A particularly colorful story from the history of epidemiology involves a single water pump on a London street. The year was 1854 and a global cholera pandemic was in full swing, claiming more than 10,000 lives in the English capital alone. Desperate to find a solution, one physician, John Snow, decided to take a different approach than his colleagues. Over the course of the outbreak, Snow had grown skeptical of the then dominant “miasma theory,” which blamed the spread of disease on noxious or “bad air.” Snow believed that some diseases were waterborne, and to prove his hypothesis, he studied the pattern of deaths and plotted them on a map overlaid with the various water districts.
The results were shocking. While all of London was touched by the illness, the area surrounding the Broad Street water pump saw a staggering 500 people die in just 10 days. A local clergyman had noted the pump was only a few feet away from an open cesspool — not an uncommon sight in London during the mid 19th century.
After battling with local community leaders, Snow convinced officials to remove the handle from the Broad Street water pump — an act that some experts credit with helping to end the cholera outbreak in the area. It was also one of the earliest suggestions that infrastructure planning can have a direct impact on public health — an idea that eventually informed much of the European and American urban build-out of the 19th and 20th centuries.
In the developed world, epidemics still exist of course, but they tend to have more to do with lifestyle than bacterial disease. Factors including excessive alcohol drinking, smoking, poor eating habits, inadequate relief of chronic stress, and lack of physical activity are at the root of many of the chronic ailments that affect more than half of the American adult population, according to the U.S. Centers for Disease Control and Prevention (CDC). These diseases, including type 2 diabetes, several types of cancer, obesity, and cardiovascular disease, are largely preventable, the John Snows of today now know. But is there a water pump handle to be removed — one that can alter public behavior and curb these modern maladies?
A growing number of researchers have become convinced that there is — and they are actively looking to classic examples of early 20th-century urban planning for inspiration. One group spearheading such efforts in the U.S. is the non-profit Center for Active Design in New York. Established in 2012, the group is dedicated to re-orienting the focus of design and city-planning practices towards supporting healthy living and improving quality of life. President and chief executive officer of the organization, Joanna Frank, explained that active design takes data and research and translates them into strategies that can be used in the building industry. These strategies are based on the theory that human behavior is dictated by the surrounding physical conditions, and that environmental “nudges” can promote healthier practices.
In order to implement their original research, the Center for Active Design took over administration of a certification system called Fitwel — developed by the CDC, the General Services Administration, and the City of New York — in 2016. Comprised of 63 strategies developed through CDC expert analysis of over 3,000 academic studies, Fitwel scores buildings based on how effectively they promote a healthy, active lifestyle. A building or community could gain Fitwel points by having weekly produce sales, for example, or by providing a space for exercise and promoting the use of bicycles over public transport.
“People need safe, convenient places to be physically active,” Christopher Kochtitzky, senior advisor of the CDC’s Physical Activity and Health Branch, wrote in an email. “Creating or modifying environments to make it easier for people to walk or bike is a strategy that not only helps increase physical activity, but it can also make communities better places to live.”
These strategies owe much to a behavioral science concept called “nudging.” Developed by economist Richard Thaler, who in 2017 won the Nobel Prize for Economics, nudge theory uses positive reinforcement and indirect suggestion to influence individuals or groups. Human beings walk through a landscape of choice every day, after all, and while some choices — like where to send your child to school — are deeply conscious and take considerable deliberation, the majority of decisions we make daily are based largely on what’s easy and what’s accessible.
Take elevators, for example. In most office buildings today, they are highly visible, while stairs are more often hidden behind heavy doors. We choose the less healthy option of taking the elevator simply because it is the most visible and convenient.
By shifting the architecture of these spaces and making large, naturally lit stairways central to the design — while of course noting that elevators are essential for those with disabilities and necessary in cases where people are transporting heavy materials — designers can have a real impact on public health. In this scenario, the nudger does not take away choice, but rather makes the healthier decision the easiest one.
Cass Sunstein, who co-authored the 2008 book “Nudge: Improving Decisions about Health, Wealth, and Happiness” with Richard Thaler, says that nudge theory is already having a positive effect on populations. “They are helping to reduce smoking, to cut alcohol consumption, and to help with the opioid crisis,” Sunstein wrote of nudges in an email. “We have a long way to go, but in the United States, the United Kingdom, Canada, the Netherlands, Ireland, and many other countries, nudges are already improving public health and saving money in the process.”
