Do Our Built Environment Redesigns Consider Health AND Equity?

Carly Hood, MPA, MPH

Population Health Service Fellow

Wisconsin Center for Health Equity

Health First Wisconsin

Wisconsin Division of Public Health

Madison, Wisconsin

Monday I attended the Population Health Sciences seminar “Retrofitting Suburbia: Urban Design for Public Health” given by Ellen Dunham-Jones who is a Professor of Architecture and Urban Design at the Georgia Tech School of Architecture. It was a great lecture with a wealth of insights on areas around the country that have undergone various methods of design to recover and invigorate the empty lots and strip malls blighting our nation. Such methods include everything from reinhabitation (repurposing of old buildings) and redevelopment (building new structures on old properties), to “regreening “or simply tearing things down to put in more space for trees, gardens and space to be active. (Archive coming soon!)

Somewhat counterintuitive and disturbing, I was surprised to learn that we have seen a dynamic shift in where poverty in our country exists, and today there are more poor people living in the suburbs than the cities (reinforced by this infographic).

This is in part the result of what’s known as the “drive til you qualify” phenomenon whereby if you want a shorter and cheaper commute, you have to be able to pay for it in home price (and vice versa). This lack of regulation on housing prices and affordability, as Professor Dunham-Jones pointed out, has led to uneven and unsustainable patterns in development as we see them today.

But it was as she shared pictures of a case study (one from her incredible database of 800 locales!) from my home state of Oregon that I got to thinking…not all suburbs are created equal. She was sharing changes made to a structure in a suburb of Portland called Lake Oswego which happens to have the greatest concentration of Portland-area homes worth more than $1 million. And so it struck me: Are the people in Lake Oswego the people most in need of retrofitting for the “public’s health?” Now I recognize that this is just one of many examples of a suburb that is reusing space for new purposes; some examples are found in impoverished communities, others in more well off areas. And Professor Dunham-Jones did share stories from both ends of the spectrum. But given that lower socioeconomic status has consistently been associated with poorer health outcomes (which holds across the income gradient), if one of the goals of “retrofitting suburbia” is to improve population health, wouldn’t we be more successful at achieving this goal if our efforts were more often targeted in areas with poor health, less community cohesion, and fewer options for safe shared space?  

There’s no doubt empty strip malls, large parking lots, and poorly designed suburban neighborhoods are not only eye-sores, but are contributing to our car-dependent and chronic-disease ridden country.

But should we be looking towards those with longest commutes, fewest parks, and/or highest rates of morbidity to consider such beneficial transformations? And even before we ask those questions, I’d explore just what may be occurring inside those communities that we can’t see from the outside…Kaid Benfield, Special Counsel for Urban Solutions at Natural Resources Defense Council, highlights, “As [suburban] properties have declined, so have their rents, making them affordable to small, often entrepreneurial businesses,” businesses often owned and frequented by inner-suburb immigrant populations. Says Benfield, “The risk is that, as we reshape these old properties with new buildings and concepts, the replacement properties will be much more valuable than their predecessors; indeed, that’s why new development is appealing to investors and how it is made possible.  Overall, that’s a good thing.  But small businesses either go under, unable to afford new rents, or relocate as a result. “ In housing policy, when an area is rezoned many cities now have inclusionary zoning policies e.g: “a percentage of units in a new development or a substantial rehabilitation that expands an existing building set aside affordable units in exchange for a bonus density. The goals of the program are to create mixed income neighborhoods; produce affordable housing for a diverse labor force; seek equitable growth of new residents; and increase homeownership opportunities for low and moderate income levels.” But that policy doesn’t necessarily translate to the rezoning of small, local businesses run by lower and middle class populations.

Furthermore, the potential negative implications of redesigning run-down suburbs don’t just apply to small business owners; development and the resulting risk of gentrification can hurt the workforce and overall economy of an entire region as is the case in DC where the free market is picking winners and losers by pricing much of DC’s workforce out of the area.

This can happen in cities and in suburbs. And—as my economics side must loudly add—that’s just capitalism functioning as it’s supposed to! Without a “check and balance” of some sort, that’s the way our system is meant to function.

Alas, the challenges remain—and professor Dunham-Jones spoke eloquently to these: How do we ensure beautifying old structures isn’t pushing out the very people who are making the only use of them? How do we even determine if in fact retrofitting efforts ARE having an impact on health? And finally, I’d push us to ask: are we getting at the roots of the problem? Increasingly more and more people across the country are spending less time using services, purchasing goods and/or enjoying public space.  America’s poor paying jobs that demand long hours, multiple shifts, and/or too much time in transit are squeezing our middle class. An extreme example, but one we could do well to learn a lesson from before it’s too late, is that of China’s ghost cities, captured here on CNN.

I see the benefits of retrofitting our suburban landscape, and through Professor Dunham-Jones’ lecture, have learned of the amazing structures and spaces erected, community built, economies revitalized and local business improved through such efforts. I recognize health is not the only goal in redeveloping our suburban landscape, and equity can’t be the sole factor in determining repurposing projects. But that’s the lens I wear. And for those most sick and in most in need of a louder voice, I can’t help but ask, “How do we decide fairly which space to retrofit?”

Time to Rewrite Our National Narrative

Carly Hood, MPA, MPH

Population Health Service Fellow

Wisconsin Center for Health Equity

Health First Wisconsin

Wisconsin Division of Public Health

Madison, Wisconsin

Looking globally, the United States (US) doesn’t fair incredibly well on a number of indicators. Research shows we rank last for female life expectancy and second to last for males compared to most other Western industrialized countries. Furthermore, comparing the US to 17 countries of similar development and Gross Domestic Product (GDP) rankings, the US has more years of life lost due to a number of causes: communicable and nutritional conditions, drug related causes, prenatal conditions, injuries, cardiovascular disease and other non-communicable diseases.

