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 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. 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. 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 of guaranteeing 30 minutes of moderate cardiovascular exercise per day are enormous. This level of exercise is associated with a in the risk of coronary artery disease, reduction in the risk of stroke, in progression to dementia and Alzheimer's in elderly patients, in depression rates, in the risk of colon cancer, and 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 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 gained, which pales in comparison to the for treatments of many long term illnesses. Other studies have shown that every $1 invested 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!