June 5-6, 2006 Symposium

Unhealthy by Design? How Buildings and Neighborhoods Can be Planned and Built to Promote Health

Los Angeles - California Endowment

The design of our communities, and the buildings within them, has a profound effect on the public's health. 150 years ago the designs of cities were modified to improve people's health by, for example, separating people from unhealthy sanitation and unclean water, and by decreasing overcrowding-- leading to the first revolution in health-- the near conquering of most infectious diseases.

In the middle of this century the country's attention turned to the medical management of chronic diseases such as cancer, heart disease and diabetes by creating a medical and research enterprise to address these health concerns.

During this second revolution in health-- with its biomedical emphasis--health promoting architecture and urban planning was not on most people's agenda.

Much has changed in the last 50 years, including the diseases which are affecting and killing Americans. People are suffering from lifestyle-related ailments in which the environment people live in is critical to the prevention and treatment of a variety of ailments. Some examples: obesity and diabetes are at epidemic proportions leading to death from cardiovascular disease; people are feeling disconnected from their communities leading to more depression; there are higher levels of violence and increased drug and alcohol use; more children and adults are suffering from asthma and other environmentally related ailments; too many infants are being born early and dying from preventable pre-maturity --the list goes on and on.

The "third revolution" in health cries out for a renewed focus on our neighborhoods and communities to improve the health of the people who live, work, learn and play within them. Communities impact health through many pathways including facilitating healthy lifestyles and creating a sense of belonging. Micro environments (home, school, office) and macro environments (neighborhood, city, suburb) must be designed so that community members can make healthy choices in order to facilitate appropriate lifestyles (good nutrition, adequate physical activity, avoidance of risks). When positive lifestyle choices are made, a population's health is enhanced.

Impact of the built environment on health

It is time to consider the health impacts from development, land use and transportation decisions. There are a variety of public and private development projects, which if planned properly, can have a profound impact on the public's health.

For example, new schools have been created as centers of neighborhood vitality and providers of an array of health promoting services and supports, thereby enhancing the health and well-being of the community at large. Schools can be built as isolated academic programs or they can become the centers of neighborhoods by co-locating schools, parks, libraries, low-income housing, and health care centers on-site. Such an approach leads to improving the health of not only the students who attend the school, but also improves the health of those in the neighborhood. By having discussions about health promoting architectural design during the planning and building phases, important and potentially inexpensive enhancements can be done leading to improved health outcomes.

The design of the places in which we live and work can have a profound effect on our mental health. We are learning that stress has a major role in many of the ailments effecting people in the 21 st century, including medical conditions such as obesity, heart disease, stroke and premature delivery; mental health conditions such as depression, suicide and homicide; social conditions such as child abuse and elder abuse, alcohol and drug use.

Housing developments linked to new schools and other public buildings take advantage of community-promoting design principles which can go a long way to decrease feelings of social isolation and stress.

Open space and parks generate important and measurable health promoting effects. Open space and parks co-located with other community assets, such as schools, improve their usefulness, share their upkeep and decrease their total cost. Parks can serve as locations for physical activities, and done right, they can also serve as neighborhood meeting places and can help create a sense of communal pride.

Effective transportation approaches aligned with other development projects can encourage bicycle and pedestrian use. Such approaches not only decrease obesity and diabetes but also serve as ways to decrease the health effects of long commutes, reduce pedestrians' risk of injury and death in traffic corridors that speed traffic by providing adequately signed/lighted cross-walks and wider sidewalks, and increase the social connections and feeling of community that are necessary for good health.

Bottom line--health promoting architectural design and planning can have positive effects across many of the major health problems effecting our population. Putting it another way... without improvements to the built space we will not be able to reverse the trends of increasingly poor health of the people in our nation. If we only consider the obesity-diabetes epidemics in our youth - if we don't improve their eating habits and increase the physical activity - for the first time in history, children born today are projected to live shorter lives than their parents. Changing the built environment is one of the key ways to reversing this epidemic and many other major health problems.

What should be done?

How should we add health promoting architectural design and planning to the process of creating the built environment? Working together, individuals from a variety of sectors can transform planning and development so that the public's health gets the appropriate attention it deserves.

One method to help make that happen is a 20 year old process used in Europe, Australia and Canada called Health Impact Assessment.

Health Impact Assessment (and related approaches) are structured processes for prospectively evaluating and synthesizing evidence about the health impacts of policies, programs or projects‹particularly ones not in the medical field. The general tenet of these approaches is that by bringing consideration of health issues early into the decision-making of other sectors, significant health impacts can be identified and communicated leading to significant inter-sectoral health promoting decisions and actions. Such actions can help mitigate potential negative health impacts and enhance the factors leading to positive health impacts.

A key feature of a Health Impact Assessment consider a broad range of economic, political, psychological and environmental factors to determine impacts on the population's health. These approaches consider health effects of the area being studied on the entire population, as well as differential effects on population sub-groups. The process is flexible and can fit any project with structured ways to determine the appropriateness, size, scope, complexity and budget.

Due to an increasing interest in the health impacts of projects and policies among planners and urban revitalization practitioners, Health Impact Assessment has had tremendous value informing decisions related to land use planning and urban redevelopment. There is increasing evidence that development strategies such as concentrating activities near transit stops, designing public spaces that encourage the presence of people throughout the day, building interconnecting streets at reduced widths in a manner which encourages bicycle and pedestrian use, and designing communities so that housing, jobs, schools and other activities are all within easy walking distanced, all impact quality of life among community dwellers.

A number of sectors need to be involved in performing Health Impact Assessments. The lead usually comes from the Local Health Department with assistance from municipal planning offices and local academics. This capability is presently only found in a limited number of locations but it is hoped that over time the capacity to provide timely and useful Health Impact Assessments will be universal.

By providing well-reasoned, objective information to decision makers, we can facilitate the consideration of health effects across sectors and can make an especially significant contribution in cases where health effects are not fully recognized and when their direction or magnitude is counter to expectations.


To make substantial improvements in the health of the people of America we must do more than improve access to quality medical care. This includes improving the health promoting characteristics of the places where people live, work, learn and play.