Design as Preventative Medicine


Slowly but surely, American cities are getting reacquainted with how design and public health are intertwinedBy Brooks Rainwater

Director of AIA Public Policy

The history of public health in America is intrinsically linked to the design of place. From the beginnings of the urban public health movement in the mid-1800s, this link was demonstrated through efforts that focused on improving sanitation in tenement buildings, which were advanced by design luminaries like Frederick Law Olmsted. Even more notably, Olmsted designed New York’s Central Park to give the residents of a dirty and crowded city acres of green space for physical activity and recreation.While the relationship between public health officials and the design community has waxed and waned over the years, it is now moving toward a collaborative approach focused on results-based analysis. This approach seeks answers both on the epidemiological side and the design side, a recognition that the design of the built environment can support activity and wellness.

Once again, cities can focus on strategies that reduce the incidence of sickness in the first place by making health by design a key policy choice. As such, the AIA report “Local Leaders: Healthier Communities Through Design provides a roadmap for cities and towns looking to help their populations stay healthy by creating environments that enable and encourage physical activity.

What this report reveals is that design is one of the most effective and cost-conscious preventative medicines available—a medicine that has been overlooked for far too long.

Design-derived public health solutions exist on a multitude of levels: from the design of single buildings, to the composition of neighborhoods, to the infrastructure that binds together entire cities. Typical suburban commuters miss out on opportunities to integrate physical exercise into their days when they drive from their mass-transit-starved neighborhoods to office buildings downtown. They might be able to walk to a far-flung bus stop, if they’re lucky enough to have sidewalks. Once at work, they might miss another opportunity for physical activity by bypassing stairs that are inaccessible, unappealing, or poorly integrated with the building, and instead use the elevator.

After decades of creating places that actively discourage physical activity, key health barometers suggest that America is headed in the wrong direction: toward diabetes, cardiovascular disease, increasing incidence of cancer, and other chronic diseases. The Centers for Disease Control (CDC) reports that one third of adults and nearly one in five children and adolescents are now obese, with 60 and 70 percent, respectively, not meeting its recommended levels of physical activity. The CDC also estimates that three quarters of U.S. spending on healthcare currently goes toward treating chronic diseases, which are now the leading cause of death and disability in the U.S.

But research has shown that even the most modest design-related change in habits can improve people’s quality of life and drastically reduce the risk of disease.

—Data from Active Living Research show that men who climb at least 20 floors per week (just four per workday) can lower their risk of stroke and death from all causes by 20 percent.

–People who live in communities with sidewalks on most streets are 47 percent more likely to get moderate-to-vigorous physical activity at least five days a week for at least 30 minutes each day.

–The American Journal of Preventive Medicine shows that 30 percent of people who use public transit are active for 30 minutes or more each day.

–The CDC Community Preventive Services Task Force, which specializes in studying the relationship between the built environment and health, reviewed 12 studies focused on livable mixed-use communities, comparing the behavior of residents in car-centric areas with those in urban communities. They found that the median improvement in some aspect of physical activity for livable urban communities was over 160 percent. Other studies have demonstrated that living in a community with a 25 percent better land-use mix is associated with a 12 percent reduction in the likelihood of obesity.

The good news is that the solutions to these problems are cities filled with things that people already like: walkable and mixed-use neighborhoods, transportation options, and greener (less polluting) buildings. The bad news is that this isn’t purely a design issue. Change can only come about in tandem with forward-looking policies, which are beginning to percolate throughout the country.

One example is New York City’s Fit City conferences, which have resulted in healthy design solutions for buildings and streets. Funding from the CDC allowed the city to advance the training of over 3,000 design professionals, who are implementing the city’s Active Design Guidelines in projects across many municipal departments. Large-scale park projects like the High Line, which transform disused industrial infrastructure into active green park space, further elucidate Olmsted’s belief that public parks are the “lungs of the city.”

Nashville is another city where civic leaders have linked design and health. In 2010, Mayor Karl Dean signed an executive order formalizing a plan to create complete streets across the city, with $12.5 million set aside for sidewalks, $3 million for bikeways, and more than $10 million for mass transit. The city is also encouraging transit-oriented development like the LEED for Neighborhood Development project The Gulch.

Milwaukee has looked to improve its health by investing $740 million in public and private money to redevelop the blighted Menomonee Valley, a disused brownfield area that was formerly home to the city’s heavy industry. Menomonee Valley Partners is spearheading the effort to redevelop and reimagine these derelict properties as vibrant urban neighborhoods. The outcomes of this investment include a dramatically reduced level of environmental pollution, over 1 million square feet of healthier green buildings, 7 miles of trails, 35 new tenant companies, and over 4,700 new jobs.

The city of Austin is prioritizing transit-oriented development with pedestrian and bike-friendly infrastructure. It’s one of six cities to receive federal Green Lane Project funding that will help integrate walking and biking trails into new projects. The recently opened MetroRail Red Line commuter rail and proposals for a new inner-city Green Line light rail weave greater connectivity through the city, with mixed-use communities beginning to arise along its route to the east of downtown. Finally, the city is spending $50–60 million to redevelop Austin’s Waller Creek district, into a High Line–style linear urban park.

Active lifestyles rely in large part on expanding the options for when, where, and how people can live, work, and play. The promotion of livable development patterns that are closer to transit, shopping, restaurants, social services, and community amenities are an essential part of any comprehensive solution for healthier cities, and a considerable departure from the way many towns and neighborhoods are still planned.

It’s typical to think of this unhealthy, sprawling car-centric infrastructure as the deeply entrenched status quo, but in reality it’s only about 100 years old. Cities have been planned with dense, walkable, mixed-use neighborhoods for most of human history purely out of necessity. The advent of the automobile and the far-off suburbs they enabled radically changed the way cities were built, sacrificing (unsustainable) convenience for healthy and vibrant urbanism. It might seem like public health and design-savvy civic leaders need to tear down and rebuild the entire way people interact with their towns and cities, but what these groups are really asking for is a bit of institutional memory, and not a particularly long one at that.


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