Implementing ideas for healthy cities can not be achieved without the cooperation of governments, the private sector, and the public. Urban design for health needs to be justified in economic, environmental, and sociological terms to best align them with people’s priorities. Previous chapters discussed the health repercussions of urban design strategies and best practices for implementing them. This concluding chapter acknowledges the limitations of urban design as a tool for promoting public health and suggests a broader understanding of the subject as a worthwhile goal for all areas of governance. The chapter discusses how governance at all levels, from municipal to national, plays a role in citizens’ health. It then presents an argument about the importance of accessible health insurance and care. Next, it argues for the importance of general health and physical education and public consultation and social marketing to involve urban dwellers in decisions about the built environment and to ensure resources are being allocated appropriately.

11.1 Government

Without cooperation from multiple stakeholders, many of the interventions described in this book will be a challenge to achieve. Urban planners commonly work with multiple levels of government and consult the public, who are the users of their design. As this book has explored, it is essential that cities are designed to maximize user well-being. But often, the different actors in a city disagree on what the city’s priorities should be. Additionally, many elements that affect public health are entirely outside the domain of urban planning.

Urban planning requires government cooperation at all levels, from municipal to national. The economic structure of a city and the effectiveness of its urban governance inform what programs are possible and what limitations urban designers will face (World Bank 2020).

11.1.1 Social Housing

To be inclusive cities should provide social housing with accessible transit and public amenities. Public housing can be designed to allow access to green space and places to exercise, and socialize, opportunities for growing healthy food, aging in place, and healthy indoor air quality. Without political will and significant public funding, these projects will not be feasible (Day 2018).

When residents can walk, cycle, or take public transit to work, stores, parks, and trails they are likely to have more opportunities for a healthy lifestyle. This chapter investigates how integrating suburban, rural, and urban areas through public transit, bike, and pedestrian paths can benefit public health. The chapter discusses transit-oriented development (TOD) and different methods for its implementation. It describes how successful urban design can promote safe active mobility and the importance of destination accessibility. The chapter ends with outlining the case of Västra Hamnen, a community near Malmö, Sweden, that was planned with shared streets.

3.1 The Built Environment and Active Mobility

As of 2018, 71.6 percent of adults in the United States were overweight or obese (Centers for Disease Control and Prevention (CDC) 2018). In Canada, this number was 63.1 percent (Statistics Canada 2018) and worldwide obesity has nearly tripled since 1975 (World Health Organization (WHO) 2020). There are genetic factors that lead to obesity, but one can also argue that what changed in the past century is our built environment and the subsequent limited lifestyle choices.

Characteristics associated with urban sprawl make places “obesogenic,” meaning they lead to obesity (Lee et al. 2011). Cities can be redesigned to give people choices in how they move around and where they can go. Increasing transportation options can address the services to which people have access, the health information they receive, and the food they eat by linking “food deserts” to better-resourced areas (Sallis and Glanz 2009).

Cities that facilitate healthy behavior are often compact, connected, with comfortable walking distances to and between amenities. These features are associated with higher rates of active mobility, defined as walking or bicycling for transportation, as single trips, or in combination with public transit (Wegener et al. 2017). Small changes in the built environment can make active mobility more convenient, faster, and safer and can encourage people to incorporate utilitarian physical activity (PA) into their daily lives. The ideal region is a well-connected network of “complete communities”: places where all residents have access to quality housing, education, employment opportunities, open space and recreation, places of worship, transportation, and health care (Vincent et al. 2012).

The built environment has a strong influence on people’s travel behavior. Unable to reach destinations by foot or public transit, people will do it by car. Density and mixed land use are two urban components that can greatly influence travel behavior. Neighborhoods with suitable density and mixed land use can promote physical health, reduce air pollution and facilitate social interaction. This chapter investigates the effect of a place’s urban form on public health. It draws heavily from settings where there are decades of evidence to support the negative health implications of car-oriented urban planning. The State of Washington’s Grow Community, recognized as one of the most sustainable developments in the United States, is presented as a case study to outline the principles discussed.

