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A History of Health + Urbanism + Architecture

One hundred years ago, the public health and urban planning professions were nearly indistinguishable

By Jocelyn Pak Drummond, Researcher, P-REXlab at MIT
MIT Center for Advanced Urbanism

Over the past two decades, there has been a resurgence of interest in the relationship between the fields of architecture, urban planning and public health. Researchers and professionals in these fields have identified the need for better connections between the disciplines in order to address today’s major health concerns. Currently, there is very limited consideration of urban health issues in the planning and design processes of cities. Part of the reason for this limited consideration is inadequate understanding of the relationships between the urban environment and urban health. Research is being conducted in cities around the United States to better understand these relationships and inform policies and design strategies that target health issues.

Organizations at the national, state, and local levels have created indicators of the urban environment and health outcomes to measure the impact of the physical, natural, and social environment on urban health. Much of this research is in the elementary stages, but the momentum to reconnect urban planning and urban health is growing, and these relationships are at the nexus of burgeoning new opportunities for urban designers, architects, landscape architects, and city planners.

It is important to note that throughout this report the term “urban health” is used instead of “public health” when referring to human health problems and urban contexts. Urban health has been defined as “the explicit investigation of the relation between the urban context and population distribution of health and disease.”1 The urban context is important to this definition as it limits the health discussion to aspects of population health that are affected by the environment of cities. There are many other components of public health, including epidemiology, health services, and health economics, but these topics will not be addressed in this report.

Urban planning and public health emerged out of the same urban movements in the nineteenth and twentieth centuries. Some scholars even considered these fields to be the same as late as the 1930s. Some have written about the two “parent disciplines” of city planning: medicine and architecture.2 Other scholars have written about the ways in which urban planning stemmed from a combination of public health and landscape architecture.3 Regardless of the language or lens used, a similar trajectory is traced in these various histories that reveals a parallel emergence of public health to the urban planning issues of the day. These parallels can be traced through time, from the Sanitary Movement in 1840s England, to the Garden City and City Beautiful movements of the early twentieth century, to the era of Modernism and post-war suburban expansion, and ultimately to the separation of planning and public health as individual and disparate fields in the mid-twentieth century.

Prior to the 1840s, land use patterns in England were determined primarily by the economic market. City services for citizens were provided privately and the role of the government in urban life was limited. John Snow, who is considered the founder of modern epidemiology, discovered that the source of a cholera outbreak in London was a contaminated water pump in 1854.4 When Pythogenic theory (or “filth theory”) made it clear that disease was caused by the decomposition of organic matter, the sanitary movement was established to address unclean conditions. In many parts of the world, rapid industrialization led to dangerously high levels of air and water pollution, insufficient disposal of hazardous waste, and deterioration of the building stock. 5 The health epidemics of the past included cholera, typhoid, yellow fever, typhus, scarlet fever, diphtheria, influenza, and tuberculosis.6 To combat these health issues, sanitary reformers began to develop new citywide sewer systems to rid cities of the diseases they believed were caused by the environment. These systems also marked a shift toward public intervention in city services, which had previously been managed privately.7 Sanitary reformers are thus considered by many to have been the first urban planners. 8

In the United States, the connections among sanitation, health concerns, and landscape architecture began with the work of Frederick Law Olmsted and his contemporaries. During the Civil War, Olmsted was the leader of the United States Sanitary Commission, an agency created by the federal government to support sick and wounded soldiers. After the war, Olmsted joined the American Public Health Association (APHA), established in 1872. He later became the chairman of the APHA’s committee on “sanitary value and uses of shade trees, parks and forests.”9 The prevailing views that dense urban populations and overcrowding were at the root of disease meant that open space and nature were cures for this disease. Olmsted’s theory of urban progress, which he formulated in 1868-1871, focused on issues of overcrowding in cities and posited that parks, parkways, and suburban neighborhoods contributed to better health.10 He also initiated the argument that visual proximity to nature and greenery is beneficial for mental health.11

While Olmsted was developing his theory, cities around the country were conducting block-by-block surveys of sanitation conditions with the goal of improving the water, air, and sewage systems.12 These surveys reflected and supported some of the main ideas that sanitarians developed regarding the effects of the city condition on health. From these surveys, a set of guidelines was developed. Density, overcrowding, and congestion were to be avoided, and thus tenement buildings were problematic. Parks, trees, and opportunities for outdoor exercise were important for the health of city residents. Establishing pure water supply and water-carriage sewer systems, as well as storm water drainage systems was essential for dry, sanitary conditions. Nuisance trades (such as slaughter houses) were to be separated from built-up residential districts.13 The seeds of urban planning theory can be found in these initial ideas aimed at ridding cities of disease, which followed Olmsted and others into the twentieth century with the Garden City movement.

Ebenezer Howard’s manifesto, revised in 1902 with the title Garden Cities of To-Morrow, established a new model for cities. The Garden City built upon previous solutions to unhealthy urban conditions that were initiated in the late nineteenth century, but focused specifically on the issues of housing and population density. Howard’s model “proposed to solve, or at least lessen, the problems of the Victorian city by exporting a good proportion of the people and jobs to self-contained new towns in open countryside.”14 The Garden City model included providing sunlight and air in housing and promoted low-density development to alleviate overcrowding.15 These prescriptions were appropriate for what were then understood to be the environmental causes of disease.

