Building a healthier future: the built environment and public health

Adrian Harvey, head of policy at CABE, explores measures taken to promote public health in the built environment.

When it comes to health and illness, doctors and hospitals are a crucial but ultimately small part of the story. The capacity to treat the sick is a necessary one, but in this case, as the old adage says, prevention is better than cure. From the Romans to the Victorians, public health has been recognised as the foundation of healthy cities - often literally, in the case of the subterranean architecture of effective sewerage and clean water beneath our streets. The importance of public health is also recognised today, of course. But a comparison of the resources and attention applied to public health initiatives with those devoted to primary and acute care shows we are very much bolting stable doors.

To its credit, the Government is shifting the focus from treating sickness to promoting health. And this 'new public health agenda' represents something of a shift in emphasis. Traditionally, public health was concerned with environmental factors - reducing exposure to infection and pollution, for example - to be dealt with through technical interventions, such as vaccination and sewerage. These measures, in the UK at least, have been largely successful and over the past two generations, the attention of public health professionals has shifted to behavioural and lifestyle issues. Smoking has been the primary focus of this approach, but increasingly obesity and heart disease are the targets of the new public health debate.

None of this is to deny the continued threat of infection. From HIV to vCJD to MRSA, the threat of infectious disease is never far away. But these are not the big killers. As the second Wanless report noted, protection against disease has been a very effective part of public health; obesity and smoking are now the most important determinants of future health and the main challenges are about changing behaviours, something both practically and theoretically difficult in a free society.

In responding to these challenges, Wanlesss argues that the main levers available to a democratic government are taxes, subsidies, service provision, regulation and information. Shaping the built environment is barely mentioned. Yet even the late Victorian municipal leaders recognised the importance of public parks and public spaces in encouraging healthy behaviour amongst their citizens. In this paper, I want to argue that, in our increasingly urbanised society, the built environment has a vital part to play in the new public health debate, particularly in relation to obesity.

Calories in, calories out

While the war on tobacco continues its long attrition, smoking has been surpassed as the biggest killer by the diseases associated with over-eating and under-exercising. Among these diseases of plenty and leisure are coronary heart disease, diabetes, and cancer, as well as osteoporosis, back pain and osteoarthritis, and mental health problems. Underpinning many of these conditions is obesity.

At the centre of the growth in obesity is a simple equation: calories in, calories out. If the former is greater than the latter for sustained periods, weight gain and ultimately obesity are inevitable. Over the past 50 years, a major transition has occurred on both sides of this equation, with the result that for most people in the industrialised world, the tendency towards obesity is the default condition.

On the input side, there has undoubtedly been a dramatic shift in the diet of Europeans since the 1950s. From the end of food shortages to today's ready availability of richer and more processed foods, there is now effectively no external limit on the calories that can be consumed. But this alone does not account for the current obesity epidemic; it is the corresponding activity shift that has taken place, with people burning up fewer calories, that has really imbalanced the equation.

Much is made of the importance of sport and exercise in an active lifestyle, and this has led for example to high levels of gym membership. But the decrease in overall activity has not been caused by a decrease in participation in organised sports. Most calories in the past were burned in the work place and through 'getting around'. The increasingly sedentary nature of work, transport and leisure - with the decline in manual work, widespread car ownership and usage and the prevalence of inactive leisure pursuits - has had a much more profound impact on levels of physical activity. On average, European adults now expend about 500 calories less energy a day than they did 50 years ago; in the UK , changes in lifestyle over this period have led to reduced physical activity equivalent to running a marathon each week. For children, the ability to burn off calories by informal exercise, either in outdoors play or in getting around have diminished more starkly through a combination of perceived traffic and other dangers, and the availability of parental 'taxis'. The result is that whereas in the 1970s, 90% of children walked to school, only 10% do now.

So promoting sport alone is unlikely to rebalance the equation. Too little time is available in busy lives - for most people, the loss of a marathon a week through lifestyle activity is a great deal to replace through jogging. Certainly, sport has a part to play, as does encouraging healthier diets. But we need to find ways to encourage 'lifestyle activity' if we are to find a sustainable response to concerns about obesity.

Building in lifestyle activity

The built environment has a huge potential to support this. The way we design and construct our buildings and public spaces - and the way we maintain and mange them - can have a huge impact on promoting greater physical activity. There are three areas where specific approaches to design in the built environment can have a direct impact on physical activity: building design, streets and neighbourhoods, and parks and green space.

