Placemaking for Public Health

Creating Health Infrastructure

Contributors

Araceli Camargo, MSc Neuroscience (Kings College London)
Marie Müller, PhD Candidate in Neuroscience at University College London
Charlotte Kemp, MSc Cognitive Neuroscience & Psychology (University of Sussex)
Josh Artus, Urbanist

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As Michael Ford says in his great TedX talk; hip-hop is the post-occupancy analysis of modernism. Low income and racialised Peoples have been relaying the experience of urbanity for decades in a variety of media; music, art, poetry as well as in social activism. At the same time; epidemiologists have been articulating the impact of impoverished environments as a condition of poor health for over 100 years. The panacea for this issue has been urban development as a trickle-down approach to regenerate places and communities in return for private gains. However, the trickle-down effects have not materialised in health improvements but the profits have been made.

Regeneration is a word used frequently in the built environment sector. It posits that as long as urbanisation is cast as regeneration it is a force for good. However, this is an inaccurate statement given that despite new housing units being delivered, social, economic and health inequalities continue and house prices continue to outpace earned salaries.

With our focus on health, and how existing urban environments are high in average amounts of stressors we would say that instead of regenerating land and place, we should be rehabilitating the land, and place to support existing communities.

Part of the problem with urban regeneration is that it is always considered that something new is the solution. For example, a new gym, community centre, or new social homes. Whilst these have their merits they can fail to address the systemic issues that are impacting urban dwellers health. For every new physical change that takes place in an area there are externalities created that impact health; air pollution, noise pollution, light and thermal increases. For areas where communities are suffering “Broken glass everywhere” and “can't take the noise” the addition of construction and new activities as a means of social improvement does not prevent someone “from going under”.

It is well known that urban dwellers;

are 21 percent more likely to have anxiety disorders and 39 percent more likely to have mood disorders. We should caveat that poor health outcomes are now prevalent in all environments due biodiversity degradation and pollutants.
PTSD is growing in urban environments and its prevalence is disproportionately higher within impoverished neighbourhoods. PTSD is now prevalent in “general public” populations, this means that it’s growing in populations who have not been to war (veterans) or experienced war (refugees) or suffered from an acute natural disaster.
Two-thirds of the 415 million people with diabetes live in and around cities. The number of people with diabetes is set to rise to more than 640 million by 2040 and with this the number of people with diabetes living in cities.

Despite the hundreds of billions in investment into urban regeneration projects in major G8 cities chronic health issues resulting from the dysregulation of natural human biological systems continue.

We propose that to stop this course of direction our understanding of what regeneration means needs to evolve from one that is capital driven and spatially focused, to one that is health driven actively targeting the environmental, social, and governance barriers to health. The aim of regeneration should be to remove barriers impeding communities to live a life of health and dignity rather than the current autocratic design of cities dictated by capital real-estate models.

Our language of regeneration needs to be one of health in order to allow communities and people to thrive. Working within the realities that change is likely to come from urban development it’s important to focus the financial might and political will, and economies of scale offered to large real estate/built environment organisations to be an impactful force for health improvement. As it stands, despite good intentions, the opposite is occurring. To quote the French Revolution quote of 1793 “They must contemplate that a great responsibility is the inseparable result of a great power” (source).

The harsh reality is that until a combination of fiscal devolution and new economic models allow local authorities and their partners to develop alternative ways of financing change, urban regeneration is the main tool. It therefore needs to adopt a philosophy of “do no harm” if it is to continue to be the chosen direction for urban change and combat the 2.2 objections received per application. There have been 1.7m since 2017.

There are 3 things to take away from this.

People know what makes them sick from the places they live in, they are just not being acknowledged.
The environmental and social determinants of health are an urban development and planning issue.
Regeneration needs to be redefined.

