Continuing a Croakey series examining the factors that have a profound, but often under-recognised, impact upon the community’s health…

Below is an edited extract from a new book from Catholic Health Australia, Determining the Future: A Fair Go and Health for All, which outlines how the recommendations of a 2008 report of the WHO Commission on Social Determinants of Health should be adopted in Australia.


Poor urban design is a health hazard

Peter Sainsbury, Elizabeth Harris, and Marilyn Wise write:

Most discussions about the social determinants of health focus on issues such as income, wealth, social class (a British favourite), socioeconomic position, education, culture, gender, age and race (a favourite in the USA).

In this chapter we focus attention on a determinant of health that is frequently forgotten in discussions about the social determinants of health—the built environment.

But the built environment is not simply another social determinant of health … the built environment is a strong influence on other determinants of health (for instance housing conditions and access to work and educational opportunities), reflects existing social inequalities and hierarchies, and potentially entrenches these inequalities and hierarchies for years to come.

Planning the city

Built environments do not occur only in cities of course—they are created in towns and rural areas, along coastal zones and highways. But globally, and in Australia especially, most of the population lives in cities and this trend is increasing. It is crucial, therefore, that we build cities that promote healthy behaviours and minimise threats to health.

Although there were many positive outcomes associated with better housing and improved neighbourhood amenities in the 20th century, the styles of urban development that appeared in the second half of the century in high income countries often had unintended harmful consequences for community health. The urban sprawl and separation of residential areas from employment zones and shopping and service areas that were features of many cities has been harmful for health in many ways.

The development of far flung residential suburbs, almost always without adequate public transport services, would have been impossible without the increase in car ownership but the people who live in them are totally dependent on their cars—for getting to school, work, shops, recreational facilities and public transport hubs. This had led to decreased physical activity as a normal part of day to day life and contributed to the increasing prevalence of chronic diseases such as obesity, diabetes and heart disease.

It has also reduced the opportunities available for social interaction (an important influence on physical and mental health) through, for instance, increasing commute times, isolating anyone left at home during the day without a car, and separating families from relatives and friends in distant suburbs. The increased dependency on private cars has also increased air pollution and greenhouse gasses, not to mention created the unproductive and unhealthy road congestion experienced in most large cities.

Rapidly developing countries like China have the opportunity as they create many entirely new cities to avoid the mistakes made in developed counties over the last century. Australia, however, will have to remodel the cities we already have.

Building healthy, safe, liveable neighbourhoods

What creates a neighbourhood that is nice to live in, that people want to live in, that helps people to be healthy?

The people themselves are important of course, but having nice, well-meaning individuals is not enough. The local built environment also influences whether people are able to live physically, psychologically and socially healthy lives.

To give just a few examples:

  • There was a vogue in the 1960s and 1970s to abandon grid patterns for streets and build suburbs with sinuous crescents and many cul-de-sacs. The idea was to create quiet, private streets that had no dangerous through-traffic and where children could play safely. Unfortunately, the outcomes often were physically and socially disconnected streets, little shared sense of community and long indirect routes from home to nearby (as the crow flies) common destinations such as shops, schools and bus routes. As a consequence, residents used cars for relatively short journeys and the resulting absence of people and interest on the streets further discouraged incidental walking and socialising.
  • During the 20th century cars, both moving and parked, progressively displaced people on foot and bicycle from the streets, a domain where before 1900 pedestrians (and animals) had been supreme. The situation became so ridiculous in the later decades of the 20th century that some new suburbs had streets without any pavements, or at best on one side of the street only. For the fit and healthy, walking and cycling became difficult; for people with disabilities and people pushing prams the situation was nigh impossible.

Creating healthy built environments

We know that not all built environments produce good health. We also know that the same built form can have very different impacts in different places, for example … the public housing high-rise estates in inner Sydney and many parts of Europe and the USA often created ghettos of disadvantage, while high rise buildings on the foreshores of Sydney and adjacent to Central Park, New York, are highly desirable and people living there have some of the best health outcomes.

This emphasises the complex inter-relationship between the built environment, the people who live there, the relationships that develop within the community and the extent to which government, the private sector and civil society invest in the ‘soft infrastructure’ that makes communities work (eg community centres and services, policing and crisis services).

The good news about the built environment as a social determinant of health is that it is possible for concerned citizens to have an influence on the planning and design of their own neighbourhood, town and city. In small but potentially important ways, individuals can also influence their own and other people’s health through the design and appearance of their own homes. And the health and education sectors can play a significant direct role by ensuring that their own hospitals, health centres and schools make healthy, sustainable contributions to the built environment.

There is now a large body of evidence that indicates that various elements of the built environment influence people’s health and it is incumbent on everyone who wants to help create healthier built environments to ensure that this is brought to the attention of developers, architects, urban planners, engineers and decision makers, many of whom, it should be said, are already knowledgeable and sympathetic.

We may not have all the answers but ignorance of the influence of the built environment on health is no longer an excuse for fundamentally poor urban design.

• The authors are from the University of Sydney, and the Centre for Health Equity Training, Research and Evaluation (UNSW). Copies of the book can be ordered at


Previous posts in this series

• The health issues that really matter

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