#26: Gridlocked
City design as the key to unlocking better health.
I recently spent 10 days traveling through Europe.
Walking through the streets of Amsterdam, Prague, and Dubrovnik, I found myself subconsciously seeking answers to why the US still spends the most on healthcare, yet suffers worse outcomes than all other high-income countries.
Here are some things I noticed:
Biking is by and large the main form of transportation.
People walk and jog everywhere.
Children and adults play in parks at all hours of the day.
Public transportation is incredibly affordable and convenient.
Moving around via motor vehicles is virtually impossible.
These observations set the stage for this week's newsletter on why city design may be the key to unlocking better health.
We Live in Cities
For most Americans (over 80%) Lorde’s famous lyrics ‘We live in cities’ ring true. By 2050, 70% of the global population will live in urban areas. In the US alone there’s Sin City (Las Vegas), the City of Angels (Los Angeles), the City of Brotherly Love (Philadelphia), Magic City (Miami), the City that Never Sleeps (New York City), and the Windy City (Chicago), to name a few.
City-Center
Cities are epicenters for culture, commerce, non-profits, academia, government agencies, and healthcare. So it’s no wonder cities are where the commercial, social, and economic determinants of health all play out.
“It’s where we live, socialize, engage or not in physical activity, are exposed to air and heat and other stressors, so cities influence our health globally… and are perhaps the largest composite driver of health.”
~ Lars Hartenstein, Co-Leader of the McKinsey Health Institute
Urban areas were also hit hardest by the pandemic, and have historically given rise to some of the starkest health disparities of anywhere in the US:
Large cities experienced a 20% higher death rate during COVID-19 than any other regions across the country.
Chicago has neighborhoods with up to 30-year differences in life expectancy.
A landmark study showed that each London tube stop, traveling east from Westminster, represented a one-year decrease in life expectancy.
Metro Health
Our built environment plays an integral part in shaping health outcomes.
Green spaces promote outdoor play.
Biking paths improve physical activity while reducing carbon emissions.
Parks foster altruistic and pro-social behavior.
Water access reduces stress by tapping into our natural fascination.
These urban lifestyle elements are not mere conveniences; they are fundamental to the health of city residents.
Urban planners are well aware of the associated health benefits of more parks and blue spaces but still struggle to address other more complex issues including noise and light pollution. These environmental hazards are harder to remedy, especially in major cities where the built environment can vary significantly by zip code.
Noise pollution contributes to hearing loss, decreased quality of life, anxiety and depression, and can even increase the risk of heart attack. Specific measures can be taken to reduce noise levels including speed bumps, decreasing traffic density, and even using building materials that absorb sound. Green spaces also insulate buildings from noise, acting as natural sound barriers.
Light pollution is associated with sleep deprivation, cognitive decline, and even obesity. Some cities have installed LED street lights along with sensors and dimmers to control outdoor fixtures.
Healthy Blueprint
Cities have long played a role in addressing public health’s greatest challenges. In the 1850s, British physician John Snow mapped a London cholera outbreak by tapping into water consumption data. He plotted each cholera death on a city map and was able to trace each case back to a single lead-contaminated water pump on Broad Street.
Snow’s methodology laid the groundwork for modern-day epidemiology, most recently implemented during the pandemic. Tracking wastewater and sewage, public health officials were able to measure COVID-19 levels for whole cities.
Acknowledging cities as the Canaries in the Public Health Coal Mine, NYC’s Health Commissioner Dr. Ashwin Vasan expressed an urgent call-to-action at the Global Health Forum just two weeks ago. He pointed out a massive shortage of city-wide health officials—just 30% of cities have a top official focused on health. Sitting alongside executives from Novartis and the McKinsey Health Institute, Dr. Vasan called more cities to create roles for experts to lead public health strategies—similar to his own city’s HealthyNYC campaign.
Wellness Capitals
On the international stage, five capitals stand out as models of health-centric urban design.
Amsterdam: Despite attempts during the 1960s to replace canals with more roads, expanded bike lanes have led to two-thirds of all travel through the Dutch capital being on two wheels.
Singapore: Fighting global warming rates twice that of the global average, the city-state is building infrastructure to cool its environment using natural breezes, trees and plants, and reflective paints.
Edinburgh: The Scottish capital is one of the most livable cities in the world owing to its 20-minute neighborhood approach, where schools, parks, grocery stores, and healthcare centers are all within walking distance.
Seoul: With one of the fastest aging populations in the world, Seoul’s built environment fosters human connection through societal participation.
Copenhagen: Referred to as the first mover in sustainable urbanization, Copenhagen has pledged to be the first carbon-neutral capital in the world by 2025 by building more bike paths, green spaces, and district heating.
No city, however, has been more deliberate about urban restoration than Paris. Anne Hidalgo, Paris’s first female mayor, first took office a decade ago—and has since transformed the French capital. Under Hidalgo’s direction, Paris has:
Introduced over 1,400 kilometers of new bike lanes.
Established green spaces amounting to 145,000 new trees and 45 kilometers of new parks.
Tripled parking fees for SUVs in the city center.
Similar to Paris, New York City will soon start fining vehicles traveling below 60th Street. Unlike Paris, however, this urban experiment is already facing public outrage, despite not going into effect until the end of this month.
The Road Ahead
As more Gen Zers move to cities to begin their professional careers, time is running out to transform urban areas across the US into environments that foster healthier lives.
In 2008, Paul Graham—Co-Founder of Y-Combinator—wrote his seminal essay Cities and Ambition about the messages of different cities and how they shape the ambitions and actions of those who live there.
New York City: “You should be richer.”
Cambridge: “You should be smarter.”
Silicon Valley: “You should be more powerful.”
Washington DC: “You should be an insider.”
Los Angeles: “You should be famous.”
Whether these messages are still true 16 years later is up for debate. Regardless, no city explicitly promotes the message ‘you should be healthier.’
So here’s my message to ALL cities:
Cities will be the driving force of health for years to come. Scientists, urban planners, and public policymakers must all be on the same page if we are to move toward restoring our urban landscapes into havens of health and well-being.
This week’s newsletter was inspired by Professor Jenny Roe, Director of the Center for Design + Health at the University of Virginia’s School of Architecture, and her book Restorative Cities: Urban Design for Mental Health and Wellbeing.
What I’m reading this week:
New York City Releases Its First Ever State of Mental Health Report, NYC Health
Prioritizing brain health: Scaling what works to add years to life and life to years, McKinsey Health Institute
Why Heart Disease Research Still Favors Men, Time
Virtual Musculoskeletal (MSK) Solutions, Peterson Health Technology Institute
Dangerous substances in Lunchables are raising concerns over children's health, The Week
There’s enormous opportunity in the $6 trillion “care economy”, Second Opinion
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