The Long Tail Impacts of Health Inequities

Health inequities are systematic differences in health outcomes that are driven by structural inequities. Structural inequities, such as poor housing, no access to green spaces, high levels of environmental pollutants, poor transport, poor access to healthcare, poor access to nourishment etc. cause systematic disadvantages for marginalised and discriminated groups leading to inequitable experiences of the social determinants of health, in turn, leading to health inequities (source). Health inequities, in turn, reinforce structural inequities because health inequities have secondary effects that further nourish the root causes of health inequities. This is a reinforcing feedback loop, a vicious cycle that we need to break. Practitioners must prioritise individual, community, and population health.

Inability to work and economic loss; The Feedback Loop

Racialised and marginalised groups of the population are disproportionately affected by poverty, which is directly tied to inadequate habitats. Income and wealth are determinants of health, and poverty has been identified as one of the causes of ill health. However, poverty causing ill health is only one part of the association. The other part is ill health causing poverty (source).

All aspects of our society are currently organised through a capitalist lens, therefore, access to financial resources is associated with access to health services and health-promoting resources (source). Income poverty, therefore, is associated with poor health outcomes. Those experiencing financial hardship are disproportionately affected by communicable diseases, mortality, and malnutrition. Being ill, in turn, means that an individual may only be able to work a reduced number of hours, may need to change jobs, or may not be able to work at all. Ill health leads to economic loss, and economic loss may mean that the individual cannot afford accessing health services, living in a clean neighbourhood, or buying nourishing food. This, in turn, will deteriorate the individual’s health even more, and the vicious cycle continues.

Impact on families

Directly associated with the health of an individual is the quality of life of their family. The disease of one family member can have dramatic effects on the other family members’ emotional well-being, psychological functioning, sleep, leisure activities, interpersonal relationships, and financial resources. Thus, the ill health of one individual can have spillover effects on the whole family (source/source).

Take the example of economic loss above: the financial impact of a disease, of course, does not only affect the individual but the whole family. The changes in employment and the potential treatment costs can have a great impact on all the family members’ financial situations. As described above, economic loss may mean that the whole family has to change their lives and lifestyles, potentially impacting negatively on their health as well.

In addition to the financial impact, there are other aspects of life that are affected, such as the family members’ mental health and well-being. Feeling helpless, not being in control of the situation, and worrying about the other family members’ condition or the family’s financial situation all are associated with higher levels of psychological distress. Further, due to caring responsibilities, family members may need to adapt their own employment/education situation and their social life and leisure activities, again impacting on their quality of life (source/source).

Understanding that the disease (be it physical or mental) of one individual can have dramatic impacts on their whole family, including socio-economic and health impacts, suggests that the disease of one individual can spill over and cause poor health in (potentially many) other individuals.

Given how poor health outcomes can affect the entire human ecosystem, it is crucial that the built environment focuses on health as an outcome rather than capital.

Development of secondary conditions

Individuals who suffer from one condition often also suffer from other conditions. When at least two conditions co-occur, we speak of comorbidities. Co-occurring conditions or illnesses can be physical/physical, physical/mental, and mental/mental. There are different reasons for why conditions co-occur: either the conditions share a common cause, or one condition predisposes the individual for the other condition(s) (source). In any case, it means that very often individuals suffer from more than one condition, meaning that there is even more strain on their health and well-being and that their own and their family’s lives are even more affected. For example, an individual with obesity (a physical condition) may also suffer from cardiovascular disease (a physical disease) and depression (a mental disorder).

Healthy environments (at housing, neighbourhood, and city levels) are crucial for individual, community, and population health. Being able to live in a healthy house/flat, in a healthy neighbourhood, and in a healthy city is important for people to have the opportunity to achieve optimal health. A healthy individual should not become sick from living in an unhealthy environment. Equally, an individual who already suffers from a health condition/multiple health conditions should not become sicker just because of where they live. Our environments should help us maintain and improve our health and well-being. Therefore, urban regeneration must put people first and focus on health. It is time to reframe our understanding of regeneration.

