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
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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