2.1 Urban Form: What Makes Cities Beautiful and Healthy?

The distinctive sense of place that defines the world’s well-loved cities is a result of deliberate urban design decisions. Tourists and residents alike love Paris for its memorable architecture and its iconic boulevard culture. Ask travelers what they enjoy about New York, London, or Montreal and they will likely reference the diverse sights and sounds, the interesting, distinctive visual character, and both manmade and natural attractions. Although those without a background in urban planning may not know what they are referencing, a large part of what people love about these cities is their form, specifically their mixed land use and higher density.

Urban form refers to a city’s physical characteristics, including natural features, architectural, and planning aspects. Ewing and Cervero’s “5Ds” of the built environment (density, diversity, design, distance to transit, and destination access) are a useful tool for categorizing cities’ urban forms and identifying how features determine travel behavior (Ewing and Cervero 2010). Certain spatial configurations result in neighborhoods that are walkable, beautiful, and diverse, while others give way to monotonous, cardominated landscapes (Dempsey et al. 2009). Deliberate planning resulted in a pleasant walk along Chicago’s Riverwalk, on the banks of the Seine in Paris, or on Manhattan’s Riverside Drive. While a river can be beautiful on its own, features like historic architecture, long vistas, and a mix of dwellings, shopping, restaurants, and other attractions are what compel people to visit notable destinations.

The home is an important locus of personal health, even in times without stay-at-home orders such as during the COVID-19 pandemic. Chapter 9 discussed design strategies to make public buildings tools for improved mental and physical well-being. This chapter investigates features that help people live a healthy life in their homes. It begins with a definition of specific strategies that can be implemented to maintain indoor air quality (IAQ) at a healthy level. Next, it describes how building materials should be selected to avoid pollution and other health risks. Then, the authors transition into a discussion about thermal comfort and the relationship between air temperature and health. The final section introduces several topics that have a more indirect effect on human health, including visual comfort and interior design. The chapter concludes with a description of a project in Seattle, Washington, United States.

10.1 Indoor Air Quality

The energy crisis of the 1970s affected trends in building design, leading to the development of thermally insulated “air-tight” buildings that helped reduce consumption. However, the lack of proper ventilation in some of these buildings has created poor IAQ conditions. A study conducted in Toronto, Canada revealed that in 20 percent of dwellings, polluted indoor air and poor IAQ caused a variety of respiratory problems (Canada Mortgage and Housing Corporation (CMHC) 2010; Bas 2004). According to a World Health Organization report (World Health Organization (WHO) 2010), indoor air pollution is responsible for 2.7 percent of the global transmission of disease. The report also estimated that up to 30 percent of all new and remodeled buildings worldwide may have problems with IAQ.

The introduction of composite wood products, stain-resistant synthetic carpets, thermally efficient rigid insulation boards, cleaning agents, and furnishings has also broadened home design options. However, many of these products tend to emit odors and can even release toxic compounds into the air (Figure 10.1). These elements are commonly emitted at a comfortable room temperature of 70ºF (21ºC) (Nugon-Baudon 2008). If the home is not constructed with effective ventilation, the concentration of harmful pollutants can compromise the physical and psychological well-being of the occupants. The health effects of poor ventilation include oxygen depletion, allergies, nausea, and even cancer (American Lung Association 2020).

Although city design operates at a larger scale than individual buildings, people spend significant amounts of time in public indoor spaces. Be it a learning institution, office space, or medical facility, public buildings can have a significant effect on people’s well-being, including their habits and moods. Therefore, public buildings need to be designed and built so they are aligned with the goal of promoting active and healthy living.

Designing healthy public buildings is rooted in the same principles that inform the other chapters in this book. The benefits of physical activity, socialization, and green space for example have been discussed at the level of the city and are now being translated to the level of public built spaces. This chapter proposes an approach to the design of public places that incorporates features for mental and physical well-being. First, it will present specific design features to be included followed by an explanation of how these features can be implemented. It concludes with a case study of the Tietgen Students’ Dormitory in Copenhagen, Denmark.

