We need to look beyond disease and individual sector silos and take into account the potential of the social and built environment to both prevent disease, and also contribute to it, say Tolu Oni and colleagues.

The need to prevent disease is well recognised globally. However, prevention efforts often largely focus on healthcare systems. We need to look beyond disease and individual sector silos and take into account the potential of the social and built environment to both prevent disease, but also contribute to it. This has been demonstrated recently by the ongoing inquest into the asthma-related death of a young girl in London, which it has been suggested may have been associated with unlawful levels of air pollution.

Urban governance and town planning processes need to ensure that policies avoid toxic decisions which have a negative impact on the health of urban populations. Healthcare professionals have a vital role to play in breaking through these silos.

The creation of the social and built environment guided by architecture and urban design is a process defined by decision points. The long-lasting effects of these decisions are increasingly understood to be determinants of human health. The social and built environment guide our behaviour, and in doing so create the habits and experiences that have an impact on our physical and mental health, negatively and positively. It is in this context that decisions require an evidence based approach to prevent the negative outcomes of poorly designed environments. This highlights the importance of the governance structures within cities in creating and harnessing opportunities for health.

The lack of dialogue between the building and development sectors and government health agencies is indicative of the poor uptake of evidence linking health and the built and social environment. In order to bridge that gap, healthcare practitioners, alongside socially conscious developers and architects, should engage with planning authorities to demonstrate where design decisions shape urban determinants of health.

As part of the discussions at the 2018 Salzburg Global Seminar on Building Healthy Communities through inclusive urban development, we developed the concept of “Toxic Decisions” defined as decisions in urban development that inadvertently result in poorer health outcomes, and miss opportunities to create health for communities in the short, medium, or long term.

In order to establish accountability for the urban determinants of health, the sectors of society most affected by the environment in question must be given the power to effect change. If urban areas are designed with local health and equality needs in mind, then they can better tackle the health and wellbeing of the local population. Specific performance metrics (such as a decrease in the number of hospital admissions for children with asthma) could be put into place to ensure that this happens. Social and historical contexts influence the ways in which potential users engage with and utilise the spaces in which they live, work and socialise, and these contexts should be taken into consideration.

Governance processes need to have in place accountability mechanisms to penalise and reward all urban developers for contributing to disease or creating health respectively. The same mechanisms that permit or deny developments based on more traditional planning evaluation metrics must also consider urban health equity.  

New developments should be systematically evaluated to take into account new knowledge, and a consideration of what decisions in urban spaces create toxic outcomes over time. Cities are complex organisms, with interlinked and dynamic systems; future research must include data from other sectors to connect place-related health determinants to population health outcomes.

This is a call to civil society to demand that urban development decisions are not “toxic” but rather create health. This will require a greater awareness of what factors influence health and a demand for those sectors and industries to be held accountable.

We argue that people working in the healthcare sector who already have a voice on platforms that make or influence strategies to improve population health have an important advocacy role. This includes advocating for the inclusion of other key players, such as architects, urban developers, mayors, or engineers. These professions, by virtue of the impact of their activities, are de-facto “health professionals”.

In addition, healthcare sector workers should take any opportunity they can to make sure that the health of local populations is a consideration in urban development decision-making processes, recognising that this will require healthcare professionals to engage outside their comfort zones as these processes often lie outside traditional healthcare sector deliberations. An example such as the Public Health England Healthy Places programme is an opportunity for the healthcare sector to champion healthy places and could bridge the gap between clinical practice where diseases manifest and prevention efforts through interventions in the urban environment.

Urban environments have become the magnetic pull for much of modern humanity. However, the focus on financial growth and profit has made sustainable urban living a choice that few people can access. Rapid urbanisation, globalisation, and climate change are the signs that this can no longer persist, and more informed design and urban practices are needed. Power distribution, accountability, new knowledge, and public and professional demands are needed to create new, sustainable, healthy urban living spaces.  

Tolu Oni is a clinical senior research associate at the MRC Epidemiology Unit, University of Cambridge, UK and Honorary Associate Professor, School of Public Health and Family Medicine, University of Cape Town, South Africa.

Judit Kockat  is a project manager, Buildings Performance Institute Europe, Brussels, Berlin.

Eliana Martinez-Herrera is a professor of epidemiology and Public Health and Head of International & National affairs at The National School of Public Health, University of Antioquia, Colombia.

Itai Palti is director at The Centre for Conscious Design and the Human Metrics Lab.

Annalise Johns is a strategy advisor, National Health Service Healthy New Towns, UK.

Waleska Teixeira Caiaffa is a professor of Epidemiology and Public Health and Head of the Observatory for Urban Health at School of Medicine, Federal University of Minas Gerais, Brazil

Competing interests: none declared.