Response to the Built Environment

Good design and construction improves the usefulness, quality, and beauty of where we live. It can save precious resources, reduce greenhouse gas emissions, and improve energy efficiency. And it can go one step further: It can promote and preserve health and human well-being.
A century ago, it was clear that health depended on physical environments. It was intuitively obvious (and later scientifically documented) that living in dark, poorly ventilated, crowded housing increased the risk of “consumption” (tuberculosis) and other diseases. Though it had been believed for years that diseases such as cholera were spread by “miasma” (or a noxious form of” bad air”), in 1854 John Snow famously demonstrated the role of contaminated water supplies during a raging cholera epidemic in London. Snow was unsure of the specific agent (a bacterium that was yet to be discovered), but when the epidemic was ended, it became apparent that contaminated water in the environment was the cause. By the turn of the twentieth century, it was also clear that living near smelters and slaughterhouses was unhealthy. Solid waste collection, water disinfection, sewage removal, and the creation of parks and protected walkways were viewed as self-evident and unitary ways to improve the quality of life, of business enterprises, and most of all, of health and survival. Housing codes evolved to separate (and protect) people from toxic elements in their environments. As housing and sanitation improved, health improved.

With an understanding that networks among people protect against disease, we inhabit a state of collective isolation.

The average life span has increased by about thirty years over the last century, with twenty-five of those years attributable to public health and infrastructure improvements. The partnership between public works and healthcare and the resulting changes in environmental infrastructure were a gift to human survival.
In the past sixty years, modern medicine has championed dramatic and impressive successes. The use of antimicrobials since the discovery of penicillin has become increasingly sophisticated, and new medicines are constantly being designed and developed. Technology has made it possible to develop pacemakers to police a heart that is “out of step,” and when body parts fail, we often have the technical and surgical know-how to replace them with man-made prosthetics or transplanted organs.


