Making Healthy Places

You may know that your zip code is a pretty good indicator of your life expectancy. But can the places where we live actively improve our health and well-being? The editors of a new volume, Making Healthy Places, Second Edition believe they can. Here, Laurie Mazur of Island Press talks with editors Nisha D. Botchwey, Andrew Dannenberg, and Howard Frumkin about the new volume. They explore current challenges—from COVID to gun violence and climate change—and discuss ways to design and build places that support the health of people and the planet.

Laurie Mazur: What has changed in the field since the first edition of Making Healthy Places came out in 2011?

Howard Frumkin: The field has seen enormous growth: more courses, more degree programs, more job openings. There's been an explosion of research and deeper understanding of the relationship between the built environment and health. 

There are also important contextual changes that influence the field. For example, there's a lot more attention to racism and inequity in this country. Tragically, that was triggered by murders and other very public abuses, but that in turn has focused attention on inequities in the built environment—issues such as the relationship between historical redlining and contemporary housing and park inequities. 

There have also been tremendous technical advances: a leap forward in the internet of things, in the instrumentation of cities, and in the collection and analysis of data such as Google Street View images using big data techniques. So, we know a lot more about human habitat.

Also, the climate crisis has worsened.  Political polarization and dysfunction are deepening the divisions between cities and rural areas and between cities and states. There’s an intensification of the housing shortage. And last, of course, is the pandemic, which highlights the potential of the built environment to aggravate the spread of infectious diseases or control them. 

Nisha Botchwey: Additionally, the current volume has a significant increase in the diversity of contributors by race, gender, discipline, and geographic location. And this edition takes a far more global approach than the first edition. We discuss the impact of the pandemic on health and the built environment.

Mazur: Has COVID slowed progress toward making cities healthier? 

Frumkin: It has both slowed and advanced progress. There’s greater emphasis on outdoor spaces for recreation, and that has led to a greater appreciation of parks and public spaces. There's been some re-envisioning of the way public space can be used, such as repurposing streets from vehicular traffic to walking, cycling, commerce, even classrooms. There’s more bicycling and walking in many cities.  These are positive outcomes. 

But there's also been a reduction in transit use—a step backward. The shift toward remote work is a mixed bag. It tends to make people want bigger homes, which drives up the demand for space. It’s also driven some migration from cities to suburban and rural locations, which may mean more sprawl. 

There's less demand for commercial space in traditional business districts, which affects the vitality of life and economic opportunities, and therefore the health of the people whose livings depend on vibrant downtowns. So, the pandemic has triggered a very complex set of phenomena: some positive, some negative and in almost every case it’s too soon to tell how they'll play out in the long term.

Mazur: How can cities be designed for a hotter, more dangerous climate—and are there cities that are getting it right?

Frumkin: Not only are many cities getting it right, but cities are doing some of the most exciting and innovative work. Many are way ahead of national governments, which tend to be slower to act. The C40 identifies more than 700 cities in 53 countries that have made net zero commitments by 2050. That's a big deal. 

On the mitigation side, San Francisco banned natural gas in new buildings; Petaluma, California banned new gas stations; Atlanta is requiring more EV infrastructure. Copenhagen, Amsterdam, and Minneapolis have put in tremendous amounts of bicycle infrastructure. Others, like Singapore and Bogotá, have sophisticated transit systems to get people out of cars. 

On adaptation, there are tree-planting programs in Los Angeles and Phoenix to help cool the streets; green storm water management in New York City and Seattle; a heat action plan in Phoenix. Miami just appointed a chief heat officer, which I predict will be more and more common. So, cities are, in many respects, leading the way.

Mazur: For obvious, tragic reasons, there is a lot of focus on America's epidemic of gun violence right now. Can cities be designed to curb violence?

Andy Dannenberg: One approach that's been around for decades is “crime prevention through environmental design.” There is less crime when people can see out through windows and you can see into windows of storefronts, for example. A classic study done in the Robert Taylor homes in Chicago showed that places with green space and trees had less interpersonal violence and aggression than places that didn't. 