9.1 Public Buildings and Health

On average, people spend around 90 percent of their time indoors (United States Environmental Protection Agency (EPA) 2014). It is therefore essential that public buildings are designed with health consideration in mind. Simple changes can have a profound effect on how the space is used. For example, if the elevator is seen first when entering a public building while stairs are relegated to the side, people are less likely to use the stairs even if they need to climb only one or two floors. When public buildings are not accessible for cyclists or transit users, it forces people into car dependency. In spaces where people spend significant amounts of time, like office buildings, schools, and university dormitories, there is often no way to exercise or access green space. The active design movement and above-code building’s certification have emerged as a response to the current state of design, as a strategy to combat rising rates of lifestyle-related chronic illness (Spula 2017).

One way to improve building users’ health is by achieving Fitwel certification. Fitwel is an active design-centered approach to optimizing office design for worker health and productivity.

The cold, long, and dark days of winter in northern communities are known to have a profound effect on people’s mental and physical well-being. This chapter investigates measures taken by cities that experience harsh winters to encourage outdoor activities while keeping people safe. Following the discussion of the challenges that winter poses to health, the chapter transitions into macro and micro-interventions that can be considered when planning winter cities to minimize wind and energy usage among others. Finally, the chapter illustrates the case of Edmonton in the Province of Alberta, Canada as an example of a planned winter city.

5.1 Adopting the Right Mindset for Winter Living

In recent years, the concept of hygge has captured the hearts and minds of people across the world. Hygge is a Danish and Norwegian word used to describe a quality of cozy well-being. The word calls to mind pleasant images of indoor sitting by a fire, enjoying a hot beverage and a book while winter rages outside. The concept brings to mind a human form of hibernation. But as luxurious as it may sound to wait out the winter indoors, the decline in activity during the coldest months of the year has serious mental and physical health repercussions. It is important that cities in the northern hemisphere are designed not for talvitelat (a Finnish word that roughly translates to “being stowed away for the winter”) (Young 2020), but for a hygge lifestyle that includes year-round activity and socialization.

Luckily, the Norwegians have a word for that, too: friluftsliv, which means “embracing the outdoors, regardless of the weather” (Poon 2020). The legacy of this concept is apparent when strolling through a Nordic city. The towns embrace the land’s natural topography. Roof slopes are flattened so snow accumulates on housetops, rather than on the streets below. Buildings are constructed with an emphasis on south-facing windows and doors to maximize sunlight and solar passive heat gain (Figure 5.1). The resulting environment is light-filled and pleasant, even warm. In places with well-planned winter infrastructure, winter is something to welcome, not just to endure. Unfortunately, many northern cities are poorly adapted to the severe climate (Davies 2015).

Contemporary social, economic, and environmental challenges call for the rethinking of city planning and architectural design. The magnitude of challenges such as global warming, inequality, and population aging suggest that some current practices need to be revisited and altered. The challenges are further magnified when it comes to public health. Ominous indicators have become apparent during the COVID-19 pandemic, such as obesity and lack of accessible health care to lower income families, exemplifying the immediate need for action. This chapter begins with a background of what led to the decline of planning for healthy living, followed by a historical overview of the relations between health and sustainability. Finally, sustainable and health indicators will be outlined.

1.1 The Decline in Planning for Healthy Living

At its best, good urban design and planning practices hold the potential to improve people’s mental and physical health. In properly designed settings, residents can walk to a public transit stop at the start of a day, pause on their way for a coffee, and reach their nearby place of work where they will be within a walking distance of healthy lunch options. After work and on weekends, they may meet neighbors, jog along a trail, visit a cultural venue, or shop at a market.

Just as easily, poorly planned communities can facilitate unhealthy daily behaviors. Residents may drive a long distance to work on highways and stop at a drive-through fast-food restaurant. They may work in an office park with an uninteresting visual attraction that does not foster social engagement or encourage walking. They may reside in a place where oversized streets, a lack of sidewalks, and limited public green space may discourage outdoor exercise and limit their interaction with other people.

For decades, urban development was defined by the second example. Despite overwhelming evidence linking sprawl to negative health outcomes, dense and walkable settings were abandoned in favor of the comfort and affordability that low-density suburban subdivisions offer (Frumkin et al. 2004). At the same time, there has been a troubling decline in public health worldwide.

Location affects how people move around, shop, and spend their leisure time. In some areas, decades of poor planning and architectural practices have contributed to unhealthy lifestyles, including a decline in physical activity and in-person social interaction to affect one’s mental health. In addition, many who live in underinvested urban neighborhoods lack the place, time, and resources to follow a healthy lifestyle because of social inequity and an inadequately built environment.

