How to Create a Culture of Health: Remake the Built Environment

East Lake Meadows public housing (pre-revitalization) / Atlanta Housing Authority
East Lake Meadows public housing (pre-revitalization) / Atlanta Housing Authority
East Lake (post-revitalization) / Atlanta Housing Authority
East Lake (post-revitalization) / Atlanta Housing Authority

“How can we create a culture of health?,” asked Dr. Donald Schwartz, a director at the Robert Wood Johnson Foundation, at GreenBuild 2015 in Washington, D.C. In the U.S., there isn’t a culture of health, Schwartz argued, just increasing investments in healthcare, which isn’t the same thing. Health is “socially and environmentally-derived,” while healthcare relates to hospitals, therapies, technologies, and costs. Our expensive healthcare-centric approach is no longer working. “In life expectancy rankings for developed Western countries, we rank 15th out of 17 countries.” It’s clear that further investments in healthcare aren’t going to solve the problem. Instead, what’s needed is a transformation of the built environment, so everyone can benefit from walkable neighborhoods and live in healthy, sustainable homes. A new culture of health can only come out of a healthy built environment.

Up until age 75, Americans actually have among the worst life expectancy among the developed world. “The other 16 developed Western countries offer far more opportunities to have a better life.” But if we make it to age 95, “we have the best life expectancy.” This is because “50 percent of our healthcare budget last year went to the last year of life.” By investing in hospitals and technologies for the very old, we created a high-cost healthcare system that benefits a “slim slice of life.”

The U.S. spends much more than other developed Western countries on healthcare, topping out at 17 percent of gross domestic product (GDP) or about $3 trillion per year. “The disparity with other countries is huge.” And with our expensive, inefficient system, we are getting poor results as well. One-third of children are overweight or obese. 75 percent of young adults aren’t eligible for military service due to lack of education or health problems. One-half of all deaths are linked to chronic diseases, which is much higher than in other developed countries.

Higher and higher healthcare costs can’t be the only way forward. “We have to redefine health as more than hospitals and ambulances.” Echoing the U.S. Surgeon General, who called for every community to be walkable, Schwartz said the way to build a new culture of health is to ensure every neighborhood encourages activity and health. A new approach to the built environment is critical, because, otherwise, “our children could end up living shorter lives than us.”

To improve health, Americans need to “change the context.” Schwartz pointed to a study in which the U.S. Department of Housing and Urban Development (HUD) randomly moved 4,600 families in public housing, asking some to stay where they were in poor neighborhoods, and some to move to new neighborhoods without poverty. They found that after 3 years, the “mental health for those who moved improved, and, after 10-15 years, they had lower levels of obesity and diabetes.” The study showed that “people got healthier when they were moved out of poor neighborhoods, even though they didn’t get wealthier.” Following up 20 years later, the researchers found that the low-income “children who had been moved and grew up in areas without poverty had higher lifetime earnings. Just being in a good environment at an early age resulted in higher incomes later on.”

Schwartz cited a few other studies that show how place is fundamental to health. But the question then becomes: what is it about a place that’s healthy or not? Schwartz said higher level of educational attainment in a given neighborhood is an important determinant of health. The structure of neighborhoods has a major impact: Communities with mixed-use developments that encourage walking, access to transit, proximity to places for employment, places to buy healthy foods are healthier. And housing is key. Research shows that “healthier housing improves the health of children.”

To further test this, the foundation is financing an experiment in inner-city Baltimore with local health care providers to retrofit homes for children with asthma. The idea is to test whether improvements in housing reduce asthma rates and lower healthcare costs. But Schwartz believes this experiment will just confirm what we already know. The relationship between better homes and health been already been made clear in the East Lake Meadows public housing project in Atlanta, Georgia. There, decrepit public housing was torn down and replaced with sustainable, healthy homes. No one was displaced — tenants came back after the renovation. The result was that “crime went down and student performance and employment went up.” All of this happened with an investment less than $200 million. “The only thing that changed was the housing.”

But Schwartz also argued that while these one-off projects are great, what’s really needed is a deeper planning approach. For example, the New York, New Jersey, and Connecticut Regional Plan, which is a highly influential regional planning framework, now has a health chapter, in part due to the foundation’s work. This can lead to more widespread efforts to reshape the built environment in the region to make it more walkable, with more healthy homes. And RWJF is now funding Urban Land Institute’s Health Corridors program, which aims to retrofit the unhealthiest thoroughfares filled with big-box stores that offer no opportunities for walking and biking, and make them healthier for the people who live near them. “It’s about finding a real estate redevelopment strategy.”

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