The COVID-19 pandemic has already severely depleted our physical, mental and emotional reserves. Even if the most ambitious timescales for a vaccine are met, it’s clear that the fall-out will last for many years to come, not only from the disease itself but from the indirect impacts of lockdown, economic crisis, disrupted medical treatment and social isolation. It is also becoming clear that those who started with fewer resources and shallower reserves are suffering the most.

In this series about healthcare after COVID-19, we’ve considered how to improve resilience from many angles – at a regional, national or system-wide level, by making individual facilities more adaptable, and through the exponentially increasing quantities of data that healthcare environments produce. But the most important source of resilience lies within people themselves: as caregivers, as problem-solvers and, more fundamentally, in the capacity of individuals and communities to cope when crisis hits.

COVID-19 has strongly reinforced what researchers already knew: that healthcare itself plays a relatively small role in the overall health of populations. The conditions in which we are born, grow, live, work and age – known as the social determinants of health – are far more influential. By confining us to our immediate surroundings, the pandemic has made some of the root causes of ill health – as well as the inequities between communities – all the more apparent.

But it has also given us an insight into what healthier, happier places might look like, and the potential for a new kind of urban design, refocused around wellbeing. Applying these lessons to our cities would not only aid the long recovery from COVID, but shore up resilience against whatever the coming decades bring.

The social determinants of health are not a new concept, but they are a growing preoccupation for a healthcare sector that has traditionally focused on treatment. Lord Nigel Crisp, a former chief executive of the UK’s National Health Service, has just published a book called Health is made at home, hospitals are for repairs. “There’s been a massive increase in life expectancy, and we’ve seen some of the biggest gains from healthcare,” he says. “Now we need some big gains from prevention, and we need to refocus on a third thing that has rather been forgotten: health creation. Healthcare is important, but it’s only 10% of health. Health is about your relationships, your context, your environment, about being everything you could be.” Crisp uses Aristotle’s concept of “eudaimonia” or “human flourishing”.

Many elements of the urban realm affect our ability to flourish: the quality of the air we breathe, the ease with which we can access healthy food, the opportunities within our neighbourhoods to safely exercise, and to connect with others and with nature. They also influence how likely we are to develop illnesses such as cancer, chronic respiratory disease, heart disease and diabetes. Incidence of these non-communicable diseases is rising rapidly around the world, threatening to overwhelm societies with the costs of healthcare over the coming decades. They are also linked to worse outcomes from COVID.   

“The social determinants model is really about capturing the stress loads on people as they age,” says Vivienne Ivory, a researcher specializing in social sciences, resilience and public health at WSP in New Zealand. “If you haven’t had those stresses that come from unemployment or poverty or living in a challenging environment, then you can cope with the additional stress from something like COVID much more easily.”

In particular, the experience of lockdown has shown what a difference our surroundings can make: “We’ve discovered that things that were seen as nice-to-haves – places to connect, to move around safely, to see the natural environment – are actually hugely important. During lockdown, people who live in nice neighbourhoods really got to know them. Everyone was out walking and saying ‘hi’ to each other at a distance, and children and families were biking around. But in neighbourhoods that aren’t so nice, no one went out because they felt it wasn’t safe. These are the populations that have suffered poorer outcomes.” This is not just a lockdown issue, she adds: the rise of homeworking will make living conditions an even more significant determinant of health.

A good first step towards addressing disparities would be to look at where health-supporting amenities are located and identify the populations without access to them, suggests Anna Robak, research and innovation manager at WSP in Canada, and adjunct professor at the University of New Brunswick. “Most municipalities probably know where the gaps are already, but it helps to see it starkly on a map like that. When you overlay health data, you’d almost certainty see that’s where the worst impacts are.”

Robak compiled a report about how the built environment could support better health for vulnerable populations, which draws together many studies that link increased physical activity with lower rates of non-communicable diseases, and with the design of the built environment. For example, Canadians living in highly walkable areas did significantly more moderate-to-vigorous physical activity than those in the least walkable, while another study in the US state of New Jersey found that children in low-income areas living within 400 metres of a park were 60% less likely to be obese.

It’s easy to dismiss built environment factors as a proxy for poverty – correlation is easy to show, but causation is hard to prove, she concedes. “What would be interesting is to look at what happens over time if you do put in a park. Is that enough, or does there need to be something more than that? Does it get maintained if it’s in a poor area, is there enough demand if the kids’ parents are busy at work and can’t take them to the park? There’s a great opportunity to learn more.”

