A neglected determinant of health: Urban design

Li (Danny) Liang is a second year medical student at the University of Toronto with a BEng degree and a deep interest in the intersection of urban design and health


Growing up in Toronto's suburbs, I slowly began to realize what was wrong with how much of the city is designed. Most of the neighborhoods outside of the downtown core are clearly designed for cars, instead of pedestrians and cyclists. Most neighborhoods in the suburbs, composed of a sea single detached houses with small oases of high-rises sprinkled in, are not very walkable nor bike-friendly. Getting from point A to point B by walking becomes a huge odyssey: it often took at least half an hour to walk to the nearest library, movie theatre, grocery store or community centre. The way the city is designed is also unfair from a social justice perspective, as most of the people living in the Toronto Community Housing apartments I lived in could not afford to drive. The overall low population density of Toronto's suburbs means that there is not enough ridership to justify building rapid transit to the clusters of high-rises in the suburbs that are drowned by single-family detached houses. As a result, people often taking more than an hour to get from high rise, low income neighborhoods like L'amoreaux, Malvern, Jane-and-Finch, Rexdale to downtown and to work by public transit, further perpetuating inequality.

As a result of the relatively low density brought on by cookie-cutter cul-de-sac neighborhoods, most people in Toronto drive. In addition, bike lanes are as rare to find in Toronto's suburbs as palm trees. Almost no one I knew ever biked to work or on errands; it was simply too unsafe without separated bike lanes. No wonder less than 15% of Canadians get the 150 minutes a week of exercise recommended to obtain optimum health benefits. Traveling to different cities across North America, this trend of car-oriented suburban sprawl was everywhere, and even worse in most other cities.

As I grew older, I started to see the connection between the way a city is designed and some of the most burdensome health conditions for Canadians, namely diabetes, obesity, stroke, depression and coronary artery disease. More and more studies are showing this connection. A study of over 8000 neighborhoods in Southern Ontario has shown that less walkable neighborhoods have absolute obesity and overweight rates of at least 10% more than more walkable neighborhoods. Another study has shown that an average male person living in a cul-de-sac suburb would be less than half as likely to get enough exercise and will likely weigh 10 pounds heavier than his identical twin living in a walkable downtown neighborhood.

In recent years, social determinants of health have become increasingly emphasized in Canadian medical education. However, a crucial determinant of health that is missing from the instruction is the effect of urban planning on health, as well as the role that physicians can and should play to shape how conducive to healthy living Canadian cityscapes are. In my first year of medical school at University of Toronto, there has been no mention of how the ways in which Canadian cities are designed are making people sick. Even when discussing the role physical environment plays, it was only in the context of air pollution and tobacco smoke instead of urban planning.

The health benefits of guaranteeing 30 minutes of moderate cardiovascular exercise per day are enormous. This level of exercise is associated with a 45% reduction in the risk of coronary artery disease, up to 69% reduction in the risk of stroke, 50% reduction in progression to dementia and Alzheimer's in elderly patients, 47% reduction in depression rates, 30-40% reduction in the risk of colon cancer, and 58% reduction in progression to Type II diabetes in patients at high risk, just to name a few.

And the most efficient way to guarantee adequate exercise on the population level is to build it into peoples' daily lives by making cities more conducive to active living, so that more people walk and bike to work, school and errands. Studies show that the vast majority of people who commute by bike get the over the 30 minutes of exercise per day that is needed every week to stay healthy. We can follow the examples of cities like Amsterdam, where over 60% of all trips are done by biking (5). Urban design health interventions also make sense from an economic perspective. A recent study on new bike lanes installed in New York City show that investments in bike lanes costs an average of $1300 per quality-adjusted life year gained, which pales in comparison to the $20000 to $100000 per QALY for treatments of many long term illnesses. Other studies have shown that every $1 invested in bike infrastructure leads to an average of $13 in health benefits.

Physicians can play a major role as health advisers and consultants to urban designers, a role that is currently largely missing in urban planning. By encouraging more physicians to play such a role, we can make current cities more conducive to active living by designing more and better infrastructure for active living, as well as making our streetscape more enjoyable for pedestrian and cyclists. In addition to revitalizing existing neighborhoods, with the population of the Greater Toronto Area growing by 100 000 every year, there is huge potential for physicians to help plan future neighborhoods so that active living can be built into our urban fabrics.

By incorporating the importance of urban design into our medical curricula and increasing the role physicians play in urban planning, we can make future neighborhoods more conducive to peoples' health, and as a result, vastly improve the quality of lives of all Canadians as well as decrease the burden that chronic diseases place on the Canadian health care system. Let's make our cities healthier! Let's add our voices to the way Canada cities are planned. Let's add urban planning to the health conversation!

