How We Build Cities Is Literally A Matter Of Life And Death

Covid-19 has been a monumental wake-up call across generations – succinctly put, a health crisis for older people and an economic crisis for the young. It calls for a substantial overhaul of the way elder care is provided, in light of the disproportionately high death rates in nursing homes—47 percent […]

Covid-19 has been a monumental wake-up call across generations – succinctly put, a health crisis for older people and an economic crisis for the young. It calls for a substantial overhaul of the way elder care is provided, in light of the disproportionately high death rates in nursing homes—47 percent of recorded coronavirus deaths across 26 countries. 

But so far, there hasn’t been discussion of an equivalent overhaul for young people, who appear to be the most deeply impacted, long term, on social and financial levels. Millions of young workers filed for unemployment since Covid-19 hit, and many young adults are hitting the pause button on getting married or having kids.  Here I’d like to discuss how living conditions for young and old, particularly those in cities, needs to be newly envisioned to support life and promulgate social instincts, rather than foster isolation and death.

The story of cities failing to support life in an equitable way has been true throughout history: while the marble monuments of Ancient Rome remain, the wooden tenements where most Romans lived—which were a perpetual fire hazard—do not. Likewise for London until 1666, and for Chicago until the Great Fire of 1871. 

Urbanization and industrialisation resulted in outbreaks of cholera and typhoid as well as smog and other forms of pollution. Air quality is still a problem today in many cities—one only has to scroll down to the Air Quality Index on the iPhone weather app to see the huge disparities (Oxford, England 1; Portland, Oregon during the wildfires, 515) between places that have gained control of industrial and environmental pollutants, and those that haven’t.  To top it off, we have intra-city and inter-city inequality in health and wealth.

How can we plan for better cities in the future?

Planners and builders of future cities face numerous challenges today, including adaptation to an aging demographic; health inequalities, unacceptable differences in healthy life expectancy; and the need to tackle not just physical but also mental health. 

First, the aging demographic. There are currently around 12 million people over 65 in the U.K., and in the U.S., over 40 million. The proportion of the “oldest old”, the over 85s, is growing fastest of all—in the U.S. this number is projected to be 11.8 million by 2035, and 19 million by 2060. 

Not all of these folks want to live in seaside cottages—they want good housing with access to friends, family and facilities like transport, healthcare and leisure. Aging is not a “bad thing”—long life should be celebrated, and with so many older people having disposable income to drive valuable consumer spending, older age becomes far less of an onus. Indeed, if global retirees were a country, they would be the third largest economy in the world, behind only the U.S. and China.

Modern urban planning does not adequately recognize this. We need more housing and better choices across all tenures for older people. This is why Legal & General donated $6.6 million to the English city of Newcastle—to create a new Model Care Home that sets the standard for how cities can deliver more options for the elderly in the future.  I hope that many cities will study Newcastle’s prototype and follow them on this journey.

Choices for elders should include multigenerational housing, better integration to create mixed-age communities, retirement villages, more supported housing for early-stage care requirements and more formal care settings—all properly integrated into communities. This needs to be supported by infrastructure that works for older people. Currently in the U.S., for example, just 3.5 percent of homes have features that allow for aging in place; couple this with four out of five American homeowners over 65 living in single family detached homes.  And in many U.S. metro areas, including New York, Boston, Los Angeles, Miami and Seattle, more than 40 percent of older adult households are “cost burdened,” according to a Harvard Joint Center for Housing study. If we can get the elder housing piece right, we can then pivot to addressing the housing crisis for the young, first by freeing up homes that are currently under-occupied by older people who currently have no better options clearly in sight.

The situation of the urban elderly brings me to health inequalities.  In London alone, around 60,000 older people live in unhealthily sub-standard accommodations which are cold and damp, with trip and fall risks, impossible to maintain or heat. New York’s housing situation is too complicated to reduce to a simple metric, but consider that if the population of all New York City’s affordable housing projects were combined, the number would constitute the 21st largest city in the U.S., bigger than Boston or  Seattle. The majority of these buildings are grossly underimproved and crumbling. 