Mazur: Density is a goal of new urbanist planning, but crowding can be detrimental to mental health. Can we have one without the other?

Frumkin: There’s a difference between density and crowding. Density usually refers to an objective measure of how many people live and work on a unit of land. Crowding is a little more complex: it can be measured by how close people are to others at a given point in time. Crowding is a subjective sensation: it's your perception of, and psychological response to, proximity to other people. That varies by culture, and from person to person. Crowding can trigger inappropriate behaviors, including aggression. 

But we know that good design can reduce the sensation of crowding, even in the context of dense urban places. We know how to build ample hallways and staircases and provide adequate transit capacity—running enough trains so that people don't have to cram in. 

We also need to provide places of respite, such as parks. We've talked about parks in several contexts: cooling cities, mitigating violence, providing respite from crowding. Certain solutions—parks and green space primary among them—serve multiple purposes. Solving multiple problems at once is one of the keys to strategies for health in the built environment.

Mazur: You have talked about the superpowers of green spaces and parks. But parks can also spur what’s called “green gentrification,” right?

Dannenberg: Green gentrification can happen when you add parks and green space, particularly in a lower-income area. The intent it is to improve the neighborhood for the people living there, but the unintended consequence is that property values rise, and the very people you're trying to help may be priced out of the market and be displaced. But the risk of gentrification is not a reason not to fix a neighborhood.

A range of policies can help—from rent control and housing subsidies to density bonuses that allow developers to put in more units if they include affordable housing. Community land trusts can preserve land from high-priced development, and cities can invest directly in building affordable housing. 

Frumkin: Community engagement and empowerment are key to improving a neighborhood, whether it's parks or any other improvements that may propel economic development. We have good examples—from the 11th Street Bridge project in Washington to India Basin in San Francisco, where holistic approaches include parks and green space, but also deep community engagement and empowerment, small business support, affordable housing, job training, and school strengthening. Approaches such as these can greatly reduce the chance that anybody will be displaced by gentrification.

Botchwey: This is where a Health Impact Assessment—a tool that looks at a proposal from a health lens—is quite helpful. Incorporating a broader perspective on the impacts of a development or improvement of a park allows for policies, systems, and frameworks to be considered that protect against displacement and mitigate against negative outcomes. This way, the people who stand to benefit most from those investments can be there for the fruit of that investment.

Mazur: The book explores the importance of social capital—the ties that bind people and communities together. How can the built environment strengthen those ties?

Frumkin: Social capital is enormously important. It's a predictor of health, wellbeing, happiness, and disaster resilience. So, everything we can do to help bind people together more closely and strengthen communities is a good thing. We know a lot about how to do that. Walkability and mixed-use development give people the opportunity to mix and mingle and get to form relationships. 

Having great public spaces is also very important. This is what the sociologist Eric Klinenberg calls social infrastructure and Ray Oldenburg calls “third places.” These include parks, plazas, sidewalks, and even indoor spaces, such as coffee shops, bookstores, and community centers. 

We know that exposure to nature demonstrably increases prosocial behavior. Nature seems to soften us and open us up to social connections with each other in ways that other environments don't. And shifting from automobiles to other modes of commuting helps promote social capital, partly because walking builds connectedness and partly because driving on heavily trafficked commuting routes often makes people angry and hostile.  

Mazur: You write about building a pipeline of practitioners who connect the dots between the built environment and health. Are academic and other institutions doing what they need to do to nurture those practitioners, and is there more to do?

Botchwey: We've seen a significant increase in the number of university courses at the intersection of health and the built environment. And you see groups like the Urban Land Institute, American Planning Association, American Public Health Association, American Institute of Architects, and Transportation Research Board providing continuing education for their members at this intersection. Yet we have so many individuals in the field today who want to have a positive impact in designing, making, and maintaining healthy places, but they don't have the tools beyond a one- or two-day continuing education offering, and they want more. 