Building design

At the most basic level, the provision of showers and other facilities in offices can encourage people to cycle to work, or to take exercise before or during the working day. But there are more intrinsic aspects of building design that can modify and shape our behaviour. The increasing invisibility of stairs in many commercial, public or even residential buildings is a case in point. If you think about the lobby of recently built offices, hotels and other public and quasi-public buildings, one of the consistent elements is the mysterious absence of stairways. They exist (fire regulations demand them) but they are more often than not invisible, hidden away, while banks of lifts signal that the way to move around the building is by standing still. Compare this with buildings of previous generations, where not only were stairs visible, they were celebrated as a central and grand aesthetic element of the building.

Of course, the technological changes - including lift technology itself - that have allowed for much taller buildings, coupled with the entirely legitimate demands of equal access, mean that stairs cannot be the only or even primary means of moving between floors. But it is hardly surprising that some people without mobility difficulties will still use lifts to move just a couple of floors if stairs are hidden, unattractive and made inconvenient to use.

Streets and neighbourhoods

If we want to encourage people to walk and cycle around their neighbourhoods, rather than use their cars, we have to make our streets safe, attractive and fit for purpose. At the most fundamental level, we need to rebalance the design of street layout so that it meets the needs of all users, not just drivers. Too many recent housing developments are built effectively as compounds, with one (road)way in and out, usually marked by a roundabout and limited, if any, footpaths. Retail parks are even more forbidding. Even the most determined pedestrian has to battle with a hostile environment, clearly designed precisely to discourage their presence, often in the interests of road safety. And usually the street layout forces pedestrians to take lengthy diversions from the logical, direct route, creating further discouragement.

These features seriously undermine the potential connectivity between areas which is essential if we are to encourage people to use alternatives to the car for local journeys. A great deal has been done, in fact, to clam traffic and improve the usability of some neighbourhoods, not least the excellent Home Zones initiative. But such 'safe areas' have to be linked if we are to create safe routes to school, work or the shops. This does not mean more soulless walk ways and underpasses to separate pedestrians and others from cars; rather we need to find ways to produce the kind of shared streetscape that exists in some of our more established urban areas.

There are good examples in the Netherlands and Denmark of radical redesigning of road layout and changes in priority which appear successful. In blurring the boundaries between 'traffic' and 'people', by removing road signs and markings, levelling pavements with road surfaces and making other physical changes to the street scene, driver behaviour has been modified. Because drivers have to rely on eye contact to negotiate rights of way they feel more vulnerable and so take more care resulting in lower speeds and reduced accidents. While probably a step too far for the UK , interesting experiments, such as the new layout of High Street Kensington, could show a way forward.

Of course, traffic is only one factor that discourages people from using their streets and public places. Vandalism, crime and the fear of crime combine to produce insecure and unattractive places. There is a good understanding now of how urban design can reduce crime and limit vandalism, which goes well beyond simply 'bullet-proofing'. But as well as safety and security, we need attractive and clean public spaces that people can feel happy to spend time in. This is in part a design question, but - as with crime - it is as much a question of maintenance and management, repairing damage and putting eyes on the street.

Parks and green space

Parks and green space can be seen as the 'gyms' of lifestyle activity. They provide open space where people can be active, from walking the dog to throwing a Frisbee, from flying a kite to kicking a ball. As with other public space, the importance of good design and maintenance is critical. A park can quickly become a no-go zone if neglected, but even a well maintained park that does not provide spaces for different uses and users will not play its full part.

The built environment has health impacts beyond obesity, of course, and this is particularly true of parks and green space. For example, there is a great deal of evidence that well designed and accessible green space can contribute to better mental health outcomes; proximity to nature and greenery can relieve some of the stress of city living, and good public space can foster beneficial social interaction, which adds to well-being. However, this requires the creation of spaces for civic engagement, rather than spaces per se . Unfriendly, insecure public space can actually undermine levels of social interaction and trust. We need to design defensible, manageable public spaces, as the "quality of people's relationships… is critically mediated by the extent to which they are able to regulate their interactions with them ".

Building healthy neighbourhoods

The Government's medium term priority for health is to move from treating disease to supporting people in leading healthy lives. Yet, in the shift from an environmental to a behavioural public health framework, the importance of the built environment risks being overlooked. We need a greater recognition that the 'physical capital' stored in our towns and neighbourhoods can be used to promote healthier lifestyles. The quality of the places and spaces where we live, work, learn and play is a major determinant of how active we are, providing the landscape within which we make choices. Changing diets and promoting more active lives through other means are essential, but unless we also design and build better places, the task becomes that much harder.

This essay represents the author's views and not necessarily those of CABE.