In January 1909, the Committee on Congestion of Population held a conference on city planning in New York City, and a second conference in 1910. These two conferences largely defined the modern era of city planning practiced today. There were two competing movements represented at these conferences, each with a different leader and spokesman. On the one hand, Benjamin C. Marsh approached city planning from a social progressive background and was interested in bringing justice to the working population of cities. Frederick Law Olmsted Jr., on the other hand, was influenced both by the work of his father but also by the City Beautiful movement and the use of built form to express public ideals and civic pride. Olmsted Jr. wanted to bring order to cities, making them more efficient, livable, and attractive.16

The clash between Marsh and Olmsted Jr. in 1909-1910 ended in a victory for Olmsted. By the end of the second conference, the social progressive roots of the city planning field were largely abandoned in favor of the City Beautiful model of comprehensive planning. A major component of these plans included public parks and citywide systems of open space. These interventions contributed to the aesthetics of cities and improved health conditions. Olmsted Jr. did not agree with the City Beautiful movement entirely and was more interested in the process of planning than the creation of “expertly crafted comprehensive plans.”17

There were many hurdles and challenges along the way for urban health and beautification advocates. In 1913, Arthur Trystan Edwards challenged Howard’s Garden City model and posited that sunlight and hygienic conditions could be attained in the classic urban fabric, that suburbs were not the only models for alleviating poor health conditions.18 The debate about relative healthfulness of suburban city forms versus densely populated city center fabrics continues today, alongside generalized opinions about the relationships between open space, nature, and health.

An often forgotten milestone in the history of urban health and city planning was the advent of zoning. The zoning ordinances of the 1920s were an important tool for planners to increase efficiency in cities but also to establish more hygienic conditions by isolating uses that were deemed unhealthy for the population.19 Zoning was associated with social progress, but this progress was narrowly defined (as it had been in the past) and involved exclusionary practices based on social class, wealth, and poverty.

By the 1930s, cities were able to control disease and create functioning sanitation systems. There was less of a need for reformers and planners to deal directly with health concerns, and therefore less of a need for these professionals to work together toward the same goals. The public health field began to drift away from filth theory and toward germ theory, which dealt with the biological causes of diseases rather than the environmental ones.20 In 1939, the American Association of Public Health published Basic Principles of Healthful Housing with a focus on pedestrian segregation from cars, the benefits of cul-de-sacs and introverted layouts of development, landscaping, and community design. During this era, planning and health were linked in title but not in practice.

In the postwar period, middle-class Americans began buying more cars and moving to newly formed suburbs. Urban cores around the country were depopulating and cities were losing their tax bases, leaving behind abandoned buildings and blighted neighborhoods. The 1949 Housing Act, Title I, provided federal funding for slum clearance, making way for superblocks and expressways through neighborhoods. 21 The results of urban renewal (particularly large scale highways located in dense residential neighborhoods) are recognized today as some of the most detrimental aspects of the urban environment in terms of urban health, with direct association between asthma, air particulates, and highway congestion to name a few.22

Over the last few decades, global and national initiatives have begun to recognize the need for reconnecting the fields of urban design and planning and public health. By 1999, the World Health Organization’s Healthy Cities project was focused on the impact of behavior, health delivery, and inter-agency coordination to take a preventive approach to health that included issues of the built environment. The WHO’s 1999 report highlighted the aspects of urban environments that support health, including ecology, sustainability, social networks, transportation, and housing.23 By the new millennium, the field of city planning had begun to deal with environmental issues again through the lens of sustainability, but without a direct focus on health.24 This missing link is what today’s researchers and designers are beginning to understand and address. Over the last ten years, the literature in both the planning and public health fields has become more sophisticated about the observed relationships between the physical, natural, and social environments and health (see Figure 1). It is interesting to note that one constant runs through the planning and health history of the last two centuries: housing and buildings. The first planners were concerned with what have now been termed “sick buildings.” Sick buildings create unsafe indoor conditions when hazardous materials are contained within the buildings.25

Before diving into any collaborative project with city design and urban health fields, it is helpful to recognize how scholars see differences between contemporary planning and health and those of the late nineteenth and early twentieth centuries. The most obvious difference is in the type of health epidemics that face urban populations today. While infectious disease is no longer a major problem in developed countries, chronic disease is widespread. Today’s health epidemics include diabetes, heart disease, obesity, asthma, and mental illness.26 A second difference is that the role of government in shaping the urban environment has grown tremendously over the last century. Today, the public sector is involved in almost all aspects of city form through regulations, zoning, public spending, etc.27 Finally, as has already been noted, while planning and public health professionals were arguably parallel fields in the nineteenth century, today they have become so separated that there is rarely collaboration among these experts. Scholars and professionals on both sides call for a reunification of their disciplines to address the pressing health concerns of today.

Endnotes and annotations >

This is an excerpt from the MIT Center for Advanced Urbanism Report on the State of Health + Urbanism.


Railroad Park in Birmingham, Ala., by Tom Leader Studio and Kennedy and Violich Architecture. Image courtesy of Tom Leader Studio.

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