The health risks these buildings pose are the tip of the iceberg. The United States is widely thought to have greater health inequality than Japan and some European countries. Looking at the work done by Sir Michael Marmot of the World Health Organization, we see huge life expectancy differentials in the U.K.: 53.3 years in Blackpool compared to 71.9 years in Richmond-upon Thames for men; 54.2 years for women in Nottingham versus 72.2 years in Wokingham. Those entering ill health earlier don’t just die younger, they spend longer in ill health—a terrible outcome for them and for society.

This is a big problem with multiple causes. The built environment and housing is a major influence, and not only for older people. According to Shelter, poor housing in childhood has a long-term impact, increasing the risk of severe ill health or disability in childhood and young adulthood by 25 percent. 

Returning to Covid-19, we have a stark reminder that our Future Cities need to recognize the risks of overcrowding and infectious diseases.  The U.K.’s Institute for Fiscal Studies uncovered that the geography of Covid-19 shows wide variation both in numbers of cases and numbers of deaths, with case numbers predictably highest in dense, well-connected cities.  But infection case numbers do not map directly to deaths, so outcomes also have to do with the resilience versus the vulnerability of the population—including health, labor market, and family vulnerability driven by socioeconomic factors.

We need to reduce all three of these vulnerabilities through the way we plan, design and construct future cities. This is not just about housing but about a healthy local economy not over-reliant on a single sector, and about the broader environment.

If we are to “level up” some of these inequalities, it won’t just be about pouring billions of dollars of investment into projects.  We are very aware that we need to work in partnership with local authorities and communities to ensure that investment creates places that improve health outcomes by design.

Which brings me to the mental health crisis, which has been so sharply exacerbated by Covid-19. Cities have an almost 40 percent higher risk of depression, 20 percent more anxiety, double the risk of schizophrenia and more loneliness, isolation and stress than rural areas. Design can reduce risk factors such as noise and support protective factors like access to green space and nature.  It can also plan communities that encourage neighborly interaction and life on a human scale.  We need to learn from previous mistakes, as anyone living in New York City public housing would tell us.

We have real power to affect lives for the better—or worse—as we design future cities to be great places to work, live and play.   The real estate industry can’t hope to tackle this alone: we’re actively engaging with local Public Health boards to learn from them as we seek to design places that reduce loneliness and create more inclusive communities.

I am an optimist about Future Cities.  I have seen what can be done by quality urban regeneration, for example in the English city of Salford, one hundred years ago a bustling port city adjacent to Manchester, then an industrial wasteland, and today the home to Media City, with many times more digital jobs than it ever had dockers’ jobs. 

Salford provides a good historical example of the key role of data in public health, as well. From 1861 to 1870 the Manchester and Salford Sanitary Association collected weekly stats on local health, prosperity and weather, in total 700,000 data points over a decade.  With this information, they could track and trace the spread of contagious diseases from typhus to scarlet fever and measles. They managed to successfully limit transmission when there were outbreaks of particular diseases in foreign ports with connections to Manchester.  They published data every week in local newspapers to allay fears or encourage vigilance as required. Over time, this initiative contributed to the massive improvement in sanitation and public health. The British Medical Journal at the time said, “…it is to be hoped that at some future time the Government may see the importance of establishing a National Registration of Disease.” In the time of Covid-19 track and trace, that statement now looks remarkably prescient.

Public health and climate must be part of urban regeneration. This isn’t a new idea but, as I said at the outset, it becomes a matter of life and death to look beyond bricks and mortar, even beyond pounds and dollars, to forge communities that put the utmost value on people, their health, and living a longer, better life.  Or as Joseph Coughlin, founder and director of Massachusetts Institute of Technology’s AgeLab, commented on the phenomenon of extending human life even as we slow the aging process, “The greatest achievement in the history of humankind, and all we can say is, is it going to make Medicare go broke?”

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