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"Green and sustainable building and community design must advance past sustainability and become 'restorative.'"




Designing for Health

By Richard J. Jackson, MD, MPH

At the beginning of the 20th century, business leaders, physicians, planners and architects saw daily the effects of bad urban environments. Most evident were communicable diseases that were known to be coming from bad housing, crowding, little sunlight, unfit drinking water, mosquitoes and unremoved waste. Virtually every family had lost a loved one to an infectious disease of environmental origin. Controlling these diseases required cleaning up and better designing urban areas. These leaders proposed and put in place the funding for large urban improvements and public sanitation efforts. It was evident that one could not be well if a neighbor had typhoid and a business partner had TB. These infrastructure improvements could not have occurred if each of the professions remained isolated within its specialty. Doctors had to care about sewers, architects about sunlight, and politicians about public health accountability.

The success of these efforts has been magnificent. American life spans have doubled since that time, and only seven of those added years have come from medical care. The other 33 years have come from "public health writ large – especially better housing, food, water, workplaces and immunizations.

Today, America must confront a different set of serious epidemics. These are epidemics of chronic diseases: long-lasting difficult diseases like diabetes, obesity, depression, osteoporosis and cancer. They are devastating to quality of life, and they are costly. In 1960, the United States spent 5.1% of the gross domestic product on health care; in 2003, the portion was 15.3%, or $1.7 trillion, a tripling in the ratio in 43 years. The one-year increase in dollars spent over 2002 was 7.7%.

Our nation is just beginning to confront the cost of caring for an immense cohort of baby boomers who are entering the most medically expensive life stages. In the year 2000, just 9% of Americans were age 65 or over; by 2020, nearly 20% will be in that age bracket. While expenditures on medical care skyrocket, efforts to delay or prevent the onset of age-related diseases are just beginning to be addressed.

The epidemic of obesity will only increase these staggering costs. In 1978, 15% of Americans were not just overweight but obese; by 2002, 31% of us were. The average 11-year-old boy today is 11 pounds heavier than he was in 1973. Being overweight and obese increase the risks of cancer, heart disease, stroke, high blood pressure, joint and bone disease and many other afflictions. The most rapidly increasing surgery in adults and in children is bariatric surgery ("stomach stapling).

Obesity increases our risk of becoming diabetic in adulthood nearly 40 times. When I was a young pediatrician, I never saw a child with Type 2 diabetes (adult onset type); now it accounts for more than one-third of the pediatric-diabetes population. Developing diabetes before age 40 shortens life, on average, 14 years, and diminishes the quality of life by 20 years. Because our children are overweight and unfit, they may become the first generation in American history to have shorter life spans than their parents.

Much of the obesity epidemic is due to a "toxic nutrition environment: abundant cheap high-calorie food and drinks (even at school) and a saturation of junk food advertising. But it is also because we cannot walk to our work, schools, sports fields, friends' homes, libraries, shops or churches.

While the good news is that technology has eliminated a lot of the really backbreaking labor from our lives, we have also "designed a lot of exercise, especially walking, out of our lives. In 1970, 66% of children walked or bicycled to school; today that number is about 16%. Overall, Americans walk or bike a trivial amount – only about 6% of our trips – as compared to close to 50% for the people of chilly Scandinavia. From 1960 to 2000, we more than doubled per person driving – from 4,000 to close to 10,000 miles per year. An American mother spends more than one hour per day in her car and half of that time is spent chauffeuring children or doing errands, again way up from a generation ago.

This lifestyle is not making us healthier and happier. Expenditures for antidepressants have skyrocketed and for many health plans they are the second largest prescription expense (after cholesterol lowering medications). Our children – many who have little chance for home- or school-based exercise – are increasingly medicated for inattentiveness or hyperactivity.

Population changes in the 21st century will be astonishing. By the end of the century, our nation is expected to have nearly 600 million people, twice today's population. Yet we continue to build subdivisions as if land were limitless.

This sad vision may feel overwhelming, but it is not surprising to the average American. For many of us, things don't feel right. We can afford homes, but they are far from work and we spend more time working and commuting than our parents did. The average American works 1,835 hours per year, more than in any other developed country, and we sit in our cars for stupefying amounts of time. Despite electronic toys, cellphones and the internet, many of our children are lonely and disconnected – more than three million American children today have significant depression symptoms.

What are the best non-drug ways to treat depression? Exercise and social connectedness. What are the best non-drug ways to treat Type 2 diabetes? Exercise and weight loss. What is the safest form of exercise? Walking. What are the most fuel-efficient, least-polluting ways to commute? Walking and biking. For persons with diabetes, walking for exercise just two hours per week reduces their death rate by nearly 40%.

I believe that reducing opportunities for walking as exercise is a national health threat. If you ask people why they don't walk or bike, you get answers like: "It is not safe. There are no sidewalks or bike routes or nearby destinations or proximal transit stops. Or "I feel vulnerable. We don't have people watching out for each other the way we did when I was a kid.

After 30 years of hard work in environmental health, I have become convinced that that this confluence of threats must be countered with a congruence of benefits: what is good for us as individuals is good for community, and is good for the planet. As individuals, we need to eat plenty of fruits and vegetables. It means that as individuals, we must walk as a major form of exercise – "10,000 steps a day. If we lived closer to work we could get those steps in and if we did not need so much car time, we might have more time with the people we love – and who care about us.

We need to belong to a community, one that is the hub and support for the routine demands of life: learning, shopping, socializing, mourning and rejoicing. Well-designed communities make this much easier. We must re-create denser communities that have privacy, safety, beauty, tranquility and culture. Such communities need to cluster near mass transit; people who use mass transit walk more and pollute less. Well-designed communities can also be the safe haven during the weather disasters that global warming will bring us.

Climate warming is real; the debate is just about the degree. We are at the tipping point with global warming, according to experts such as James Hansen of NASA. Unless we dramatically reduce the carbon loading of the atmosphere, a two- to three-degree temperature rise is inevitable, and this will accelerate icepack melting and cause an average sea level rise of 80 ft. Green and sustainable building and community design must advance past sustainability and become "restorative.

As I see it, the biggest challenge is not knowledge (though plenty more research is needed) and it is not good will (we all want to give our children a planet as healthful, diverse and beautiful as the one we were given). The biggest challenge is one of leadership: we need to be articulating and getting ownership of a vision of healthy communities that superbly support families, children, the elderly, workers and parents, as well as the natural world around us. Well-designed communities can make this much easier – it is not the only solution, but a community that is a place of the heart, as well as the wallet, is a big step towards health.

Technology benefits our lives and is built on specialization. To achieve good health for people, communities and the planet, the barriers that separate the disciplines of health from business, design, transportation and politics must be torn down. The challenges are daunting but critical: we need to confront them just as the doctors, designers, business people and politicians did a century ago. A first step is for the medical, public health, urban design and planning professions to work together to create active and livable communities.  

Richard J. Jackson, MD MPH, is an adjunct professor at the University of California, Berkeley, School of Public Health. He has also served as director of the CDC's National Center for Environmental Health and as California's Health Officer. He is one of the two "public members" of the Board of the American Institute of Architects.

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