What Will It Take to Design (Actually) Healthy Cities?

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As the latest COVID-19 variant sweeps through New York City, I’m struck by how much of this public-health crisis is being framed as a matter of individual responsibility — of vaccine status, of shopping for the right mask, of being able to afford the time and money to get a test. City and state officials have neglected that the circumstances in which there really isn’t much individual control — where you live, your employer’s policies, and how you get around — matter a whole lot as well. During the first weeks of COVID, who had access to open space and fresh air — and who didn’t — was one dividing line that defined the early response to a virus that we knew was spread through respiratory fluids and required people to quarantine and self-isolate as part of their treatment. The richest areas of the city became ghost towns as those residents fled for homes that offered them more space or more security. For those who stayed, apartments with access to outdoor space — patios, roof decks, balconies — became holy grails, as the real-estate industry plugged wellness as a premium. Meanwhile, areas that lacked green space and walkable streets, with higher rates of asthma, diabetes, and obesity, saw more infections and deaths. Same for residents with longer commutes and overcrowded households (not to be confused with density).

“It was like watching all of medical history compressed in the past year and a half,” says Sara Jensen Carr, a professor at Northeastern and author of The Topography of Wellness: How Health and Disease Shaped the American Landscape, a new book from the University of Virginia Press that explores how urban design has privileged a distinctly American notion of health that turns it into a pay-to-play commodity, like real estate. Just as the pandemic “ruptured structural faults that had thus far been held together by Band-Aids,” as Carr writes, it also showed how the city holds tremendous capacity for change. “As we debate how homes will accommodate work and school from home or celebrate streets given over to dining, we must also remember that many are still without the basics of housing, fresh air, fresh water, and safe public spaces,” Carr writes. “A true landscape of wellness starts with these provisions for all.” Cities need to reframe health as an ethic, not an amenity.

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Carr has been working on The Topography of Wellness for the better part of the past decade and submitted the complete draft one month before COVID-19 showed up in New York. But she got the idea for the book even before that, when she was practicing architecture in New Orleans, mostly for the health-care sector. When Hurricane Katrina hit, she witnessed the design community propose to convert the flooded swaths of the city into parks, drawing green circles over the areas they wanted to redevelop, claiming that these green spaces would make New Orleans a healthier and more livable place. There was just one problem with this now-infamous Green Dot map: All of the dots were in low- and middle-income neighborhoods. Residents in those areas were rightfully outraged. How could planners so enthusiastically depict building parks that would rip these neighborhoods apart? Carr became interested in “how these ostensibly ‘good’ measures are actually very fraught.” She adds, “There’s a lot of great evidence-based design out there on the health benefits of [green space] in landscape and urban design, but the way it’s written about is that it’s very straightforward to apply and it’s not.”

Part of the problem lies in how urban design came to care about health in the first place. As architecture and urban planning became professionalized in earnest in the mid-19th and early 20th centuries, its practitioners began to look to science and medicine for credibility. They styled themselves like doctors, prescribing spatial cures to illnesses. That was mostly fine in early days of city planning, when the focus was on problems like cholera and dysentery: It’s hard to argue with clean water and better sewers. But after public health shifted to reducing chronic and so-called social illnesses in the 1920s and 1930s — like diabetes, cancer, and heart disease, which eventually came to be viewed as the result of individual moral failures — illness became a justification for technocratic intervention to control the public realm and specific groups within that realm. At the same time, the mortgage industry and the federal government pathologized the built environment based on who lived there through redlining maps, entrenching racism more deeply into cities. Likewise when urban planners and policy-makers used urban renewal to declare neighborhoods “blighted” — another concept loaded with ethnic prejudice — and ran highways through them so people living in “healthy” suburbs could commute to work. These are the same areas that experienced disparate COVID-19 impacts. The legacy of racist urban planning also ruptured vital community bonds — social and neighborhood networks that are critical to health. (We saw how critical mutual-aid groups were in the pandemic, for example.) The emotional effects of disinvestment and displacement are not widely recognized as public-health issues. The CDC recognized displacement and gentrification as a public-health issue in its Healthy Community Design Initiative until the Trump administration defunded the program.

