9 minute read
Health creation through landscape
Making much more of SuDS in Germany for play in Freiburg, and as a cooling feature Winnenden. Paving and decoupled roof drainage is conveyed in channels, reducing excavations. The water storage feature is re-circulated to maintain water quality. © Studio Engleback
Human health and wellbeing are affected directly and indirectly by the environment at every scale. This article sets out the context of why healthcare should be considered differently, and why funding to invest in health creation by design is important.
Systems thinking
Conventional funding of health, housing and the environment is considered in silos, but a holistic approach is needed to repair the complex adaptive socio-ecologicaltechnical system of which humans are a part. Human health and wellbeing are affected from planetary to microbial scales, with system scientist Donella Meadows explaining, “Systems surprise us because our minds like to think about single causes neatly producing single effects. We like to think about one or at most a few things at a time.” However, “Systems happen all at once. They are connected not just in one direction, but in many directions simultaneously.”
The human microbiome is a biodiverse dynamic system comprising over 1,000 species of microorganisms that outnumber human cells by 10:1 and without which we cannot operate. We acquire our microbiomes mostly in childhood through what we eat, touch, breathe and experience, but these non-genetic influences on health, termed the exposome, continue through life. Urban human microbiomes are invariably less diverse than those living in rural areas, which is an issue, as low biodiversity in the gut is linked to health issues including obesity and inflammatory bowel disorder. Studies show that children raised in green environments have better health and pre-school children playing in leaf litter and soil have a more diverse microbiome, with a lower level of pathogens than children playing in sterile spaces.
In the United Nations’ sixth Global Environment Outlook report, Healthy Planet, Healthy People, evidence shows that a healthier planet contributes directly to healthier people, whereas environmental degradation increases the burden of disease and exposure to pollutants, and reduces ecosystem contributions from nature. Landscape-led planning and design can make a significant contribution through measures that address the climate, biodiversity and pollution emergencies alongside health.
Healthcare investment
Spending on conventional healthcare is no guarantee of more successful health outcomes. For example, the USA has the greatest per capita spending on health but ranks 35th in the global league table of healthiness, behind Cuba. The UK ranks 19th and it seems that quality of life (wellbeing) and nutrition play a major role in the best-performing countries. Green spaces are also vital: the Natural Capital Accounts for London showed that public green spaces had saved the NHS almost £1 billion in averted admissions, while also addressing a range of other issues including carbon sequestration and storage, and thermal and flood regulation.
Taking another perspective, the global healthcare sector accounts for over 10% of global economic output, but it is also responsible for around 4.4% of global carbon emissions – a larger share than global aviation or shipping. Healthcare has become increasingly medicalised with 100,000 tonnes of pharmaceuticals consumed globally every year, raising serious concerns about pharmaceutical pollution in the environment.
Health and wellbeing are related concepts, but not synonymous. Two measures in particular build on the view of better health contributing to economic progress and happiness: Disability Adjusted Life Years (DALYs) and Quality Adjusted Life Years (QALYs). The World Health Organization (WHO) uses DALYs to illustrate years of life lost to ill health, disability or death, instead of simply counting disease and death. In the UK, the National Institute of Health and Care Excellence (NIHCE) uses QALYs to assess the cost-effectiveness of drugs and interventions, but this assessment is viewed only through a single-disease lens.
In the same vein, Sally Davies, a former Chief Medical Officer for England, advocates for ‘total health’, comprising the wider health environment and expanded healthcare systems. Nigel Crisp, former CEO of NHS England, is also an advocate for health creation which considers the causes of health, rather than the causes of disease and ill health. He has set out his view in Health is made at home: Hospitals are for repairs (2020).
Evolving health concerns
Global humanity changed rapidly from being 92% agrarian in 1800 to 56% urban today, although in Europe this percentage is much higher, with the population ageing and living longer with multiple morbidities. By 2039 people in the UK over 65 will outnumber those under 16 by 6.3 million, which will bring new healthcare challenges.
Non-communicable diseases (NCDs) are responsible for 73.2% of all deaths each year and cause long-term ill health, which the UN estimates will cost the global economy $47 trillion by 2030. However, NCDs currently receive only 1–2% of global financing for health.
