Confining us to our neighbourhoods, covid-19 has woken us up to the impact of the places we live on our wellbeing. It’s midweek in Hoxton, early afternoon, and I’m here with Paul Kelland to try and deepen my understanding of the links between our environment and our health. Former architect turned GP, Paul is walking me his north London patch. He’s been a GP here for twenty-five years—his life’s work he says.

Paul is slim and bearded, dapper in a tweed suit and ox-blood Doc Martens. He talks like he walks, rapidly, restlessly, impatient to get his ideas across. He swings open the door to his practice and we’re already into medical history—the practice was first run by a Dr Thorpe, a formidable woman apparently, tall and whip thin, one of the first female GPs in England. We cross into Shoreditch—formerly “sewer ditch”—Park. It’s a little threadbare this early in Spring, a little windswept. Scraped down from slum clearance, it’s now overlooked by a pair of matching hexagonal brick towers where three bed flats go for £1.5million. We pass the local pub—closed after a stabbing in the toilets—cross a road and into a triangle of grass between solid council blocks. 

Municipal mown space. Let’s call it MMS. The phrase is new to me, but I’ll never look at a city the same way. It’s the name Paul gives to the numberless fragments of grass between buildings—scuffed and yellowish fragments and offcuts. They look great on a drawing, he says, little green spaces, full of strollers, picnickers, playing children. But no. Dogs shit here and that’s about it. No benches. Ball games prohibited. Dead space, sore on the eyes. Space built to fail. Exercise is impossible, pushing people back into their homes—or gyms if they can afford it. Now he’s given a name to it, MMS is everywhere. And it’s a tell-tale. The thing about MMS is its cheap to maintain. The council buzz it with a lawnmower. 

Hoxton has been shaped by inward migration: Huguenots, Jewish émigrés, Muslims from now Bangladesh—more recently those fleeing conflict in East Africa and the greater Middle East. As we turn to head north, Paul is met with an exuberant Arabic greeting—I love you Dr Paul. Bulky, eyes alive under a shock of dark hair, he is from a Kurdish village in northern Turkey so remote that Google Earth shows no roads. 

We pass a local landmark—a bottle-shaped sign on the side of a corner shop advertising “Cheap Booze”—the dilapidated original refreshed by trendy new owners. It’s still possible to buy a three-litre bottle of white cider for £3.99 though. 24 units of alcohol, more than enough to knock you over.

We know that rates of crime in a neighbourhood have an impact on wellbeing, with strong links to poor mental health, alcoholism and addiction. In the 70s, the architect and planner Oscar Newman responded to an urgent question: why do some neighbourhoods continue to be high crime despite the complete turnover of their populations? His answer was defensible space theory: if people have ownership of their built environments they will co-operate in its security. Look not at the population, but at the place. Everywhere Paul points out human attempts to take a little control—to stake out a patch of garden, to gate their end of the balcony.  He compares the multi-million-pound Victorian houses of neighbouring  De Beauvoir square: the graded move from main road to side road to pavement to front garden. The progressively defensible space leading to the sanctum of the home. A lot of social housing opens straight onto the street or gantry—places to hurry through to the safety of a triple-locked door. Newman’s theory is contested, but after MMS it’s the thing Paul talks about most. Combine this with the Government’s commitment to a “public health approach” to violent crime, and the links between wellbeing and the built environment could hardly be stronger. 

We are standing in front of the De Beauvoir estate. Five “sentinel” towers interwoven with low rise “snake blocks.” Underneath us are basement garages, long bricked up and locked down—too much violence, too many cars torched. Entropy is much on Paul’s mind, the tendency of things to fall apart. The white woodwork on the estate is peeling, the yellow spandrels rotting from the base. How well things are built matters. Some of the earliest social housing is impressively solid, made with an eye to the future. But without maintenance, even that decays. But work costs. Most of the bigger blocks were designed to have concierges, someone to keep an eye out. But they’re long gone. 

As we walk it becomes clear that the dilapidation of these buildings and the exhausted spaces between is not inevitable. It is the outcomes of successive choices. Fail to maintain and decay settles in. Build cheap and it sets in that much more quickly. 

We look north over the snake-blocks and sentinel towers. I always want to bring architectural students here says Paul. It may look groovy—one of Paul’s words—on a drawing, but ask yourself how you get in, how you navigate it. Try to find your way around here for an emergency call he says. He answered an emergency call to a seriously mentally ill patient on the 8th floor of one of these blocks. The lifts were out. He arrived exhausted.

We head back to the practice. Paul holds a powerful mental map of his patch, contoured with stories of fortitude and survival, of struggles with illness, of peaceful deaths, and deaths less peaceful. He is an extraordinary man, a great guide, and committed to the wellbeing of those on his patch. He talks of the funeral of a local lad killed by addiction—all the community coming out to pay their respects. He talks of a patient dying slowly as just outside her bedroom the steel bones of a new and glitzy high rise go up in winter light. But walking this tangle of streets it’s hard not to think of what he is up against—the knowledge that illness can be built into a place, designed into it by the myopia of architects, locked further in by slashing maintenance budgets, pulling the services that support it.  If we want our cities, and their inhabitants, to thrive, we must build better. And look after what we build.

Julian Sheather is ethics manager, BMA. The views he expresses in his opinion pieces are entirely his own.

Competing interests: none declared.