Louisville Medicine Volume 67, Issue 10 | Page 24

INTERSECTION OF DESIGN & MEDICINE DESIGN AND T N A B RA UR TH AU OR John Da vid Ko lter, MD NS PO O ur built environment is an inextricable part of our daily life and is a determinant of many aspects of our health as individuals and as a society. The built environment in our US cities (a city as defined by the World Health Organization has at least 100,000 people) certainly has evolved over the past century (1) . This has led in many locales to an auto- centric environment that places secondary importance on those who travel actively, and also minimizes the accessibility and social acceptability of public transport. 80% in the Southeast (3) . Many of these metropolitan areas, having experienced more contemporary growth and development, have a larger volume of less dense development, with limited opportunity to live in walkable/bikeable communities. This can lead to a cultural shift, defining what a ‘normal’ urban lifestyle is for the more affluent, one that doesn’t necessarily have positive supportive health data. We can see potentially negative social determinants of health in the more affluent. They spend more time sedentary in a car, eat more fast foods, and have greater exposure to car-exhaust air pollutants. These determinants can often be overlooked in a typical practice setting, given our tendency to focus on social determinants of health on the lower end of the socioeconomic spectrum. While the connection between physical activity and health is well established in society and in medical education, the study of physical and social environments as determinants of health is a relatively new area of study, concentrated primarily in this millennium (2) . These fields of study, and even these ideas, may seem far from the exam room, but to the contrary, they play a daily role in the health and happiness of our patients. Physicians are powerful voices in patient’s lives, and we can influence the decisions people make about their place in the built environment as it relates to their mental and physical health. Physicians are also powerful voices in the community, and we have the ability to advocate for transportation, land use and design policies that encourage and facilitate the good health of our patients. Moreover, the trend of decentralization is a double-edged sword. The older, centralized neighborhoods often become hollowed out, in a sense, and become a focus of negative social determinants of health on the opposite end of the socioeconomic spectrum. Increased crime, food deserts, retail loss, inadequate transportation infrastructure and a relative lack of health services follow the loss of higher earners. Urban designers and planners are increasingly evaluating how their work and design of the built environment interplays with the health of humans, the end users of their design product. A scan of the cited research, not surprisingly, focuses on more contemporary forms of suburban development contrasted with more traditional, dense forms of urban development. In many US cities, the trend for many decades has been a slow decentralization of the populace, particularly those on the higher end of the socioeconomic spectrum. Moving far out into car dependent, less dense suburbs is often seen as an achievement, leaving the ills of the urban environment behind, and a privilege of the more affluent. This trend is happening in our own backyard. The top 10 sprawling metro areas in the US are located in the South, with 22 LOUISVILLE MEDICINE Sprawl is variably defined in the literature, and there is no one clear definition. Urban dwellers are no strangers to sprawl, however, and almost certainly know it when they see it. A generally agreed- on definition is that sprawl is a form of less dense, decentralized development with limited access from one neighborhood to another. Numerous public health studies have looked at the effect of urban and suburban structure on characteristics such as walking for task-oriented purposes, distances walked, and modes