At the same time, design and construction has advanced apace with high-efficiency windows, temperature control, and increasingly sophisticated photovoltaics. Specialization has led to many accomplishments within our disciplines, but these gains are in the shadow of larger, looming threats. In the case of design and architecture, the benefits of individual high-efficiency buildings are blunted by the large-scale wastefulness (and immense demand for fossil fuels) that comes with low-density development.
Now, in the early years of the new millennium, we face health challenges that are very different from those of a hundred years ago. Today, people are much less likely to succumb to a single infectious disease than they are to suffer from (often multiple) chronic diseases such as coronary artery disease, diabetes, or cancer. Though we are more prosperous than ever before, we do not seem to be happier for it, and rates of recognized mental illness such as depression and attention deficit/hyperactivity disorder are rising. Our specialized medical tools are sharply focused on the advances that have given us those hard-won extra five years of lifespan.
And yet, what threatens us most now is not how hard the ocean wave crashes on the shore, but the fact that the tide of chronic illness is rising out of control. Type 2 diabetes was practically unheard of in children just twenty years ago, and now it is estimated that up to 45 percent of children with newly diagnosed diabetes in fact have Type 2 diabetes. This rise in diabetes is due to the rapidly increased prevalence of obesity among children, which parallels the increases among adults. This rising epidemic of obesity has important consequences for myriad chronic diseases, including not only diabetes but also coronary artery disease, hypertension, stroke, gallbladder disease, and cancer. But though there is an impressive accumulation of research on the role of diet quality. We live in a modern world that is fueled by cheap high-fructose corn syrup, which adds calories but no nutritional benefit. Despite sound findings about the importance of physical activity, our environments prioritize automobile travel over walking. And despite an understanding that social networks among people protect against disease, we inhabit a state of collective isolation in place of community. The default reality of our environment simply does not reflect what we know to be optimal for our health.
We find ourselves now at a critical juncture when it comes to the health of the population. We can choose to work harder in advancing our specialized medical knowledge, which is the corner that we know best (and where we invest the vast majority of our resources). Or, we can take in the landscape of what is making us ill, and recruit help.
There is a parable widely shared in public-health circles. In this story, three doctors are walking along a river. They notice that there is a drowning victim floating downstream. One of the doctors jumps into the water for a heroic rescue, pulling the victim onto the riverbank to resuscitate him. Minutes later, they notice that there is a second person struggling in the river. The second doctor jumps into the river and rescues him. Exhausted, the first two doctors look up in disbelief as they see their colleague is headed uphill. “Where are you going? There’s surely another coming- it’s your turn next!” The third doctor replies. “You two can stay here if you like, but I am going up to find out why everyone is falling into the river.” Even the most diligent doctors can only do so much, and sooner or later, we must look upstream.
This story illustrates the most fundamental concept of preventive medicine, which is that examining and intervening in upstream causes of disease is critical in protecting health and combating illness. In 2004, B. Milstein created a sophisticated model of society’s health response to varying levels of health and illness, and a modified version of that model is provided here.’ In this model, moving along the central axis from left to right signifies going from a state of good health toward worsening illness and related complications. Movement toward the right is the “downstream” direction, and toward the left is “upstream.”
Like the doctors at the riverbank, nearly all of medical care is at this downstream end. Consider, for example, Type 2 diabetes. After years of exposure to high levels of blood sugar, complications such as blindness, nerve damage, kidney failure, foot ulcerations, and gangrene can develop. While a diabetic with kidney failure could begin lifelong renal dialysis or have a kidney transplant, both are examples of tertiary prevention in order to prevent dying from complications of their disease. If we go back in time to when that person had diabetes but didn’t yet have complications as a result of the condition, efforts to keep their blood glucose under control with medications and exercise would be examples of secondary prevention. Because diabetes has a genetic component, and having family members with diabetes increases one’s own risk of having the disease, we have a reasonable way to identify a large number of people at risk for diabetes. Lifestyle changes such as diet control, weight loss, and regular physical activity to get to an ideal body weight are examples of primary prevention that can help individuals at high risk for diabetes before they actually manifest with the clinical disease.
We need the technical expertise of planners and architects to come upstream with us, to design communities that foster physical activity and support the production of more healthful food. Our patients require cleaner air and safer roads and living communities that do not strain the human capacity (and need) for connection. The field of medicine, including public health, cannot address the many factors that are contributing to chronic illness. If we consider the health of a population more generally, as we did a century ago, we are reminded that there is more success when agencies are endowed with knowledge and responsibility for health protection. There are many stewards for the health of a society. Some attend to medical care. Some shape the space in which we live. Some oversee the responsible disposal of waste. Each one in this diverse assortment works with different tools, and success in the face of chronic disease will depend on using every last one in the toolbox.
Though the tools associated with moving upstream become progressively less medically sophisticated, the tasks at hand become complex in other ways. Milstein creates an important distinction between prevention and protection. Moving a population of people who are at risk for diabetes not only “out of harm’s way;’ so to speak, but actually toward the direction of positive health status represents a significant task of society’s health response, which is known as targeted protection. This active movement toward health-and not just the avoidance of disease-culminates with the concept of general protection, where society directly addresses the adverse living conditions that prevent vulnerable populations from becoming healthy or making healthy people vulnerable in the first place. Physical activity not only stems the progression to obesity and diabetes but also can confer health benefits such as increased self-esteem and improved mood. However, there are often many barriers to physical activity, such as concerns about safety and lack of infrastructure, facilities, or leisure time. Society is charged with treating these issues not just as civic duties but as health-protection responsibilities, however far removed the tools for health protection are from those available in medicine and even prevention.
Upstream, tools such as medications or even health education do not have the same power that they do farther down the river. However, here is exactly where those who plan and design can effect the most change. One area that has received much attention has been the role that design plays in people’s everyday active living. People who are physically active can decrease their risk for diabetes, obesity, cardiovascular disease, depression, and a great many other afflictions.
Physical activity seems to offer a protective survival benefit for obese individuals as well. Evidence from over one hundred thousand women in the “Nurses Health Study” in the United States showed that exercising at least three-and-a-half hours per week translated into a lower mortality risk for both lean and obese women. However, as of the last half century, it has become apparent that physical activity has become engineered out of our lives. Technological progress has automated many functions we used to do manually; sprawling design and increasing car dependence have translated into an overwhelming number of hours spent sitting rather than walking; and simple amenities such as sidewalks are now often erased from the streetscape of new housing developments. Smart design that prioritizes physical activity over the primacy of the automobile can contribute greatly to protecting people’s health.
Urban design shapes the immediate surroundings of each individual in a society at a microscopic level. But design patterns also operate at a macroscopic level. A large component of the obesity epidemic is the imbalance in our energy equation. As a society we expend too little energy and consume too many calories. How have we come to consume too much? Certainly, social norms about portion sizes have been important. But it is impossible to ignore the insidious role that land use can play in what ends up on our plates and in our stomachs.