Closer to home, we can compare how Milwaukee, Wisconsin specifically lies in relation to the rest of the state and the US in general on a number of indicators. The Milwaukee Health Report shows that the city has a much higher rate of infant mortality compared to both Wisconsin and the US. When divided by social and economic status (SES), you can see that those in the lower SES group have higher rates than both middle and high SES categories. And the report shows similar trends for smoking rates, sexually transmitted diseases, dental visits, cancer screening practices, teen birth rates, violent assault, social support, lead poisoning, access to healthy foods, uninsured adults and obesity rates. Milwaukee fairs worse in all of these areas compared to both Wisconsin and the US.

Despite these wide differences, as a country the US spends more on health care than any other country in the world: nearly $8000 per person on average!! It is clear many countries achieve higher life expectancy rates with much lower spending.

One reason for this—and very politically charged currently—may be that the United States lacks universal health insurance coverage. Our health system has a weaker foundation in primary care and greater barriers to affordable care. This lack of access to primary and prevention services means US patients are more likely than those in other countries to require emergency department visits or readmissions after hospital discharge…which ultimately increases costs. But health is determined by more than health care. And I would argue this is a small piece of the larger puzzle we need to be considering.

Literature continues to show that 40% of health outcomes are driven by social and economic factors and 10% by our physical environment. That means that nearly half of health outcomes are a result of what we call the social determinants of health. This includes things like poverty/income, education, and where we live. Going even further upstream, health and wellbeing are considered within the context of racism/discrimination, sexism, classism, and power (this is an entirely amazing body of literature I would suggest you start reading more about here).

 Honing in a bit more on the social determinants of health, we know that employment gives working individuals an opportunity provide their families with nutritious food, educational opportunities, and healthy living situations. There is a clear relationship between employment and health—life expectancy for male workers has risen 6 years for those in the high income brackets, but only 1.3 years for those in the bottom income brackets. Employment translates directly to income, and we know the wealthier you are the healthier you are likely to be. Not only are high income individuals more likely to have insurance and medical care, but also have better access to nutritious food, opportunities to be physically active, ability to live in safe homes and neighborhoods, and feel less stress associated with obtaining these things.

This is interesting in and of itself, but when we take a step back, these problems don’t stop with the individual. They are perpetual and impact families generation to generation. Models increasingly show if you grow up in a low income house you are less likely to have access to education—amongst other things—which in turn decreases your opportunity for higher paying employment, ultimately starting the cycle over. An emerging body of research suggests that inequality of income makes family background play a stronger role in determining the outcomes of young people than their own “hard” work (what does this say about the bootstrap story we tell ourselves??) Inter-generational earnings mobility is low in countries with high income inequality—Italy, the United Kingdom, and the US—and is much higher in the Nordic countries, where income is distributed more evenly. The media is finally picking up on this, and more studies continue to link poor health outcomes in the long run to stressors associated with poverty at a young age. I believe it’s the cyclical nature of this issue that has increased the inequality gaps in our country over the last forty decades. Once you’re stuck in a lower education or lower income bracket, it becomes that much more difficult for you to get out.

So we know that things like education and income seriously impact health outcomes. But as a nation we are highest in poverty rates and third to last in educational rates compared to similarly developed countries. Social policies, or a lack thereof, show what a country prioritizes and how they fund those priorities. The US ranks second to last in social benefits—support with sickness, unemployment, retirement, housing, education and family circumstance—and some of the countries with the best health outcomes rank the highest in terms of social transfers. Health policy experts have noted how easy it is to “connect the dots from inadequate social spending to excess poverty and income inequality to more chronic illness and higher health care spending.”

In recent months, the medical associations of both Canada and Australia have called for a focus on the social determinants and poverty as focus for both medical professionals and policy work, clearly recognizing health should be considered beyond the clinic and hospital (watch an amazing 3 minute clip of Canada’s political perception on health). Here in the US we are still myopically funding medical services rather than the upstream drivers of health which would have the greatest impact on outcomes and equity.

How we choose to live reflects both the citizen and consumer in all of us; we are each at once a citizen who supports our individual and community well-being, and a consumer who seeks cheap prices and large returns on our investments. For decades we’ve let our inner consumer speak louder than our inner citizen, and this has resulted in increased deregulation and financialization, threatened wages and working conditions, falling taxes (and ergo less support for a plethora of public services), and increasing environmental degradation. And while we’ve listened to the consumer voice and voted this way for the benefit of ourselves and our families, whether knowing it or not, these decisions have had the greatest impact on the health and wellbeing of the poor, people of color, and marginalized groups around the world. Inequality is a choice however, as noted recently by Nobel economist Joseph Stiglitz. To him, we are entering a world divided not just between the haves and have-nots, but also between those countries that do nothing about it, and those that do. I couldn’t agree more.

It’s clear the dominant narrative we’ve told ourselves as a society is one supportive of individual behavior, personal choice, freedom and strong work ethic. Unfortunately, the data show this doesn’t seem to be producing a particularly equal, healthy and productive population. And while creating a more equitable society has benefits for economic growth and cost savings, that shouldn’t be the only rationale we use in an attempt to create solid social policy. It’s ok for the rationale to be about the moral obligation we have to create opportunity for all to lead healthy lives; it should be about nurturing the relationships and connections we foster in our families and communities; living on a planet we are proud to leave to our children; finding support in every environment in which we exist—our homes, schools, and places of work; and it should be about sewing the safety nets that catch any of us who might occasionally fall. In the United States, we can and should be rewriting the narrative so that our dominant societal view is one which reflects these ambitions, not just coping with the “individualist” story we’ve read to ourselves for so long.

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