Landscapes of Risk and Protection
Public health has come to recognize place as an important determinant of health. While assessments of health have traditionally emphasized individual behavior and risk factors, we now understand that risks and protection are also socially determined. Risk is the “probability of damage or harm in a specified period” and is elevated in places lacking protection or resilience (Fitzpatrick and LaGory). Risk and protection are functions of spatial structure, itself constrained by group status and income level, neighborhood conditions, and other social forces. Important forms of protection, like individual immunity and social organization, are compromised by chronic socio-environmental stressors common in high-risk neighborhoods. Stressors tend to intersect and cascade, including violence, childhood underdevelopment, food and housing insecurity, environmental toxins, and poor social affiliations. Richard Wilkinson’s work on the interrelationship between social structure and illness shows that wealthy countries with the largest income and equality gaps—despite the highest expenditures on medical care—experience the poorest overall health outcomes. The paradox of material success is that it has decreased life span and wellness among disadvantaged populations. Yet, egalitarian societies, rich and poor alike, have not exhibited these differences in wellness. Context then is a more impactful shaper of health differences than individual behavioral differences related to drinking, smoking, and exercising, according to studies cited by Wilkerson in his The Impact of Inequality: How to Make Sick Societies Healthier. Since health status is in large part predicted by one’s zip code, neighborhood design matters.
Conversely, populations of all income levels have experienced an epidemic of preventable “lifestyle diseases” (high blood pressure, cardiovascular illness, obesity, diabetes, etc.) due to abundances in food, automobiles, technology, and energy—a challenge of affluence. If human evolution and behavior were shaped by scarcity, then abundance poses new challenges to our consumer habits and general decision making (Offer). Affluence unchecked by decision making that values resilience generates fragility. Resiliency is the ability of systems and beings to recover from disruption or shock, while fragility represents a system’s diminution, even fatality, from disruption. Resilient systems are redundant, encompassing options and back-ups in functioning. Resilient systems honor local carrying capacities or limits. And resilient systems use feedback for self-correction (i.e., they are learning systems). Arguably, design should aim for antifragility since cities are a complex system that can gain from disorder (Taleb). The operating systems organizing our places are more determinative of our health than we had previously thought.
For instance, auto-dominant metropolitan fabrics do not readily accommodate walkability nor encourage physical activity as lifestyle options. Auto-dominant street networks create higher health risks, while Complete Streets policy that democratizes access for pedestrians and bicyclists offers significant protection. Meanwhile, the loss of place-based food systems to industrialized production has homogenized food products. Not only has industrialized agriculture led to declines in nutrition and food security, but also erosions in general health and culture. Local growing alternatives to industrial production offer important protections. On the matter of water and the city, urbanism tends to eliminate watershed functioning and the 17 life-affirming ecological services that all healthy ecosystems deliver, including flood and disease control (Costanza et al.). Repair of degraded urban streams can be a powerful force (protection) for reinventing physical environments and ecological performance in post-industrial cities. Consider that the greatest ongoing challenge to design and planning is design within human-dominated ecosystems. Future urbanism will be tasked with delivering ecological services in addition to conventional urban services related to transportation, land use development, commerce, and housing.
Beyond matters of physical health, the status of mental health is undervalued in the design of places. Former U.S. Surgeon General, Dr. Vivek Murthy, declared loneliness a serious health epidemic, a “more common pathology than heart disease or diabetes” in his practice experience. Loneliness directly impacts mental and physical health, and is a gateway condition to deviant behavior. Here, housing is an important form of protection when designed for affordability and sociability. The U.S. will need more than 40 million housing units over the next 30 years, especially for aging populations. This presents opportunities to explore new modes of well-being and social connectivity through innovative residential formats that remake place, suburban and urban (Maak; and University of Arkansas Community Design Center a). The mediatization of social environments has eclipsed investment in physical public space, arguably the best predictor of community resilience. The public health community is telling us that solutions for today’s thorniest public health challenges are based in design thinking, rather than the medical model. Are architects and allied design professionals prepared to engage these challenges?
- Fitzpatrick, Kevin and Mark LaGory. Unhealthy Cities: Poverty, Race, and Place in America, Routledge, 2010.
- Taleb, Nassim Nicholas. Antifragile: Things that Gain from Disorder, Random House, 2012.
- Costanza, Robert, Ralph D’Arge, Rudolf De Groot, Stephen Farber, Monica Grasso, Bruce Hannon, Karin Limburg, Shadid Naeem, Robert O’Neill, Jose Paruelo, Robert Gaskin, Paul Sutton, and Marjan Van Den Belt. “The value of the world’s ecosystem services and natural capital”, Nature, 387 (May 15, 1997).
- Maak, Niklas. Living Complex: From Zombie City to the New Communal, Hirmer, 2015.