Beyond Medicare levies: joining the dots to create places that are good for our health

We have lots of open space, but no real parks. – participant in Airds Bradbury study

When you build a park, put a cafe there and a newsagent, or something, people will buy coffee and a newspaper and sit and read and that’s encouraging that interaction. Or even chess sets, things like that, activities to encourage people. – participant in Victoria Park study

Two basic classifications in health distinguish between diseases we catch from each other – communicable – and those associated with our lifestyles and genetic inheritance – non-communicable.

It’s relatively easy to justify government funding for communicable diseases as these very quickly affect a lot of people. We obviously need medical infrastructure to deal with the patients, as well as environmental improvements to prevent outbreaks in the first place – such as access to sunlight and fresh air, clean water and waste disposal.

Non-communicable diseases are different. These include the many chronic conditions that plague modern Australians and cost our health system dearly – heart and respiratory diseases, obesity, diabetes, cancers and mental illness.

Contributory factors are complex, however, and include personal preferences, such as patterns of eating and drinking, and levels of physical activity. Many then argue that preventive intervention is “nanny”-like and should not be the responsibility of the state.

This is a wicked problem – its complex and interrelated causes and consequences are hard to pin down. As a result, it isn’t easy to allocate responsibility. But governments are implicated in many ways.

Where does government come into this?

Governments organise employment arrangements that dictate work-life balance. They fund “sedentary” car-based transport over “active” transport – walking, cycling and public transport.

They plan urban areas, which should increase walking and cycling and provide inviting spaces for physical and social activity and restorative “greenness”. Governments can also influence access to nutritious foods.

However, in a move seemingly towards reduced state responsibility, the New South Wales government has deleted a well-conceived objective of “health” from proposed planning laws and abolished its well-respected Premier’s Council for Active Living.

Such disconnects flow down. Our recent study of four new residential communities in Sydney, Planning and Building Healthy Communities, found a host of good intentions for a health-supportive environment were simply not carried through. For example:

• residents don’t use a link to a regional cycleway offering access to a greater range of facilities because it is on a busy highway and they consider it unsafe;

• restrictive booking policies limit use of estate recreation facilities;

• an extensive pedestrian and cycle path network is designed for recreation activity, but is too circuitous to encourage active transport use;

• high-rise residents are frustrated about not knowing their neighbours, but regard foyers and lifts as too impersonal to be meeting places; and

• garden maintenance is contracted out, so residents don’t garden and enjoy the benefits of improved fitness and contact with nature.

A bike lane should promote healthy physical activity, but it won’t if potential users feel it’s unsafe. Richard Masoner/flickr, CC BY-SA

One explanation points to a lack of engagement by designers, builders and managers. Research suggests this derives from the long-held notion of a need for “professional detachment”.

This is curious when one considers the responsibility of professionals to be client-focused and responsive. No doubt professionals’ own heath aspirations and experiences would mirror those expressed by our study participants.

But it is not just practitioners who are implicated. Much research is still organised around the model of linear and quantifiable cause-and-effect, which is typical of communicable disease. This approach doesn’t work for people-place-health relationships, which are broad, qualitative and networked.

A ‘deep immersion’ response to problems

In response, our study took an integral, “deep immersion” method. This included:

• partnerships with key health and built environment “players”, state health and urban development authorities, and the Heart Foundation;

• a comprehensive audit – not just reviewing census, medical and GIS data, but pounding the footpaths (or lack thereof), buying food in local shops, and observing how spaces were used day and night, on weekdays and weekends; and

• detailed interviews with residents, asking about behaviours, aspirations and needs, followed by workshops to explore further what worked and what didn’t in terms of their health.

The audit, interview and workshop processes are available for others interested in conducting similar comprehensive studies.

Instructively, the participating residents invariably “got it” in terms of what is actually needed – action by each of us as individuals, combined with action by us as a community to provide effective policy, design and management. One workshop participant summed it up:

So … you’re asking, what do I do to keep healthy? That’s us. We need to do that. What should I do to keep healthy? That’s [also] us. What is helping me to keep healthy? This is about our community. What could actually help us? By having better gyms, all this sort of stuff … What I need to [do] … that’s where I see the linkage coming through … We’ve got to do that and make the choices…

A sympathetic “putting oneself in the shoes” of residents via the deep-immersion techniques used in our research will better equip designers, builders, managers and researchers to plan and manage health-supportive environments for all.