The link between cities and public health has long been described, particularly with the rise of industrialization. The urban landscape has a lot to say about how active we are able to be, which, in turn, relates to the incidence of chronic conditions.
Whether it's a sprawling development pattern that favors driving to walking or a lack of safe, well-maintained spaces to play and recreate, cities are at least partly responsible for the health outcomes of their residents. A recent study found, for example, that, according to 2010 data, "life expectancy was significantly higher in compact counties than in sprawling counties."
Researchers have found connections between the built environment and health care costs, mental health outcomes, walking and biking, and even social cohesion. Where dumps, industry and other environmentally hazardous sites get located or have historically been located also impacts public health.
There are, of course, other factors that contribute to public health. As one recent study looking at the connection between land use and walking found, for example, areas that had zero car ownership did tend to rely more on walking to get around but also saw higher obesity rates, "likely reflecting socioeconomic and demographic characteristics of people living in zero-car households." Racism and compounded disadvantage also play a large role in disparate life expectancies, for example. And while the built environment is not the only piece of that puzzle, it is certainly part of the feedback loop that tends to disadvantage poor, non-white communities when it comes to things like safe pedestrian infrastructure.
In other words, the form of our cities plays an important part in our health. "So much research is proving the obvious," was how Ellen Dunham-Jones, currently the director of the Urban Design Program at the Georgia Institute of Technology and co-author of Retrofitting Suburbia: Urban Design Solutions for Redesigning Suburbs put it back in 2010 in Pacific Standard magazine.
Despite awareness of this connection, as a 2003 American Journal of Public Health article pointed out, there's often a gap between planning and public health professionals.
"[T]oday’s public health advocates have been largely absent from discussions about major planning or land-use decisions involving the built environment. Many cities and counties around the country have large planning departments or other bureaucracies that regulate land use and buildings. These frequently include urban planners, architects, lawyers, economists, transportation engineers, environmental scientists, and demographers. They rarely include public health officials."
Another study, published in Preventive Medicine in 2018 and drawing on a 2014 survey of local officials, found that while most of the municipalities surveyed had some sort of comprehensive/general plan, transportation, land use or bicycle/pedestrian plan, among those with a plan, only roughly 37 percent had specific objectives tied to Complete Streets, while more had goals relating to street connectivity and mixed-use development (roughly 54 percent and 67 percent respectively).
Some cities have taken other approaches. In Baton Rouge, for example, where health concerns are many, the city is hoping the recently created Baton Rouge Health District, a new take on the traditional medical center, will make a difference for public health there. The design of the district itself is meant to encourage walking and transit use but the district also aims to channel funds from the health care facilities there back into the community.
Given the ways in which urban design and planning can both create and replicate inequity, effectively joining public health and planning strategies will also mean addressing things like environmental justice, segregation, disinvestment, gentrification and displacement and other processes often tied to race.
In the end, when it comes to improving health outcomes for communities, education is just one piece. "The built environment affects health in a number of ways," concluded the Georgetown University Law Center scholars. "It is not sufficient to educate people regarding healthy lifestyles; the built environment must promote, or at least allow for, engaging in healthy behaviors."