Reframing Urban Regeneration:

Towards a Biological Definition

In the context of urban development, urban regeneration refers to the improvement of a place or system and is typically measured by economic outcome first rather than human outcomes, such as health. In order to reframe regeneration, it is necessary to move away from a capital understanding of and towards a biological understanding of urban regeneration.

In biology, regeneration refers to growth and to renewal or restoration of a body, body part, or biological system after injury or as a normal process (source/source). All living organisms have the ability to regenerate. Regeneration is a natural process and key to survival (source/source). Viewing regeneration through a biological lens, it means resilience, adaptation, and survival. This is what we should apply to urban regeneration: improvement of a place or system measured not by profit but by the sustenance and health of life. What do people need to be resilient to stressors, to adapt to change, and to live healthy lives? They need a clean and healthy environment. This is what urban regeneration needs to put first: people, not profit. Therefore, at Centric, we work with the following definition:

urban regeneration as the improvement of a place or system, where improvement is measured by individual and community health

Therefore, urban regeneration can only ever be successful when a healthy environment with healthy people is made possible through the removal of environmental, social and financial barriers to health.

The Key Elements of Regeneration

Regeneration is Restoration & Growth

Regeneration can be both the restoration of something old and the growth of something new. Thus, regeneration is dynamic and flexible and allows for both maintenance and development, always aiming to secure dignity, adaptation, functioning of all Living Beings. In urban regeneration this means communities are given the adequate tools and infrastructure they need to restore and to grow on their own terms, rather than being dedicated upon or ignored. To achieve this an equatable relationship needs to be established in order to understand a community’s varied health needs. We need to use the agency of development organisations to solve community health matters beyond the building of new buildings.

Regeneration means resilience to overcome adversity

Regeneration can happen both as a continual adaptive process and as a response to a harmful event. In Humans, regeneration can be the continual regrowth of skin cells or the process of forming a scar after an injury. The ability to regenerate after a harmful event is associated with resilience. A living Being with greater capacity for regeneration is more resilient to adversity. In the context of cities, communities need to be given the adequate environmental infrastructure (social, built, economic) to be able to build resilience for everyday life adaptation. This means working from the soil up to the building exteriors to provide clean and healthy ecosystems for all people, so communities have enough resources to cope with additional adversity. Currently, communities are being forced to be resilient without adequate affordances and that is contributing to disease pathology. We cannot ask a community to be resilient without systemic support. It is also important to observe that Nature gives us the affordances to be resilient, whether it is our biological infrastructure or external environment (water, air, nourishment etc).

Regeneration is self-sustaining

The ability to regenerate means that communities of living organisms are self-sustaining. There is a mutualistic symbiosis between an individual and community regeneration; the individual contributes to the regeneration of the community and the community to the individual, ensuring a healthy adaptation to changes that lead to self-sustenance. In other instances, Nature works the same way, a careful orchestration of an ecosystem ensures their ability for self-sustenance (oceans, rivers, meadows etc). In the context of urban regeneration, this means that communities should be seen as self-sustaining ecosystems. The role of organisations is to both provide the relevant tools and resources for self-sustenance and the removal of harm. For example, providing robust and adequate housing and the removal of harmful elements such as air pollution. These basic affordances can leave room for a community to imagine and dream their future rather than just surviving the present.

Every living Being regenerates in their own way

Regeneration is a natural process. Every living Being has the ability to regenerate, and every living Being regenerates in their own way. In urban regeneration, we must acknowledge that all communities are able to regenerate, but that different communities need different tools to successfully regenerate. Therefore, for successful urban regeneration, practitioners must talk to communities and give them the opportunity to make their own decisions about their own regeneration. It is crucial to understand that every living Being should be responsible for their own regeneration. Communities should be given the opportunity and responsibility to lead their own regeneration because communities themselves know best about what works well, what needs to change, and what exactly is needed for that change to happen.

