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Making Healthy Places
Designing and Building for Health, Well-being, and Sustainability
By Andrew L. Dannenberg, Howard Frumkin, Richard J. Jackson ISLAND PRESS
Copyright © 2011 Andrew L. Dannenberg, Howard Frumkin, and Richard J. Jackson
All rights reserved.
ISBN: 978-1-61091-036-1
CHAPTER 1
An Introduction to Healthy Places
Howard Frumkin, Arthur M. Wendel, Robin Fran Abrams, and Emil Malizia
Key Points
• The environment consists of the external (or nongenetic) factors—physical, nutritional, social, behavioral, and others—that act on humans, and the built environment is made up of the many aspects of their surroundings created by humans, such as buildings, neighborhoods, and cities.
• Health can be defined as complete physical, mental, and social well-being. This definition extends beyond the absence of disease to include many dimensions of comfort and well-being. While clinicians care for individual patients, public health professionals aim to improve health at the level of populations.
• The design professions include urban planning, architecture, landscape architecture, and transportation planning. Each of these focuses on an aspect of the built environment.
• Both the public health profession and the design professions took modern form during the nineteenth century, in response to rapid population growth, industrialization and urbanization, and the resulting problems of the urban environment.
• Public health practice is evidence-based, relying heavily on surveillance and data collection.
• Leading causes of morbidity and mortality include heart disease, cancer, diabetes, stroke, injuries, and mental illness. Many of these are related to community design choices.
• Even though public health has evolved as a distinct field from planning and architecture, these domains have numerous opportunities to collaborate, and this collaboration can lead to improved health, well-being, and sustainability in many ways.
Introduction
The citizens of Bay City were fed up. Getting across town to go to work or shopping had become an ordeal; the streets seemed perpetually clogged, and it was impossible to find parking. For people who had bought homes in the suburbs, life seemed to take place more and more in their cars—chauffeuring children to school and soccer games, driving long distances to stores, and worst of all, commuting to work. Meanwhile, the Bay City Courier reported a steady drumbeat of bad news: air quality was worsening, the health department reported a growing epidemic of obesity, and nearly every day there was a tragic car crash that killed or injured somebody.
The mayor, the city council, and the transportation department teamed up to address some of the quality of life problems. They envisioned an ambitious program of road building. Key components included a six-lane arterial highway along the bay shore, two new arterials crossing the city, and thousands of new parking spaces. Although this plan would destroy historic and beautiful bay views, sever a few older neighborhoods, and remove half of a prized city park, it would move traffic more effectively.
But the roads were never built. The local health department, urban planners, architects, physicians and nurses, park officials, historic preservationists, environmentalists, and neighborhood associations all came together in a remarkable display of unity. The coalition they formed proposed an alternative plan, one that centered on extensive pedestrian and bicycle infrastructure, investments in bus and light-rail transit, mixed-use development along the bay shore, and investments in parks throughout the city. The plan emphasized equity and included policies to avoid displacing established communities and to ensure a mix of housing types. The cost of this alternative plan would be slightly less than that of the combined road projects, and it would create a similar number of construction jobs.
The alternative plan won the day. It took more than twenty years to implement, and it required considerable political leadership to stick with it during the inevitable cost overruns and budget crises. But after twenty years, a remarkable series of changes had ensued.
The proportion of people walking or biking to work had risen from 3 percent to 14 percent, and the proportion of students walking or biking to school had risen from 5 percent to 21 percent. Transit ridership had increased more than fourfold. Traffic volume had actually decreased, air quality had improved marginally, and the epidemic of obesity had stabilized and was showing signs of reversing. Because many young families had moved into the city, the public schools had improved considerably and were now among the best in the state. And Bay City had become a destination city, attracting several prized high-tech and biotech firms because of its well-recognized commitment to environmental sustainability, health, and quality of life.
This is a book about healthy places—places in which people can grow up, live, work, play, study, pray, and age in ways that allow them to be safe and healthy, to thrive, and to reach their full potential.
A healthy place can be very small, such as an ergonomically designed chair that reduces strain on the back, shoulders, and arms. A healthy place can be immense, such as a planet with a relatively stable climate that allows ecosystems, forests, waterways, and farms to remain balanced and productive, which in turn allows humans to pursue their lives in relative safety, security, and predictability. The healthy places we explore in this book are intermediate in scale, ranging from buildings to metropolitan areas. Nearly all of these places are designed and created by people. In this introduction we define some basic concepts in environment, health, planning, and design. We note that these are human enterprises with a long history—that our forebears have been working toward healthy places since before the dawn of written history and that the modern health and design professions took shape during the transformative events of the last two centuries.
In Merriam-Webster's Collegiate Dictionary, the first definition for environment is straightforward: "the circumstances, objects, or conditions by which one is surrounded." The second definition is more intriguing: "the complex of physical, chemical, and biotic factors (as climate, soil, and living things) that act upon an organism or an ecological community and ultimately determine its form and survival." From a human health perspective, the environment includes all the external (or nongenetic) factors—physical, nutritional, social, behavioral, and others—that act on humans. The built environment consists of those settings designed, created, and maintained by human efforts—buildings, neighborhoods, public plazas, playgrounds, roadways, and more. Even seemingly natural settings, such as parks, are often part of the built environment because they have been sited, designed, and constructed by people. The built environment depends on supporting infrastructure systems for such necessities as energy, water, and transportation, so these systems are also considered part of the built environment.
A widely accepted definition of health comes from the 1948 constitution of the World Health Organization (WHO 2003): "A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." This broad definition goes well beyond a narrowly biomedical view to include many dimensions of comfort and well-being.
