A Healthier Agenda

TEXT Tye Farrow

Our culture has developed a lopsided focus on illness rather than health. This misguided emphasis is vividly demonstrated when we search for the terms “cause” and “health” on the Internet. Running a Google search will typically yield one or more of the following possibilities: “cause health problems,” “cause health abnormalities,” “cause health risks” and “cause ill health.” Any positive results on how we might actually create–or cause–health is missing in the torrent of health-care deficiencies and disease prevention tips that bombard us on a daily basis. The larger question for architects is how can we find ways of integrating the societal issues associated with health into the ways in which we resolve our clients’ design challenges.

It is unfortunate that the word “health” has become synonymous with “health care.” Debates over medical care efficiencies, wait times and public or private delivery have obscured the much larger question of how to reduce overall usage and dependence on medical services. We are therefore living in a culture of negative health. It is no wonder that costs associated with keeping our society healthy have become unsustainable.

Moreover, no local or federal government can hope to build a strong economy under the weight of productivity-draining chronic diseases that cost the Canadian system over $90 billion every year in costly treatments and lost productivity in the workplace. By extension, health-related costs linked to deficiencies in the built environment are threatening our universal health-care system altogether.

This dismal situation presents an opportunity for the architectural profession to assume a greater leadership role in minimizing the burden of illness on society. Nevertheless, architects are living in a time of opportunity, one in which our profession has the opportunity to change the definition of health so that it is no longer centred on illness and prevention. Architects can instead accelerate a quest to identify factors in the built environment that can be seen as causes of health. These factors can then be integrated into the design of a more healthful built environment. In the process of changing the very meaning of the word health as it is known today, architects can increase their presence as important players in creating healthier solutions in our built environments.

Is it possible to imagine a future where a large portion of the many billions of dollars spent on traditional health-care delivery methods every year are directed to resolving issues best left to architects? Absolutely!

To begin this quest, one of the larger questions we must ask ourselves is why do we even have terms like disease-causing or pathogenic, while the corresponding word for health-causing is missing from our vocabulary? To fill this gap, we can look to the pioneering research developed by medical sociologist Aaron Antonovsky whose books Health, Stress and Coping (1979) and Unraveling the Mystery of Health (1987) highlight the relationship between health and illness. Antonovsky coined the term salutogenesis, a concept which reframes health as a positive force rather than a collection of deficiencies. Salutogenesis is derived from salus, a Latin word meaning health, and the Greek word genesis, meaning origin.

“I learned a lot of pathology, and a lot about medicines. We were taught virtually nothing about health,” writes Richard J. Jackson, chair of the Department of Environmental Health at UCLA and host of the popular television series on PBS entitled Designing Health Communities. “I had to learn a whole lot more about the embedded health in the world around me if I was to make an impact.”

Public awareness of the value associated with positive health attributes in our built environment can change dramatically in less than a generation. Does anyone remember non-smoking rows on airplanes? That gesture was a baby step that can be compared with current “share the road” strategies for cyclists. Segregated bike lanes will surely become the norm in the future, while current share-the-road options are destined to seem as anachronistic as designated smoking sections on airplanes. Such baby steps in pursuit of health might have been acceptable in the past, but today we need to react much more quickly to address the chronic disease cost crisis.

Fortunately, there are vanguard players. For example, the government of Scotland has recognized the potential for salutogenesis to guide them toward a wider spectrum of research. Dr. Harry Burns, the country’s chief medical officer, wrote in his 2010 Annual Report that, “by concentrating too strongly on the treatment of disease, we might be missing an opportunity to build health more effectively. Even over the past year, there has been a growing international interest in the value of salutogenesis and its potential implications for health improvement.”

While ongoing research aimed at pinpointing what’s bad for us will continue to yield crucial medical breakthroughs, it’s time to balance pathology-oriented discoveries with an entirely different pursuit. If we really want to minimize the burden of illness on society, we need to launch a quest to discover the causes of health and how this will affect the social and economic prosperity of Canada.