Community Sovereignty

An umbrella term that brings together methods of practice for organisations and scientific researchers to establish equitable engagement with communities. Every community has the right to conserve governance over their Knowledges and Practices that determine their health and wellbeing.

Using Data to Identify the Need for Health Infrastructure

Investigating hotspots is an effective way of incorporating various data related to health infrastructure into a more informed understanding of how to approach regeneration. The hotspot approach does not rely on finding correlation or causality but instead focuses on identifying where community members may be faced with a combination of environment based challenges to their health. To do this, we find at least two or three relevant datasets at the same geopolitical boundaries then identify locations that are in the top 5 or 10 percent in all of the datasets. This information can be used to ask further questions on a more local level, investigate the history and current activities in the identified areas, and understand macro qualities shared amongst the identified areas.

We present two case studies where using a combination of environmental, psychosocial, and infrastructure based data helps identify hotspots.

Flood Disadvantage

Many urban citizens may not be aware of the flood risk presented by where they live. As climate change starts to affect cities more, health infrastructure will be more tied to the resilience to natural occurrences. This study looked at data on the flood disadvantage of areas in London at the Middle Super Output Area (MSOA) level. Investigating these scores with the Biological Inequality dataset leads to identifying hotspots where the environment may already influence the ability of citizens to build resilience while also providing less relief to surface level flooding. First we identified which MSOAs have the highest scores for Biological Inequality and then selected the 30 highest floor risk scores to narrow down areas of greatest health risk.

Biological Inequity at MSOA level

Biological Inequity is the amounts of environmental pollutants and psychosocial stressors present in an area, which may create a dysregulation of various biological systems.

Purple = High levels of stressors

Yellow = Low levels of stressors

Flood Risk Assessment

Surface water flood disadvantage. The disadvantage score shows how socio-spatial vulnerability scores combine with scores showing % area of the MSOA unit covered by extents of flood zones associated with a 1 in 30 year event.

Purple = High levels of Pluvial flood disadvantage

Yellow = Low levels of Pluvial flood disadvantage

Data: Environment Agency 2016

Zooming in to the areas that are the areas of highest flood disadvantage and those that score highest on the biological inequity scale we can see a clustering in west London. The results showed an overwhelming presence in the west London boroughs of Hammersmith & Fulham and the Royal Borough of Kensington & Chelsea. The top 20 highest risk areas include the areas popularly known as North Kensington (the Grenfell Tower area), Ladbroke Grove & Latimer Road, Hammersmith, Chelsea Worlds End, Earls Court and Shepherds Bush.

The geospatial mapping of the highest correlating MSOA regions.

Fuel Poverty

Fuel poverty is a very relevant dataset to investigate alongside biological inequity because it presents populations where the environment is likely to dysregulate their systems while their household has a relatively low ability to regulate their temperature and add psychological stress. Using the London Datastore set on the % of homes with Fuel Poverty in these areas we were able to identify pockets where in the event of flooding these areas pose the greatest risk to London’s citizens based on the level of stressors prevalent and the inability to regulate one’s home as a mitigation against the outside world.

In North Kensington: 14.4% of homes in the MSOA code E02000579 have fuel poverty

In Notting Hill: 13.64 of homes in the MSOA code E02000583 have fuel poverty

In Holland Park: 13.24 of homes in the MSOA code E02000585 have fuel poverty

In West Kensington: 15.48 of homes in the MSOA code E02000386 have fuel poverty

In Baron’s Court: 18.20 of homes in the MSOA code E02000385 have fuel poverty

Community Sovereignty

Community Sovereignty is an umbrella term that brings together methods of practice for organisations and scientific researchers to establish equitable engagement with communities. Every community has the right to conserve governance over their Knowledges and Practices that determine their health and wellbeing.

The following interviews were conducted by researcher and scientist Charlotte Kemp with two individuals who have been at the forefront of community development in two differing times. They illustrate the citizen voices that need respecting in the fight for healthy and more equitable cities.

Creating Health Infrastructure

CONTENTS

Introduction