All of us feel better when we’re surrounded by beauty and good design. It’s why we put so much effort into DIY, interior design or gardening. And it’s why, for our holidays, we often seek out places that will make us both physically and mentally healthier than we can be in our working life.
This might seem blindingly obvious. Yet public policy often points in the opposite direction. Developed societies rightly spend huge sums of money on health – hospitals, primary care, and new and old drugs account for at least 10% of GDP and more in some countries.
But if you look at what we know about health there is an odd paradox. According to the Robert Wood Johnson Foundation, one of the world’s largest funders of health, summarising a huge amount of research, the causes of premature death are roughly as follows: 40% behavioural patterns, 30% genetics, 15% social circumstance and 5% environmental effects. The remaining 10% is attributable to healthcare (some estimates are higher, but none above 25%).
Given that medicine is an evidence-based field you would expect that this widely understood knowledge would be reflected in how funds are allocated. Instead, the opposite is the case. The vast majority of health spending goes to healthcare and within that to particular industries, notably pharmaceuticals. 95% of health research funding still goes to cure rather than prevention.
We take this for granted. But it wasn’t always like this. In the 19th century when rapid industrialisation and urbanisation left cities like Manchester, Birmingham and London wracked by ill-health, crime and misery, huge efforts went into dealing with the physical causes of ill-health. Vast public spending projects worked to deliver cleaner water and air; comprehensive sewers; better housing; and later such things as safe roads. These were all seen as just as important to a healthier population as better hospitals.
Indeed, there is a long history of using urban design to promote health. This thinking was integral to the great projects of Bournville and Peabody, the garden cities of the early 20th century and the new towns of the 1940s, and more recently it’s shaped the NHS Healthy New Towns initiative.
Yet health design has never had the same prestige or support as more narrowly clinical knowledge, and although much is known, relatively little has been rigorously tested.
We can fairly safely say - based on evidence - that hospitals are more likely to promote recovery if they make good use of nature, light and art, and if they offer privacy rather than long soulless wards.
Similarly, health centres work better if they give people the scope for interaction rather than long lines of chairs or grim corridors.
But we don’t have strong evidence or detailed work on just how much impact these designs have, and even though much of this may appear fairly obvious, a moment’s reflection confirms that it’s at odds with how far too many hospitals and surgeries were designed, with unappealing colours, lack of natural light and air, and long soul-less corridors.
The same imbalance is evident in the ways that towns and cities are planned. You can deliberately design transport and roads to make it easier to walk, cycle or run rather than always depending on cars.
You can shape cities to make them full of nature, or even edible, with plenty of fruit trees for example. Planning can be used to reduce fried chicken outlets near to schools, to cut noise levels and to promote clean air. Much is known about how the presence of green and blue spaces – which means water, ideally in motion – can be good for mental health. Social norms can be influenced in a healthy direction, for example encouraging people to stop their cars from idling. And we’re beginning to see more systematic attention to what could be called MEEs – Mind Enhancing Environments - which can both calm and stimulate us in healthy ways.
But most cities being built around the world are drawing on little or none of this knowledge. Instead what is proliferating is a model of city almost ideally designed to impede health: large tower blocks that discourage social interaction; dependence on cars and road-based designs that make walking or cycling unpleasant and unsafe; and an absence of nature.
For those wanting to do things differently however, although much is known and much is common sense, there is surprisingly little rigorous evidence and surprisingly little use of systematic experiment, so that when new initiatives like the Healthy New Towns one are started they have relatively little to draw on.
This underdevelopment of health design reflects a broader mismatch in where we direct resources. Over the last few years an ever-larger share of public funding has gone to biomedical research even as the results of that research have continued a remorseless long-term decline in terms of impact on health outcomes.
It’s not that we shouldn’t fund such vital research: it’s just that the imbalance with other fields that focus on behavioural, social and environmental influences on health has become huge, and indefensible.
Health is still essentially pathogenic - trying to eliminate direct causes of illness, rather than salutogenic, trying to promote health positively.
Many architects and developers would like to do better, and there are obvious commercial reasons why a developer might want to promote the health-enhancing properties of their buildings. Yet most new urban developments ignore what’s known about health design, and the situation is even worse in countries like China where cities are being built that are highly likely to be bad for physical and mental health.
Next month we will be publishing proposals for a new institute – which we propose to name after Florence Nightingale, the great pioneer not just of health but also of statistics – to promote systematic research, experiment and action on the behavioural, social and environmental causes of ill-health. One of its areas of focus will be the built environment and we hope it will raise the performance of architects and developers so that new buildings really do design in health and well-being.
Over the last generation new thinking about climate change has radically changed how cities are shaped, with far more attention to energy efficiency and carbon emissions, and better measurements, regulations and technologies.
We need an exactly comparable shift in relation to health. We shape our buildings and our buildings shape us, as Churchill famously put it. For now, too many of them aren’t shaping us well. We need a new generation of doctors, architects and planners to help put this right.
This piece is based on a keynote given by Geoff Mulgan at the European Health Design conference at the Royal College of Physicians in London in June 2019. A version of the piece was carried in City Metric.