Another ominous sign is a troubling decline in public health worldwide. Recently, COVID-19 has made it clear that the virus is not the only threat to our collective well-being. Diabetes, to which obesity contributes, and asthma, all of which have been on the rise globally for decades, are listed as contributing causes to the pandemic’s fatalities. The most vulnerable members of society, people with preexisting conditions, the elderly, and low-income were disproportionately affected by the crisis.

The authors of this book argue and demonstrate that good urban design has the potential to be a powerful tool in health promotion. Introducing healthy food choices, pedestrian paths, safe bicycle lanes, and recreation areas near homes can have far-reaching effects on residents’ well-being. These measures can also play a role in combatting climate change and addressing social justice issues. The increased attention to public health as a result of the pandemic presents a unique opportunity for planners, architects, and public officials to reimagine cities and neighborhoods as devices for living well.

The authors advocate the retooling of existing environments and the planning of new ones with features that help tackle the current public health crises and set the stage for improved well-being. Some solutions draw from ninetieth-century urbanism, like placing public institutions in the hearth of communities while others involve new technologies such as the use of digital applications or a combination of both. Each chapter focuses on a specific aspect of city planning such as mobility and open spaces to present recent research on the topic and its relation to well-being.

The public health crises and the planning of today’s cities are closely linked to several highly important contemporary social challenges such as global warming, population aging, and income inequality.

According to Green (2020) integrating nature into cities brings the myriad benefits of the natural world into day-to-day urban life. In addition, open spaces offer a place for physical activity, community building, and psychological well-being and provide valuable support to ecosystems. This chapter investigates the health benefits of green space beginning with a broad overview of how nature and the built environment can be integrated. Next, we describe how green spaces can be designed to promote physical activity and social interaction, improving physical and mental health outcomes. We then introduce planting and landscaping techniques to create a sense of place, spatial harmony, and various health benefits. This allows us to transition into a discussion of the relationship between biodiversity and health as well as equitable access to the outdoors. The chapter concludes with a case study of Skaftkarr, a community in the Finnish city of Porvoo.

4.1 Greening the City

By 2050, 68 percent of the world’s population is expected to live in cities (United Nations 2018). Rapid and uncontrolled urbanization is often depicted as a threat to the well-being of the Earth and its inhabitants, and not without reason: cities are associated with environmental degradation (Yale University 2020) and increased health inequalities (Kuddus et al. 2020). Urban trees filter air and remove pollution: the total annual air pollution removal by US urban trees is estimated at 711,000 metric tons, a USD $3.8 billion value (Nowak et al. 2006). “Green exercise,” or exercising in nature, has specific health benefits (Wolch et al. 2014). Lack of park access is linked to all causes and cardiovascular mortality (Coutts et al. 2010), while increased residential green space is correlated with reductions in mortality (Villeneuve et al. 2012). Green space can also reduce noise, lower temperatures, and provide food (Escobedo et al. 2010). In the wake of COVID-19, people craved to be in public green environments. A survey, conducted in late 2020, revealed that 86 percent of people want to spend more time in parks and squares than they did before the pandemic. Prolonged isolation, stress, and the inability to visit with loved ones indoors have offered people a new understanding of parks as regenerative spaces for physical and mental health preservation (Garcia 2020).

In a New Yorker article published in June 2021, Clare Sestanovich extols “the joy of crossing paths with strangers.” The author describes fleeting but meaningful encounters with strangers and friends on the streets of New York City. According to the author, these moments were made possible by intentional urban design in spaces like subway stops and busy pedestrian intersections that allow for casual social contact. However, the trends described in previous chapters such as sprawl and low density, make these sorts of chance meetings less common. Cities, we argue, can facilitate gatherings both large and small, spontaneous, and planned when properly designed.

This chapter defines and discusses the decline in social capital and community gathering and the health repercussions of this trend. Then, it introduces urban design features of various scales that can be incorporated in cities to make them organic meeting places and ends with a case study of the High Point community in West Seattle, Washington, USA.