Meanwhile, climate change continues to adversely affect vulnerable groups. Older people, especially older women, are more vulnerable to heatwaves, which are more acute in urban areas. In April 2024 over 2,000 Swiss women successfully sued their own government at the European Court of Human Rights over climate change inaction that threatens their future health. Loneliness is also recognised as a major public health problem that can be amplified or diminished by quality of place. Social isolation is associated with increased risk of cardiovascular disease, hypertension, diabetes, infectious diseases, impaired cognitive function, depression and anxiety.
Finally, increasing health inequality and deprivation are underlying drivers of poor health. Michael Marmot’s reviews of health and inequality in England (2010 and 2020) showed a gap of 19.9 years in life lived in good health for a woman from the 10% most deprived areas compared with a woman from the least deprived. The equity challenge extends further to awareness and action for disabled and neurodiverse people as well as gender and racial equality.
Health creation by design
The WHO constitution defines health as “A state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”.
At the macro scale, action to reverse global environmental decline reduces threats to human health and wellbeing. Environmental changes cause direct, ecosystem-mediated, and displaced effects on health (Fig 1). Climate change brings a variety of risks to communities, healthcare systems and population health as a consequence of heat-waves, flooding, drought and cold (Fig 2). These environmental emergencies need to be tackled together and the United Nations Environment Programme (UNEP) report, Making Peace with Nature (2021), outlines how through the framework of the 17 UN Sustainable Development Goals (SDGs). SDG3 is directly concerned with good health and wellbeing.
A more tangible impact on individual health is made at neighbourhood, street or site scales. Barton, Grant and Guise have brought together evidence and examples of working with natural systems in their book, Shaping Neighbourhoods (2021). The urban exposome drives around 70% of the non-communicable disease burden (including obesity, asthma, depression and diabetes), but as most urban environments can be modified, this provides a great opportunity for disease prevention and health creation.
The EXPANSE project is researching those aspects of the urban environment that contribute most to heart disease, urban-environment health connections, and interventions that most effectively promote health. Some conditions have several drivers: obesity, for example, is not only linked to exercise and diet but also to the density, connectivity and greenspace in a neighbourhood that shape an individual’s lifestyle.
With this in mind, Sustrans’ Healthy Street Design Check tool is worth noting to encourage walking, wheeling and cycling by addressing the whole street environment through ten indicators that measure the experience. A key focus is to reduce traffic volumes and speed, and improve safety and air quality. Small interventions such as rain gardens, shelter, shade, better lighting, and improved road crossings are recommended.
Design takeaways
In summary, the multiple drivers for good health in the urban environment27 include:
Density and proximity: Essential amenities located within 15 minutes of home.
Mobility and transport: Good connectivity by foot, bicycle and public transport.
Mixed use: A ‘complete neighbourhood’ mixing of public services, green spaces, access to good food, and commerce.
Landscape and environment: Diverse, linked green and blue spaces encouraging conviviality, recreation and regular contact with nature.
Housing and energy: Quality homes that minimise energy and water bills through design.
Increasing accessibility and reducing loneliness by design.
An excellent example of this approach is the Healthy City Generator, a new design tool developed by Healthy Cities in Barcelona with EIT Urban Mobility and the University of Lisbon. Connections between health outcomes and urban design inputs are made to calculate the effects of interventions using 20 urban determinants of health and 30 health indicators. The health impacts of interventions such as green streets are illustrated in terms of life expectancy improvement per person, deaths avoided per year and DALYs avoided per 100,000 residents. The economic impacts are shown as estimated overall health cost savings per year, per person, and the return on investment in an intervention over time. This allows design measures to be tailored to a particular area, and for iterations and benefits to be tested at the design stage.
The health impacts of interventions such as green streets are illustrated in terms of life expectancy improvement per person, deaths avoided per year and DALYs avoided per 100,000 residents.
One of the key changes needed in the NHS is to relieve the chronic overloading of this healthcare system of last resort. Planning, design and retrofitting healthier cities up-streams health care into health creation: an essential investment in future health outcomes. In mending the broken NHS, it is important for the government to think in systems rather than silos and take a broader view to reducing the burden on the health service. The 1.5 million new homes it has committed to must demonstrate and deliver this.
Luke Engleback CMLI FRSA sits on the Landscape Institute Policy & Communications Committee and various design review panels. Studio Engleback is a founding signatory of UK Landscape Architects Declare.