According to Kochtitzky, the idea to put nudge theory and active design into public use was directly inspired by early city planning initiatives. The 18th- and 19th-century mass migrations to industrial metropolises like London and New York created rampant sanitation problems and, subsequently, the spread of disease. Squalid environmental conditions became commonplace in working class areas, with filth and garbage accumulation on the streets.
Unsurprisingly, a survey of tenement housing lasting two weeks in New York’s 16th ward found more than 1,200 cases of smallpox and more than 2,000 cases of typhus. Early experts theorized that the diseases were carried into the U.S. by immigrants from foreign shores, but officials began to realize that urbanization was at the root of the sudden increase of viral epidemics. In response, cities like New York decided to start attacking the problem through design and infrastructure, creating state-funded initiatives like the Department of Street Cleaning in 1881 and passing laws like the Tenement House Act, which set new standards for lighting and ventilation in New York State, in 1901. By 1940, the percentage of deaths from infectious diseases in New York City went down to just 11 percent, thanks largely to these and other infrastructure changes.
Through active design and the Fitwel initiative, the Center for Active Design and the CDC hope to produce the same effect for chronic diseases — which also disproportionately impact low-income families: Obesity, for example, is more prominent among lower wage earners in part because fast food is often cheaper and far more accessible than fresh fruits and vegetables. Similarly, the psychosocial stress of living in a dangerous low-income neighborhood can deter more active lifestyles. “If I don’t trust my neighbors, if I don’t trust police, I’m less likely to walk down the street,” Frank says.
It is still far too early to divine whether or not the effects of active design and nudge theory will have the same sweepingly positive effects that turn-of-the-century city planning initiatives did, but early results are promising.
Currently, the Fitwel certification system has more than 650 registered projects in more than 35 countries across the globe. This number includes seven long-term case studies located in California, Virginia, New York, Minnesota, Maryland, and Ontario, Canada. The Fitwel case studies range from buildings that modified their existing practices to fit within the certification system to construction projects built with Fitwel specifically in mind.
Health insurance company Anthem, Inc., for example, adapted one of their buildings in Norfolk, Virginia by offering price discounts on healthy foods in the cafeteria, adding fitness facilities, and installing a well-located central staircase to promote physical activity. The Pearl apartment in Silver Spring, Maryland, on the other hand, was built to adhere to the Fitwel certification system and features open green spaces for residents, an on-site urban farm, a two-story fitness center, expansive views of the outdoors, and a communal kitchen where chefs show residents how to cook healthy meals sourced from the shared garden.
The Pearl is an example of a more upscale Fitwel-certified building project, but the Center for Active Design is also focused on affordable housing and low-income community projects. One of its earliest undertakings was an affordable housing complex called Aria Apartments located in Denver, Colorado.
Opened to residents in 2013, Aria is a far cry from the dilapidated high rises that spring to mind at the word “affordable.” Rather, it consists of 72 brightly colored, spacious low-rent apartments and 13 market-rate townhomes. An on-site fitness center looks out onto a verdant lawn, and a community garden is available to all residents, along with a pay-as-you-can fresh produce stand. And Aria is not just a one-off: in 2017, the Center for Active Design partnered with Fannie Mae to create the Healthy Housing Rewards initiative, which offers “below market-rate loan pricing for borrowers who incorporate health-promoting design features into their newly constructed or rehabilitated multifamily affordable rental properties.”
Though hard data is not yet available, researchers throughout the field are hopeful.
“It takes a very small shift in behavior to have a very significant impact on outcomes, so just 15 minutes of exercise more a week,” Frank says, can increase life expectancy.
“I don’t think that we will cure chronic disease — at least in my lifetime,” Frank added. But, referencing nudge theory, she says, “it is these small incremental changes in lifestyle that have a very profound impact over a lifetime.”
UPDATE: An earlier version of this article incorrectly described cholera as being caused by a “deadly virus.” The disease is caused by a bacterium known as Vibrio cholerae. The story has been updated.
Addison Nugent is a freelance journalist based out of Paris. Her work has been featured at the BBC, OZY, Vice Motherboard, Atlas Obscura, and Dazed Digital, among other publications.