We can expand the education of current professionals through university partnerships with these fantastic organizations – APA, APHA, ULI and others—to provide targeted training on topics like green infrastructure, equity, Health Impact Assessments, and more. We can provide deep-skill training for these individuals so they can collaborate with diverse partners, communicate and think across geographies, and adapt to whatever conditions and needs they're facing in their community.

We also need programs in K-12 schools that introduce students to the intersection of health and the environment. One example is UN Habitat’s use of Minecraft. If you know any pre-teen, you know that Minecraft is a space where they spend a lot of time. UN Habitat is using Minecraft to engage them in healthy design thinking to create their own communities and neighborhoods. It’s a great use of technology for communities around the globe, not just in high-income countries. 

Mazur: Speaking of technology, how will new tech like AI and the internet of things affect how people interact with the built environment?

Dannenberg: “Smart cities” are capturing more and more data on who's doing what, when, where, why, and how. There's this old line that says, “what gets counted counts.” For years, we've counted automobiles to measure  traffic volume. So, they keep widening the roads. Now we have better bicycle and pedestrian counters that could be used to improve infrastructure for biking and walking.   

Mazur: You end the book on a hopeful note, by asking a diverse group of thought leaders what gives them hope for the future of urban design and planning. So, what gives you hope for the future of this field?

Frumkin: There are great ideas emerging all the time: inventive solutions, creative improvements in how space is used, new economic arrangements. And there are great new technologies, especially in the climate space with the development of electric vehicles and batteries, and incredible price reductions for renewable energy. 

Young people give me hope: their love for cities, their activism and optimism about the future, their impatience with old solutions that don't work and their demand for quick action. 

Botchwey: Dick Jackson, one of the editors of the 2011 edition, said in the foreword, “Just because it is this way, doesn't mean it has to be this way.” There’s an opportunity to innovate, to embrace the impatience of youth, and use the skills and tools of the current society to make a better society, and healthier places. That's what excites me—knowing that we are not stuck. But change requires action and creativity; it’s not just going to happen because we think about it.

Laurie Mazur is a writer and editor for the Island Press Urban Resilience Project.

Nisha Botchwey, PhD, MCRP, MPH is the Dean of the Hubert H. Humphrey School of Public Affairs at the University of Minnesota and the Russell M. and Elizabeth M. Bennett Chair in Excellence in Public Affairs. She previously served as Associate Professor in Georgia Tech’s School of City and Regional Planning, adjunct professor of Public Health in Emory University’s Rollins School of Public Health, and Associate Dean of Academic Programs at Georgia Tech Professional Education. She coauthored Health Impact Assessment in the United States and multiple peer reviewed publications.
 
Andrew L. Dannenberg, MD, MPH, is an Affiliate Professor in the Departments of Environmental and Occupational Health Sciences and Urban Design and Planning at the University of Washington. Before coming to Seattle, he served as Team Lead of the Healthy Community Design Initiative at the U.S. Centers for Disease Control and Prevention (CDC). He served as lead editor of the first edition of Making Healthy Places.
 
Howard Frumkin, MD, MPH, DrPH, is Professor Emeritus of Environmental and Occupational Health Sciences at the University of Washington School of Public Health and senior vice president of the Trust for Public Land.  He previously served as head of the “Our Planet, Our Health” initiative at the Wellcome Trust in London, as Dean of the University of Washington School of Public Health, as Director of the CDC National Center for Environmental Health and Agency for Toxic Substances and Disease Registry (NCEH/ATSDR), and as professor and chair of Environmental and Occupational Health at Emory University’s Rollins School of Public Health. In addition to the first edition of Making Healthy Places, his previous books include Planetary Health: Protecting Nature to Protect Ourselves and Planetary Health: Safeguarding Human Health and the Environment in the Anthropocene.