So what does designing a healthy city look like when health and space are both pay-to-play? In many ways, it isn’t a question of physical design at all; it’s about a deeper understanding of what health is. In 1948, the World Health Organization defined health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” Even though it’s over 70 years old, it’s a radical sentiment. “What goes unsaid in that definition of health is a sense of autonomy, and that has a lot to do with your well-being — how much control you have over your daily life,” Carr explains. She cited the research of the architect Roselyn Lindheim and sociologist Leonard Syme, who “wrote about strong social connections and mental well-being, and building resistance to disease,” Carr says. “Because at the root of what exacerbates a lot of these illnesses is stress, and that could be stress from racism, stress from economic inequality, stress in your daily life.”

Reading The Topography of Wellness, I kept thinking back to one of the cardinal rules of medicine: First, do no harm. It’s a philosophy that ought to be extended to urban design. It’s not as easy as planting more trees. Designing healthy spaces without the policies that equitably distribute them often ends up encouraging a greener version of the same old gentrification. Take, for example, the redevelopment of Water Street in Tampa, Florida — a $3 billion mixed-use development and the first neighborhood to receive certification from WELL, a program that establishes building standards for health and wellness. The lowest-priced one-bedroom apartment was asking two and a half times as much per square foot as the citywide average. Health just became another luxury marketing tool. In New York, walkable neighborhoods close to parks, shops, and services became even more prized during the pandemic. Windsor Terrace, for example, saw the median sales price rise 62 percent between 2020 and 2021. As Carr asks, “If designers are going into neighborhoods to improve them, what do we need to be aware of, and how do we stop these recurring patterns of displacement and gentrification?”

As The Topography of Wellness explains, designers and planners need to stop offering solutions the way a doctor would treat an infection, with a single-minded focus on addressing one problem, and start thinking about healthy systems. (The American way of providing health care, focusing on cures rather than prevention, has some of the same problems.) Prescribing, say, nice bike paths and better connectivity won’t improve urban public health without the host of other policies required to support bike riding and public transit. “Instead, can we think of multifaceted solutions?” Carr asks. Part of that broader thinking, she argues, means incorporating climate concerns. “Climate change is probably, after COVID-19, actually the biggest threat to everybody’s health.”

Thinking about healthy cities as a system looks a lot like the Green New Deal. Housing is health care. Jobs are health care. Climate justice is health care. But we don’t have to wait for something like the Green New Deal to move toward this vision. Washington, D.C., is in the process of building the 11th Street Bridge Park on an abandoned bridge between Capitol Hill and Anacostia. The project included an equitable development plan that included launching a community land trust to maintain affordable housing and commercial space in perpetuity, a workforce training program that began well before ground breaking so people in the area could be hired to build and maintain the park, and seven community gardens in Anacostia to address food insecurity. (During the pandemic, the nonprofit behind the park also paid out $2 million in direct cash assistance to the community.) As Carr writes, “The truly healthy landscape is one of negotiation, equity, and resilience, built from the ground up,” and this project, which included partnerships with multiple community groups, showed what could be accomplished through an ethic of health.

Applying the Green New Deal philosophy on a smaller scale, like school retrofits, also brings this holistic framework to places where it might have the most impact. Earlier this year, Jamaal Bowman introduced the Green New Deal for Public Schools Act, which would reframe schools as community infrastructure and provide funding for environmental remediation. (Nothing has happened with the bill since it was introduced.) This distributed approach to urban-design interventions in the name of health holds potential. “That’s the biggest thing — examining where these interventions take place,” Carr says. “Are we addressing the most vulnerable neighborhoods first? Can we think about sort of like more distributed networks of green space or health improvements?”

As we enter another COVID winter, the evidence of missed opportunities to make New York actually healthy is everywhere. As testing lines snake around city blocks, rents skyrocket, and traffic congestion returns, it feels like the city forgot the lessons of 2020, when we got a taste of what urban design and policy that centers health looked like. Enhanced federal unemployment programs served as universal basic income. Expanded free health care in the form of COVID testing was available throughout the city. The city recognized how little green space there actually was and quickly converted streets into open pedestrian spaces in response. Through the eviction moratorium, the state recognized how important a secure place to live is. These measures didn’t go far enough — and many of them were downright embarrassing, like the failed attempt to provide better ventilation in schools and offering spoiled free meals that made Fyre Fest’s abysmal sandwiches look like a Michelin experience — but they were headed in the right direction. These shouldn’t be temporary measures. We need a fundamental shift in cities that puts health first.

What Will It Take to Design (Actually) Healthy Cities?