These are not necessarily major investments, but they may not be a priority for municipalities because they are not facing the rising costs of treating chronic conditions. Robak suggests that a more holistic view would see government health authorities co-fund improvements to the urban realm, and make municipalities responsible for a proportion of health outcomes. “Like it or not, what municipalities do already affects our health,” she points out. “The way we invest right now means that our most vulnerable populations are the least healthy because they are further away from parks, transit and active transport corridors, and that puts a further load on the healthcare system.” Those who are most vulnerable to chronic illness tend to have lower incomes, to be older, to be less able-bodied or minded, to belong to First Nations or other minorities, be a recent immigrant, or to live in remote or rural areas.

It’s one thing to provide health-creating amenities, it’s another to get people to use them. COVID achieved overnight what city planners and doctors had been trying to do for decades. As indoor activities were restricted, there was a mass exodus as people of all ages went outdoors to exercise, to socialise or just to pass the time. Rates of walking and cycling soared, as a safer alternative to crowded public transport.

“What COVID has taught us is that there is a willingness to change behaviour, but also what we can accomplish when behaviour does change,” says Rasmus Duong-Grunnet, director at Gehl, a Copenhagen-based design and analysis firm. “At a very fundamental level, we should look at how we can use this momentum.” Copenhagen’s world-beating levels of cycling are just a behaviour that has developed over time, he points out.

Gehl has developed a data-driven approach to measuring activity in public spaces, so that interventions can be targeted and measured, rather than just based on assumptions. This helped to make the case for the pedestrian-friendly renewal of New York’s Times Square and the transformation of 45km of riverfront in Shanghai into continuous public spaces. More recently, it compared outdoor activity – how much, what kind, by who – in four Danish cities before COVID, during lockdown and in the early stages of reopening. In particular, it found that local neighbourhood meeting places were thriving more than ever, both during lockdown and afterwards. The most successful shared certain characteristics: they were walkable and accessible, with a diverse mix of amenities.

This supports the increasingly popular concept of the 15-minute city, made up of neighbourhoods where almost all needs can be met within a short walk, cycle ride or trip on public transport. Melbourne’s 2017-2050 land use plan is structured around the 20-minute neighbourhood, while “la ville du quart d’heure” was the centrepiece of Paris mayor Anne Hidalgo’s 2020 re-election campaign. “COVID has made it very clear that this is how we should plan cities moving forwards,” says Duong-Grunnet. “Big cities, especially cities that have grown very quickly, are exploring local communities much more as a potential solution.”

One place looking to do this is the Toronto suburb of Brampton. During COVID, it has seen an influx of Torontonians fleeing their condos for its detached homes with gardens, exacerbating an existing shortage of affordable housing. For the future, it will be promoting higher-density, transit-oriented developments, says City of Brampton policy planner Daniella Balasal. “We’re really seeing the benefit of mixed-use communities that include everything people need within a 20-minute walk. We’ve identified two or three locations and we’re working with the community to develop homes with a mix of social services, retail and high-rise buildings.” This is particularly important for older people, she adds – Balasal is responsible for Brampton’s age-friendly strategy and she says the aim is to build new retirement housing on sites where there are already amenities within walking distance. But how to reconcile higher density with the desire for a backyard? “We can meet some of those preferences in innovative ways. Shared community gardens are a great alternative, or parks or POPS – privately owned public spaces – where a developer could make a private space open to the public. I think we’ll be redefining public spaces and appreciating them a lot more.”

Active travel – walking and cycling – is something of a magic bullet for health creation. “It obviously makes people more active but it can also have a whole heap of mindset benefits as part of the working day and by getting people outside,” says Katherine Bright, director of transportation planning at WSP in the UK. “It helps to improve air quality and helps to take cars and congestion out of the city, which makes the streets a much nicer place and more enticing.”

But taking space from cars is controversial, and meets with fierce opposition from local traders. This is typically why active travel schemes fail, adds Simeon Butterworth, Bright’s colleague and also a director at WSP. “In most transport strategies, the economic viability of the high street takes precedence over the health agenda.” COVID abruptly turned things upside down, forcing through changes that would have taken years. In May, the UK government set up emergency funding for active travel measures. Butterworth and Bright have since worked with more than 30 local authorities to implement measures such as adding cycle lanes and reallocating road space.

Active travel is most viable for the first and last mile of a journey, so it needs to be integrated into transport networks, says Butterworth. “For this to have any long-term influence on how we travel, we can’t just do it in glorious isolation.”

