Place matters: A look at urban planning and its impact on health

An op-ed in the New York Times last week described the United States’ disproportionate spending on healthcare in comparison to other social services that have an impact on health – a characteristic that puts us in the minority, as one of only three industrialized countries. The chart below shows the ratios of healthcare:social service spending in the U.S. vs. peer countries (for details on these numbers and information on which countries are included, check out the published study).

In addition, when considering the combined spending on health and social services, the U.S. no longer leads the pack (as it does when examining only healthcare spending) – in fact, we come in 10th of 30 OECD countries examined. Furthermore, the authors of the study found that infant mortality, life expectancy, and potential years of life lost outcomes were significantly worse in countries where health-care spending was high and social-service spending low.

As the authors note, “The implication of our findings is that, if improved population health is our goal, then the United States should be looking beyond the health-care system to achieve that goal. Current reforms—targeting medical care and health services only—are unlikely to deliver that result.”

Amen. So, let’s look beyond the healthcare system. Each Monday starting today, I’m going to kick off our week here at occupy healthcare examining something outside the healthcare system that has enormous implications for our health (i.e. social determinants of health). I’ll try to end each post with a practical step or two you can take to address the topic at hand.

This week, let’s talk urban planning.

The idea that where you live, learn, work, and play is a major – perhaps the major – factor influencing your health is a core principle of public health.  Place matters.

While this idea encompasses far more than just physical living space, physical living space is certainly a key component. Development decisions can affect our physical health (through walkability, green spaces, proximity to healthy foods, pollution caused by vehicular traffic), our emotional and mental health (length of commutes, spaces for social interaction) and societal well being (spaces for civic engagement, degree of segregation by race and income).

Many in the fields of urban planning and public health have come to this realization, epitomized by the smart growth movement, which holds among its principles:

*Mixed land uses

*Mixed income housing – providing a range of housing opportunities and  choices

*Taking advantage of compact building design

*Creating walkable neighborhoods

*Preserving open space, farmland, natural beauty, and critical environmental areas

*Fostering distinctive, attractive communities with a strong sense of place

*Providing a variety of transportation choices

*Encouraging community and stakeholder collaboration in development decisions

Imagine the potential benefits:

*Less segregation could lead to more equitable policies across communities, and ultimately more equitable health and wellness outcomes

*More walkability and green spaces could increase physical activity

*Providing a variety of transportation choices could minimize our reliance on motor vehicles, and the resulting pollution and sedentary lifestyle

*Attractive communities with a strong sense of place could make us happier and more connected, reducing rates of depression

The list goes on. Moreover, many of these benefits have already been demonstrated through research. It is clearly time for us – and the U.S. – to invest in smart growth for healthier, happier communities.

So, what can we do? Today’s practical step: encourage use of health impact assessments in your local community when any kind of development project is being discussed, and advocate for state and federal laws that mandate or incentivize HIAs. HIAs provide a way to assess the health impact of any policy (development or otherwise) and would likely reveal the positive impact of smart growth, and the detrimental impact of development projects that don’t take into account smart growth principles. Certainly, there are complexities and challenges involved in conducting HIAs, and it is important to make sure they are being conducted in useful, cost-effective ways – but that is a topic for another post! Despite the complexities, I think HIAs when done well provide a concrete way to start thinking about the specific ways in which any policy that impacts the places we live also impacts our health and well being – and hopefully provide the impetus to start not just thinking about, but acting upon the results.

(This post is cross-posted at

Vinu Ilakkuvan received her Masters of Science degree in Society, Human Development, and Health from the Harvard School of Public Health in May 2011. She currently works in youth violence prevention in Richmond, Virginia, and blogs about public health at

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Posted in Community, healthcare, Innovation, public health, Social Determinents of Health
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  • Phil Lawson

    “I’m going to kick off our week here at occupy healthcare examining something outside the healthcare system that has enormous implications for our health”

    If I may ask, if it impacts health is it really “outside” the current system or simply an unrecognized vital element of the whole of health?

    Do HIAs themselves recognize and capture the whole of health?

    Do we yet know and agree on what constitutes the whole of health?


  • Carmen

    I sense a lot of convergence with what you propose to what the Buckminster Fuller Institute is advancing regarding sustainability in our urban developments. (see more here ) There is so much material to consider, you might want to delve deeper on the topics you address. That is, where “place” is concerned, the ideas and suggestions in improving where we work and play are separate avenues worth talking about individually. I like where you’re headed!

  • pursuitofPH

    Thanks for the comment, Phil! I agree with you completely that things like urban planning are an unrecognized and vital element of the whole of health, but I still would consider them outside of the current healthCARE system. I think of healthcare as a term that refers to the medical system – hospitals and clinics, treatments and procedures.

    Do HIAs recognize and capture the whole of health – it depends on how well they’re done, and likely even the best ones won’t capture everything. I think the enormous advantage of HIAs is that they provide a way to recognize and consider a far more “whole” picture of health then if they weren’t used.

    As for what constitutes the whole of health – certainly, we don’t know and agree on this entirely, but surely there are many of us that think we should be looking beyond the medical system and capturing things like urban planning, food access, societal norms, marketing and framing of messages, etc., etc., etc.

    Thanks again for your comment!

    • jon

      Many cities are smartly beginning to implement impact assessments to make sure that they are getting the most out of scarce public dollars. I think that HIAs give us another tool which can be used to evaluate potential outcomes of development, other than economic or environmental for example.

  • pursuitofPH

    Thanks, Carmen! I hadn’t heard of the Buckminster Fuller Institute before, thanks for pointing me in their direction – definitely seems to be in line with a public health approach, I love the idea of “comprehensive anticipatory design science”. And yes, I agree, this was definitely a broad overview, there is so much to delve into, and I hope to do so moving forward!

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