2 thoughts on “A neglected determinant of health: Urban design

  1. Gordon Friesen

    Dear Li,

    The important point, I believe you are missing, is the sheer depth of the popular desire to enjoy the autonomous freedom and economic benefit of driving a personal automobile.

    This desire has two parts. The first concerns quality of life.

    I quite understand your critique of life in a multi-apartment structure situated, literally, in the middle of nowhere, for a person who possesses no independent transportation. (In fact, a friend of mine recently purchased such a building and is learning from hard personal experience just how difficult it is to rent those units.) However, as soon as we add a personal automobile to the equation, the portrait is magically transformed. The false bargain that my friend thought he was making on the apartment building is a very real bargain for a person desirous of owning their own home: the land is vastly less expensive ; the taxes are a fraction of core urban taxes ; and that highway access ramp which appears as such an eye-sore beside the high-rise apartment building, becomes, -- for the home-owner/car-driver -- a magical instant access point to any destination or opportunity, near or far, North, South, East or West. And of course, our specimen Homo-Automobilus is living in a space much larger and much more comfortable ; which he/she can modify to his/her own specifications ; which costs less than the price of even the smallest condo in town ; which can be paid for with a mortgage that is less expensive than rent for even the shabbiest apartment ; which has the positive asset value of capital invested ; and above all, which is surrounded by its’ own yard and garden ! In my own personal experience, no one who has ever tasted this kind of independence and dignity in life (aside from children temporarily immersed in the student-single-childless-couple scene) will ever voluntarily renounce it.

    And the second aspect to the “dream” is purely practical.

    Honesty would force any objective observer to concede that there are not now, and can never be, sufficient employment opportunities in the urban core to provide work for all the people who already live there (let alone the tens of thousands of new arrivals shoe-horned in on a yearly basis). And even those jobs are often held by people who arrive by car. However, even the notion of commuting into town has became less important (unless you happen to be a lawyer or a banker) because major enterprise, riding the same techno-sociological wave, began long ago to locate in outer urban areas where land prices, taxes, regulations and polyvalent transportation links have made the cost of business much lower and post-urban workers can always be relied on – given the choice -- to simply appear, magically, from whatever areas they choose to inhabit, at the wheel of their own personal automobiles.

    (My own son currently lives in Montreal, and he reverse-commutes to the exterior, about two hours per day, back and forth to his job. But then, he actually has a job, fresh out of school, whereas the same job market in town is totally saturated, and his fully urbanized ex-classmates are simply twiddling their thumbs. The car has thus become an essential tool. Its’ purchase price is simply the investment required to hold gainful employment.)

    The key word, here, is “choice”. Given the “choice”, rational active people will simply refuse to live in a vast waste land of government assisted poverty, (however functionally and aesthetically improved by well-meaning planners spending public funds). They will refuse to live where there is no work (and where there can never be a sufficient source of work) without the means to go where that work is located, which is to say: a car and easy in-out highway access. And they will also refuse to be squashed into tiny living quarters, with their children cooped up like house cats, or alternatively roaming the urban landscape like stray dogs.

    This is not speculation on my part: These same active and rational people HAVE chosen. The current paradigm of light density single dwelling communities has deep roots and shows no sign of spontaneously changing. Vehicle ownership by household continues to increase, in Canada, (1.43 in 2000 to 1.5 in 2015). The stark fact, then, is that social managers could not possibly change the current operation of rational choice without applying coercive force well beyond the accepted parameters of our democratic society.

    In other words, I believe that urban planners, operating within the real world, must fundamentally embrace the automobile along with the economically active people who drive them. To obstinately behave otherwise, is to guarantee the creation of large urban enclaves of poverty where dependant populations are artificially warehoused outside of the real economy.

    And on a closing note of heretical irony : If even a small part of the money currently spent on mass transit were rationally used to subsidise low income car ownership, both quality of life and the practical benefits of work would be extended dramatically.

    Feel the Love,

    Gordon Friesen, Montreal

    1. You make a lot of good points.

      However much planners want urban density and the idyllic live and work situation downtown for everyone, there are realities that conflict with this utopia.

      Firstly, most commutes these days are suburb- to suburb. Also, vast economic inequality has resulted in urban housing often just accessible the subsidized poor and the well-off, and many middle class people move as far out as they need to to buy a house, a nicer car, and raise a family. The neglected population is actually the scraping-by working class that end up in the worst of both worlds on the urban fringe. This area does not have the transit options that the downtown has, and they don't have the car ownership rates that the suburbs do.. resulting in the wonderful life of taking the bus from fringe to fringe neighborhood for one or two jobs!

      I wish that cities could negotiate this situation a bit better, because life is simply better when you have reliable transportation.


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