Enter the “mobility hub” – another concept that is fast gaining ground, and which WSP’s UK mobility teams are also helping local authorities to implement. This brings together new and traditional ways of travelling – trains, buses, taxis, shared bikes, e-scooters, delivery robots – alongside facilities or services that may be missing in the local area, whether that’s a supermarket, walk-in clinic, community centre or parcel lockers. “The idea is to make it easier to travel by sustainable modes,” explains WSP associate John Bradburn. “Rather than someone driving to drop their child off at nursery, then driving to work on the other side of town, then to the supermarket and back to the nursery, they might just be able to travel to the local hub to do everything they need and travel to work from there.” “It’s about being people-centric and place-centric,” adds Toby Thornton, technical director of future mobility at WSP in the UK. “It’s grounded in understanding the specific needs of an area and then looking at the gaps this intervention could fill. That might be a lack of access to essential goods, or to education. Some of the components might be temporary so the function of the hub will evolve over time.”

With a greater focus on prevention, health systems might choose to invest in apparently unrelated areas, like transport. Mobility and health are intrinsically linked, argues Stacey Matlen, a WSP employee currently seconded to the City of Detroit as a senior mobility strategist. She has a background in public health and has been working on a pilot project to give seniors access to health-enabling activities using autonomous vehicles. “My goal isn’t just to demonstrate the technology, but also to demonstrate the business model and the value of transportation to health – to make that causal connection between transportation access and access to basic services and health outcomes.”

Active travel is easier in some climates than others. In the sweltering summer temperatures of the United Arab Emirates, making cities walkable would mean providing some form of shade over the majority of walkways, points out Farah Yassine, WSP’s sustainable resource management lead in Dubai. Existing UAE green building regulations do enforce a percentage of shading, and Yassine says that clients are becoming more interested in outdoor thermal comfort as they realise the positive commercial impact of higher footfall, in addition to the health benefits that a connection to nature can offer. Standards such as WELL can be useful for helping developers to understand the features that support health, she says, “but what is really key is that health and wellbeing is a priority in the project brief. Good design that is people-centric will inherently encompass health and wellbeing principles.” Yassine believes that communities should be invited to play a much greater role in shaping new developments. Health can mean different things, she points out: “For some people, it might be having a gym in their building, but for others it might actually be having a playroom for kids. We can create healthier places by asking people what works for them, which will ultimately help them to lead healthier lifestyles.” Empowering people to shape their communities can have a positive impact on mental health too, she adds.

A more people-centric design process would place far greater priority on accessibility and inclusiveness, not only to encourage everyone to move around more but to foster social interaction. This has been one of the great takeaways of the pandemic: just how severely a lack of contact can affect us. Researchers were already discovering a rising trend for feelings of loneliness among those living in big cities. If we don’t manage to arrest this, a bleak future beckons.

“If we’ve learned anything from the last 12 months, it’s that our built environment needs to be more inclusive and reflect the world in which we live,” says Michael Tyrpenou, principal of social strategy and design at WSP in Australia. “This is an opportunity to recast the role that cities play, and the way that people use them. We need to include a more diverse range of views and lived experience, and we need to challenge the codes and standards that we design to by involving end users in the process.”

“Third places” that are neither home nor work – cafes, libraries, park benches – are a good way to promote casual contacts, says Vivienne Ivory. “Even a bus can be a third place if you go there regularly and you feel that you belong. Designing for those opportunities will become really important.”

Loneliness is often framed as a problem for older people. But we need to worry about the young too, says Ivory. “The uncertainty around COVID, in terms of what it means for the next three months, let alone the next ten years, threatens to disengage our youth in particular. We need to find a way of keeping them engaged because if we don’t, society is going to have a real problem.” As unemployment rises, the built environment needs not only to make space for young people, but to invite them to help create it. “We need to think about it in a social value sense: how do we design and construct in a way that involves youth, so that they’re getting that sense of purpose when traditional paths may not be open to them.” In New Zealand, she adds, there is an emphasis on “green jobs” or conservation activities in native forests – could the built environment offer similar opportunities for meaningful work?

Ultimately, designing healthier places is essential to ensure the future of cities themselves. COVID and the growing acceptance of homeworking has prompted many urban dwellers to consider a move out, to smaller towns or rural areas where they can find more space, fresh air and nature. Meanwhile, public transit ridership is down and private car use is rising for short trips, increasing congestion, air pollution and carbon emissions. If the pandemic results in a shift to lower-density urban sprawl, it could frustrate our attempts to prevent catastrophic climate change and ecosystem collapse – with consequences for human systems far beyond healthcare.

We urgently need to reframe the debate, says Duong-Grunnet. “The question shouldn’t be ‘should we live in cities or not’, it should be ‘how should our cities be designed so that we can live healthy, equitable and sustainable lives in them’.”