Many health professions exist. Some are clinical and focus on providing health care (and preventive services) to individuals; examples include medicine, nursing, dentistry, physical therapy, and occupational therapy. Other health professions operate at the community level, focusing on populations more than on individuals. These professions collectively make up the public health field. Public health is dedicated to fulfilling society's interest in assuring conditions in which people can be healthy, conditions that range from effective health care systems to healthy environments. Public health professionals pursue this mission by assessing and monitoring community health to identify problems, developing public policies to solve these problems, and working to ensure access to appropriate and cost-effective care, including preventive care. These functions have been codified as the "ten essential services of public health" (Figure 1.1), a common framework for health departments and other service providers (CDC, National Public Health Performance Standards Program 2010).
Environmental health, a subfield of public health, focuses on the relationships between people and their environments. It aims to promote healthy environments and to control environmental hazards. Traditional environmental health focused on sanitation issues, such as clean water, sewage, waste management, food safety, and rodent control. In recent decades, environmental health has expanded its scope to address chemical and radiological hazards, such as pesticides and air pollution. And most recently, environmental health has addressed cross-cutting issues, including the built environment, climate change, and sustainability—topics that are addressed in this book.
The design professions are those that focus on how things are made. There are many design professions, ranging from industrial design (consumer products) to graphic design (visual images). In this book we focus on several design professions whose work relates to the built environment. Each has specific training pathways, professional organizations, and areas of specialization (Table 1.1).
Urban planning (also known as town planning, city planning, or city and regional planning) is dedicated to envisioning, planning, designing, and monitoring the layout and function of cities. Transportation planning (along with the closely related field of transportation engineering) focuses on transportation infrastructure—not only streets and highways but also mass transit and the infrastructure for nonmotorized travel, such as sidewalks and bike paths.
Architecture is the design profession that operates at the scale of buildings. Architects may specialize in a certain class of buildings, such as commercial or residential structures or, even more specifically, hospitals or laboratories. Many architects now incorporate green building principles, such as energy conservation and the use of renewable resources.
Figure 1.1 Public health professionals focus on providing ten essential public health services designed to maintain and improve health in communities (CDC, National Public Health Performance Standards Program 2010).
Civil engineering is the field of engineering focused on the design, construction, and maintenance of built environment elements such as bridges, roads, canals, and dams. A related field, environmental engineering, emphasizes environmental performance. Civil and environmental engineers might collaborate in designing storm water systems and working to prevent erosion, conserve water, and reduce contamination of rivers and streams—all goals that directly or indirectly promote human health.
Landscape architecture focuses on the arrangement of natural and built elements on the land, from the design of parks to plans for large-scale watershed management.
All of these professions are related. The health professions, in promoting health, may consider features of the built environment such as land use or transportation strategies. The design professions may identify health as a key goal of their work. In this book we explore why and how these professions need to come together to achieve safe, healthy settings for all people.
Health and the Built Environment: Ancient Origins
Designing and building safe and healthy places must have been a goal for our earliest ancestors (even if they did not put it in quite those terms). The elements can be harsh, and we know that our forebears sought protection in caves or built crude shelters.
The greatest of ancient civilizations were built according to careful and complex plans, from the scale of buildings to the scale of vast cities. In ancient city remains across the world, there is evidence of gridlike, hierarchical street arrangements, of monuments and public spaces, of terraces carefully built to manage water flow, and of sophisticated building designs. Many of these achievements reflected efforts to protect health.
Modern health challenges in the built environment often have ancient origins. In the ruins of past civilizations from India to Rome and from Greece to Egypt to South America, archaeologists have found the remains of water pipes, toilets, and sewage lines, some dating back more than 4,000 years (Rosen [1958] 1993). Indoor air quality has been a long-standing challenge; there is evidence in the sinus cavities of ancient cave dwellers of high levels of smoke in their caves (Brimblecombe 1988). Mold was apparently a scourge in some ancient buildings, described in vivid detail in the Old Testament as a greenish or reddish "plague" on walls (Leviticus 14:33–45). European history was changed forever when rats spread the Black Death in fourteenth-century cities (Cantor 2001; Kelly 2005). Modern cities continue to struggle periodically with infestations of rats and other pests (Sullivan 2004), whose control depends in large part on modifications to the built environment.
Birth of Modern Public Health
Modern public health took form largely during the age of industrialization, with the rapid growth of cities in the seventeenth and eighteenth centuries. "The urban environment," wrote one historian, "fostered the spread of diseases with crowded, dark, unventilated housing; unpaved streets mired in horse manure and littered with refuse; inadequate or non-existing water supplies; privy vaults unemptied from one year to the next; stagnant pools of water; ill-functioning open sewers; stench beyond the twentieth-century imagination; and noises from clacking horse hooves, wooden wagon wheels, street railways, and unmuffled industrial machinery" (Leavitt 1982, 22). Epidemics of cholera, typhoid, yellow fever, and diphtheria occurred with regularity. Social reformers, scientists and engineers, physicians, and public officials responded to these conditions in various ways across the industrializing nations (for full historical accounts see Rosen [1958] 1993; Duffy 1990; Tarr 1996; Melosi 2000).
Many interventions by early public health leaders focused on the built environment. For example, regular outbreaks of cholera and other diarrheal diseases in the eighteenth and nineteenth centuries (Rosenberg 1962) highlighted the need for water systems with clean source water, treatment including filtration, and distribution through pipes. Similarly, sewage management became a necessity, especially after the provision of piped water and the use of toilets created large volumes of contaminated liquid waste (Duffy 1990; Melosi 2000).
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Excerpted from Making Healthy Places by Andrew L. Dannenberg, Howard Frumkin, Richard J. Jackson. Copyright © 2011 Andrew L. Dannenberg, Howard Frumkin, and Richard J. Jackson. Excerpted by permission of ISLAND PRESS.
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