Is your neighborhood more likely to have fast food joints or farm stands? Can your children walk or bike to school along a system of safe, connected sidewalks? Does your workplace keep you safe from secondhand smoke and other environmental pollutants? None of these things are accidental. They are all a result of public and private policies and laws, funding decisions, and community action. In their book, Prescription for a Healthy Nation: A New Approach to Improving Our Lives by Fixing Our Everyday World,Deborah Cohen and Tom Farley describe several factors that shape our “healthscape.”
Our community shapes our choices, but we can help shape our community.
For example, if we live in a walkable neighborhood with sidewalks, well-lit streets, and destinations (e.g., shops, libraries, parks), we are more likely to take walks and get exercise. We are more likely to meet neighbors and feel a sense of belonging.
But “walkability” doesn’t happen by accident. It is shaped by public policy, urban planning, neighborhood redevelopment funding and zoning decisions… and the concerted action of citizens to influence these things.
In fact, public health and urban planning share common roots; both disciplines began as cities became crowded, ghettoes formed, infectious diseases spread, and it became necessary to intervene by improving sanitation and housing conditions. One of the seminal events in public health was when Dr. John Snow mapped the London cholera epidemic to the Broad Street water pump in 1854. The reduction of infectious diseases, largely through advances in sanitation, clean water and food, as well as vaccination, has been hailed as one of the ten great public health achievements of the 20th century.
Shifting the Curve
Cohen and Farley propose “shifting the curve” so that we are all healthier. Shifting the curve means using strategies that improve health for everybody–not just targeting a few. Similarly, Thomas Frieden’s “A Framework for Public Health Action: The Health Impact Pyramid” points out that targeted interventions, such as individual or small-group health counseling, are often too resource-intensive to be successful at improving the whole society’s health. It takes a population approach to make the biggest difference.
Community-level strategies that change the overall HealthScape are most effective, reach the greatest number of people, and produce the best results.
Frieden calls this “changing the context.” Cohen and Farley call this “curve shifting.” I call this HealthScaping.
HealthScaping–creating healthy community conditions–will have a stronger impact than just targeting interventions to the highest risk individuals
“HealthScaping” is a new term for an old practice: Health Promotion.
Health promotion focuses on preventive strategies that create the conditions in which people can be healthy. Our health is inextricably linked to the community in which we live. As expressed in the Ottawa Charter for Health Promotion (1986), “Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love.”
Good health is not merely the result of good medical care but the result of what we do as a society to create conditions in which people can be healthy. Public policy can be one of the most effective approaches to protecting and improving the health of the population. “Healthy” public policy is particularly important in a time of scarce resources, because it can diminish or preclude the need for other, more costly and potentially less effective interventions. For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges, Institute of Medicine
HealthScaping to Reduce Chronic Diseases
HealthScaping is all about changing the context, making healthy options the “default choice,” as Frieden says.
Just as iodized salt has virtually eliminated goiter and cretinism, and water fluoridation has reduced tooth decay by 40-70 percent, we can HealthScape our neighborhoods, schools, and workplaces to reduce obesity, diabetes, heart disease, and cancer. We can improve quality of life, extend length of life, and reduce healthcare costs.
Cohen and Farley list several aspects of our environment, our context, our HealthScape, that can be changed:
1. Design neighborhoods to increase safety and promote physical activity
2. Make healthy foods, especially fruits and vegetables, easier to get
3. Make unhealthy items, like junk food and tobacco products, harder to get
4. Make healthy behavior more socially acceptable (smoke-free workplaces, physical activity breaks at work)
5. Harness the power of popular media, advertising, and movies
For example, we can reduce obesity, diabetes and heart disease by making healthier food available in workplace and school cafeterias and vending machines. We can reduce youth tobacco use by licensing tobacco retailers, getting rid of menthol and other flavored “starter” tobacco products, and by making more public places tobacco-free. We can promote breastfeeding, which reduces obesity, infectious diseases, and improves school success by providing paid family leave.
Future posts will cover all these HealthScaping ideas, and more!
In the meantime, what ideas do you have to create a healthier community where you live, work, study, or play?