6.1 Urban Loneliness in the Social Media Age

Poor urban planning practices are a partial explanation for the decline in social capital according to Robert Putnam in his book Bowling Alone (2000). Putnam defines social capital as the collective value of all social networks and the inclinations that arise from these networks to do things for one another. Putnam’s theory of social capital and its decline in society has held up through the decades and has been cited as a partial explanation for the recent rise in political extremism (Cox et al. 2020). Many studies have shown significant correlations between social capital and individual health. Being part of a social network acts as a buffer against stress, which can be beneficial for both physical and mental health (Eriksson 2011). Yet, the definition of social networks has shifted in recent years.

The beginning of the 2020s made clear that society has truly entered the digital age. The decade opened with the COVID-19 pandemic, which ushered in an era of remote everything: work, school, even remote family gatherings, and holiday celebrations. These conditions became more extreme during the pandemic; however, they are a natural continuation of past trends.

People’s ability to follow the World Health Organization recommendations (2021) about healthy eating often depends on where they live. Living in proximity to grocery stores with fresh produce is a key public health determinant (Good and Healthy South Dakota 2015). Unfortunately, urbanization and inequality have made it increasingly expensive and unsustainable for healthy food to reach stores in many urban centers (Stage et al. 2010). To make healthy eating more accessible, the built environment must be reconfigured to include methods of local food production and distribution. This chapter details how the built environment affects people’s access to fresh food and proposes interventions that make nutritious food widely available. The chapter concludes with a description of an urban agriculture (UA) project in the heart of Detroit, USA.

7.1 Health and Diet

Long commutes, high-stress jobs, and an abundance of convenient and fast-food options make it difficult to find time and motivation to cook healthy meals at home (Okrent and Kumcu 2016). There are also cost barriers that prevent lower income populations from consuming fruits and vegetables and instead buying more high caloric food (French et al. 2019). The dietary habits of many people consist of over-consuming low-nutrient food that originates halfway across the globe (Good and Healthy South Dakota 2015). According to Abraham et al. (2018), when people are overly busy or under a financial strain, they prioritize convenience and affordability over nutrition. For example, a 2019 study showed that diets in the United States improved in the past two decades, signaling that American’s tastes and preferences are changing to favor healthier options (LaMotte 2019). However, nutritious options still remain unavailable to many, mostly lower income households (Good and Healthy South Dakota 2015). The authors argue that as people become more motivated to make nutritious choices, the built environment should be modified to assist them to do so.

Illnesses associated with poor diets such as diabetes, which is often linked to obesity, were found to contribute to COVID-19 mortality (Tartof et al. 2020). Severely limited access to high-quality food is characterized by two extremes: food deserts and food swamps.

The United Nations projects that by 2050, two billion people worldwide will be aged 60 years or over, many of whom will live in urban areas (United Nations (UN) 2017). In fact, as of 2015, cities were home to 43.2 percent of the elderly population (OECD 2015). While urban living is beneficial to seniors in many ways (Perek-Bialis et al. 2017), it is still important that the possible negative effects are mitigated through built environment interventions. Cities can adapt to the needs of the elderly by encouraging socialization, physical activity, and safety to name a few measures. This chapter begins with a discussion of planning interventions that can occur at the city or regional level. It then transitions into an explanation of how planners can design urban public spaces to be safe and health-promoting for the aged. It concludes at the level of the home, and how new developments can encourage aging in place. Finally, the chapter includes a case study of a housing development for seniors in El Paso, Texas, United States.

8.1 Seniors and the City

According to Mulwa and Ruedenbach (2016) cities are often associated with a sense of youthful vitality. Young people move to the heart of cities to take advantage of their walkability, nightlife, and culture. But around the world, the population is aging. Thanks to advances in healthcare and improvements in quality of life, the number of people living alone in their 80s and 90s is projected to rapidly increase (Molinsky 2020). In 1950, 205 million people were aged 60 years or over and by 2050, the United Nations projects that figure will reach two billion (United Nations (UN) 2017). It is imperative that cities are designed to enable their oldest citizens to lead independent, healthy lives. An age-friendly city is a city that enables residents to safely grow older and offers extensive opportunities for their participation in their families, neighborhoods, and civil society (Fitzgerald and Caro 2016).

According to Perek-Bialis et al. (2017) overall, living conditions are better for older people living in cities than for their rural counterparts.