As a public space, the main library was an ideal venue. To model accessibility, materials were available in large font and multiple languages; captioning, sign language, and assistive-listening devices were provided; and translators for non-English speakers were on site. Attendees sang along to “I left my heart in an aging-and-disability-friendly San Francisco.” Dance Generators, an intergenerational troupe, performed with attendees dancing at their seats. The keynote speaker from Grantmakers in Aging discussed eliminating negative stereotypes by reframing conversations about aging. An inaugural ADF-SF Champion Award was given to the Municipal Transportation Agency for passing a policy providing free public transit to low- and moderate-income older adults and people with disabilities. Breakout groups were formed to identify and prioritize critical policy actions. A reception followed where guests mingled before departing. The parting, however, was only temporary. To make and remake the city together, the effort must be ongoing. Next steps include establishing a task force to develop an action plan that evaluates continuous improvements within and outside of government.

DISCUSSION AND IMPLICATIONS

Rarely are celebrations considered occasions to grieve over changes in a city. ADF-SF’s A Party With a Purpose! showed that celebratory spaces perform the dual tasks of engendering social action and fostering community cohesion. Such gatherings motivate a public health commitment centered on social justice that strengthens the collective voice and participatory governance of older adults and people with disabilities.

Although the premise of this approach is inclusivity, it has limitations. ADF-SF found that the age-friendly domains of (1) social participation and (2) respect and social inclusion are major determinants for community health, yet they are the most difficult tenets to fulfill and thus may hinder progress in the other domains. Moreover, conditions for consensus-based knowledge production may obscure individual differences. Community members and stakeholders may overcome these limitations by committing to collaborative learning and continuous communication, as well as multifaceted interventions, even if the work to transform social policy will take time.

Because fundamental causes of health inequalities are collectively experienced, they require collective action. As urban populations grow, building healthy cities must benefit all residents. Although this sounds aphoristic, it is complex. WHO provides legitimacy to San Francisco for being age-friendly, and their guide functions as a useful checklist to help identify city structures and services that need adaptation in key domains.¹ To supplement this effort, communities must leverage this guide to catalyze an ideological transformation in the public consciousness, one that actively includes older adults and people with disabilities in urban change and values them as members in society.

Initiatives involving older adults and people with disabilities in age-friendly efforts have the potential to curtail trends that privilege the rich, young, or able-bodied. Public health must work holistically to build inclusion and social justice into everyday engagements and community infrastructures not only to promote healthy and prosperous cities but also to transform them into aging- and disability-friendly spaces.