    Even the most diligent doctors can only do so much, and sooner or later, we must look upstream.

Agricultural tax subsidies that promote vast overproduction of corn, soy, and other commodity crops cause the unhealthiest foods to be the cheapest, and the longer shelf life of these foods contributes to their ubiquity. These same farm land-use patterns give rise to concentrated animal feed operations, which in turn consume vast quantities of commodity grains, produce large amounts of waste (including greenhouse gases), and put productive agricultural land out of commission.
Though physical inactivity and inappropriate diet are health issues that garner much attention because of the obesity epidemic, they are by no means the only ones on which design and planning have tremendous potential influence. Asthma is a chronic medical condition that is tightly linked to air pollution: particulate matter and fumes such as carbon monoxide are well-known culprits, and ozone levels (which are rising because of an eroding atmosphere) are clear offenders as well. When asthma symptoms are out of control, there are more lost days at school and lost productivity at work in addition to hospital visits. Automobile traffic is the largest contributor to poor air quality, and car dependence and long-distance commutes to work are unfortunate consequences of lower-urban densities in sprawling urban design.



Paradoxically, historical mandates from public health and planning intended to separate residents from industry have contributed to increased levels of air pollution. Increased suburban sprawl not only leads to commutes in unpleasant traffic and to decreased overall quality of the air we breathe, but is also associated with higher numbers of fatal automobile crashes.
Injuries and deaths from automobile traffic are an area in which strategies and technical contributions from design and traffic engineering can offer wider upstream impact than medical care. Indeed, there have been advances in the emergency care of trauma patients, such as use of bedside ultrasound technology or faster CT scans to look for internal bleeding during initial evaluations. However, injury research has demonstrated that prevention can save more lives than medical care after a collision, and speed and volume of traffic playa critical role in occurrence and extent of injury to automobile passengers and pedestrians. Traffic engineers have designed environmental interventions that can, by design, enforce slower traffic and lower volumes of exposure to cars. Known as traffic calming, interventions such as speed humps, traffic circles, and other devices that narrow the roadway have been shown to decrease the incidence of traffic injuries: Finally, it is imperative to point out the role that design and architecture has in supporting social networks and community. Human beings are innately social creatures, and networks among people can have important health effects. People who have many social ties live longer than those who are more isolated. They are less likely to die of cardiovascular disease. They seem even to live longer with a cancer diagnosis.
Much research has shown that there is a definite health benefit associated with higher degrees of social networks, though it is still not completely understood why this is. Our living environments impact our relationships to one another-and manipulations of space and building materials can create degrees of privacy but also shades of isolation. The technical expertise to foster human connection in interior spaces and communities lies with architects, not health-care providers. The art of medicine reaches its highest potential for healing when humanity-the patient and the family-is an equal partner with technology. This offers an important lesson for design.

Originally printed in Living Green: Architecture and Planning.


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