Such a shift in thinking requires much more than placing a positive spin on intractable problems. For example, salutogenesis can help liberate us from playing the role of a passive medical patient. The traditional focus on efficiencies and deficiencies in the health-care delivery system is so pervasive that many people are baffled by the question of what actually causes health in their lives. At best, health is commonly perceived to be freedom from illness or injury, rather than something more ambitious. The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Clearly, the health-related concepts can be found everywhere in our built environment, encompassing a holistic approach to living. This broader concept of health means that we should strive to achieve a higher quality of life than to live out our lives where our primary goal is to prevent ourselves from getting sick.

In brief, a salutogenic orientation has the potential to change the fundamental nature of health research, and by extension–how architects can design solutions for a population that is resilient, energetic and creative enough to thrive in a knowledge economy, while building healthier cities.

For instance, although the benefits of replacing car-dependent suburbs with walkable neighbourhoods are now widely recognized, what will all these new neighbourhoods look like in 20 years? Will they possess qualities that cause health, or will they merely add to the anxiety, alienation and depression that cause disease? What are the visual, physical and spatial qualities that nourish our brain, ignite our spirit and motivate our bodies? How will such places become assets that inspire and enable people to reach their full potential in our increasingly stressful urban environments?

Solutions to the chronic health-care dilemma are firmly rooted in the realm of architecture and the physical environment. However, we must recognize that these solutions exist above and beyond current environmental sustainability initiatives. An in-depth comprehensive understanding of how the physical, mental and social environments we create can cause health is required.

“The primary factors that shape the health of Canadians are not medical treatments or lifestyle choices but rather the living conditions they experience,” according to T
he Canadian Facts
, a report1 by York University’s School of Health Policy and Management. Non-hereditary, non-communicable factors that have an effect on people’s health are known as “social determinants of health.” The social determinants of health identified in York’s report include these elements that are directly affected by the built environment and incorporate working conditions, housing quality and social inclusion, among others–all of these components certainly have real implications for designers.

To improve these factors, public health and urban design professionals need to restore their close working relationship held prior to the late 19th century. At that time, the two professions collaborated on improving living and working conditions in overcrowded, disease-ridden cities. Although urban design and public-health professionals have since diverged away from each other–blame it on the ways in which research is funded and conducted–there are certainly growing concerns over alarming rates of inactivity, obesity, and associated chronic diseases. The two elds have begun to work together once again to build environments that encapsulate salutogenic public policy and design.

Architects can lead this quest for a “health creation society” and thereby change the meaning of health at every level, by everyone, everywhere. CA

Tye Farrow, co-founding partner of Farrow Partnership Architects in Toronto has launched CauseHealth.org which is an open-source website for visitors to post their ideas, news and links to research regarding how to accelerate the shift to active societal health. 

1 www.thecanadianfacts.org 

The following examples illustrate how architects and urban designers are changing what people expect from their built environment by designing places that cause health.

WHAT: EngAGE is a program in the Los Angeles area that is the opposite of the assisted-living model. It provides arts and other classes for some 5,000 people living in (mostly low-income) senior apartment communities. 

WHY: “We live in a society that’s very acute-care based–we wait till someone’s sick,” co-founder Tim Carpenter said. “We decided to try to get people to take on healthy behaviours without having to go to the doctor.”

CAUSES OF HEALTH: The social determinants of health that this project addresses include bringing people together to pursue creative interests that stimulate the mind and keep people active well into their retirement years. One of the “artists’ colonies” within this project includes a 77-seat theatre in the lobby where residents will deliver performances they have written, created and produced themselves. 

WHAT: Via Verde is an affordable housing development in the South Bronx that is a model of health-causing infrastructure. 

WHY: “Via Verde helps shift the conversation,” says The New York Times, and “…it goes out of its way to be healthy.” 

CAUSES OF HEALTH: The narrow footprint of the buildings allows apartments to wrap around a leafy semi-enclosed courtyard, which provides them with cross-ventilation. To encourage people to walk and take the stairs, staircases were placed ahead of the elevators and stairwells have windows. A fitness centre is located in a highly visible spot rather than in the basement. Via Verde’s signature feature is a 40,000-square-foot terraced roof planted with communal garden and fruit trees.

For more information on EngAGE, please visit http://opinionator.blogs.nytimes.com/2012/08/15/for-healthy-aging-a-late-act-in-the-footlights/. For information on Via Verde, please visit nytimes.com/2011/09/26/arts/design/via-verde-in-south-bronx-rewrites-low-income-housing-rules.html?pagewanted=all.