INTERSECTION OF DESIGN & MEDICINE
of transport used. So far, data has shown positive trends of lower
obesity rates and hypertension incidence in the more compact
locales (4) . Not surprisingly, urban dwellers in denser, more traditional
neighborhoods walk more in general and more for tasks. However,
even in less dense neighborhoods, having infrastructure for walking
and cycling—not just in a park—encourages more utilitarian travel
and a more physically active populace (5) . Patients have caught on to
this rather intuitive notion with the popularity of smart watches and
our recent obsession with “getting our 10,000 steps daily.” Moreover,
these concepts are not applicable to some utopian communities
outside our own. The Center for Health Equity within Louisville
Public Health and Wellness submitted the Health Equity Report
in 2017 to the community. The report provides numerous, well
cited, recommendations for improving the built environment,
transportation infrastructure and equitable policies to reduce
incidence of asthma, diabetes, stroke, obesity and arthritis (6) . Our
local public health players recognize what the international data is
telling us, the built environment and the quality of design not just
matter, but also affect our health outcomes.
The effect of urban design on health is not just physical. Mental
health and happiness, by multiple measures, are issues we discuss
with our patients. Research abounds to define and measure mental
health and happiness in societies and their effects on social and
health outcomes. One example is the World Happiness Report from
the United Nations, published annually since 2012. A key force
in happiness, evaluated from year to year, is pro-social behavior,
or behavior that puts the good of the community ahead of one’s
own personal benefit (7) . Part of generating an interest in pro-social
behavior is generating a sense of community and common bond
among inhabitants of cities. The well-known urban studies theorist
Richard Florida has shown this in several studies in the last decade.
The importance not only of job opportunities, commuting time,
housing, income inequality and services, but also of community
identity and emotional connection to a community, are key parts
of happiness within a metropolitan community. This human capital,
the intangible talents and contributions of members of a community,
plays a vital role in the happiness of a community (8) . However,
as we decentralize our cities, a trend that thankfully appears to
be reversing, and homogenize our community experiences from
one corner of the country to the next, we risk losing community
identity and the community institutions that have fostered human
capital and happiness over time. So many people in our city and
offices have suffered the loss of their once proud neighborhoods,
churches, social clubs and shops. Libraries have shuttered, schools
have consolidated and human capital has scattered. Yet, as we turn
inward and look toward design as a solution, our neighborhoods
can regenerate, new social fabrics can emerge and life can return
to places that give metropolitans pride, a sense of belonging and
into patients who are, on average, more sedentary, walk less for
tasks, are isolated from services, and are more socially detached.
This affects our physical health, mental health and overall happiness.
Urban locales with pedestrian and transportation infrastructure
enhance access to services across the socioeconomic spectrum. The
Louisville Metro Health Equity Report spells out the health issues at
hand in our community and notes clearly where built environment
and transportation are relevant. The report stands as a challenge
to physicians to recognize common health issues in our patients,
the ‘root causes,’ and move to affect change with advocacy (6) . The
Environmental Protection Agency in their report “This is Smart
Growth” nicely assembles the issues of equity and health in urban
development and land use on a national scale. The report is a robust
starting point for anyone seeking to gain a broader understanding
of these issues.
Physicians have powerful voices in our communities and should
speak up for equitable land use and development policies, wise use
of taxpayer dollars, investment in human capital and maintenance
of community identity for the health of ourselves and our patients.
Educating ourselves on these issues allows the medical community to
become team members with our public health colleagues and create
synergy. Our urban design is vital to who we are as a community,
how we will grow for future generations and the health outcomes
of our patients today.
1. Peen J, Schoevers RA, Beekman AT, Dekker J. The current status of urban-rural
differences in psychiatric disorders. Acta Psychiatr Scand. 2010 Feb; 121(2):84-93.
2. Sallis JF, Bauman A, Pratt M. Environmental and policy interventions to
promote physical activity. Am J Prev Med. 1998;15: 379–397.
3. Measuring Sprawl 2014 (2014 April). Retrieved from: https://www.
4. Ewing R, et al. Relationship Between Urban Sprawl and Physical Acitivty,
Obesity, and Morbidity. American Journal of Health Promotion. 2003 Sept/
Oct; 18(1): 47-57.
5. Saelens BE, Sallis JF, Frank LD. Environmental correlates of walking and
cycling: findings from the transportation, urban design, and planning literatures.
Ann Behav Med. 2003;25: 80–91.
8. Division of Public Health and Wellness. (2017). Louisville Metro Health Equity
Report 2017. Retrieved from https://www.louisvilleky.gov
7. John Helliwell, Richard Layard and Jeffrey Sachs (2015), World Happiness
Report, United Nations. Retrieved from https://worldhappiness.report
8. Richard Florida , Charlotta Mellander and Peter J. Rentfrow (2013), The
Happiness of Cities. Regional Studies, 47(4):613627
Dr. Kolter is a practicing internist with Baptist Health.
Physicians have a real interest in the design of our environment
and infrastructure. In the clinic, poor urban design can translate