Extra mural

Science in society – politics, development and social justice.

One Health and the built environment

leave a comment »

A tumble-down house sits above a poluted stretch of water, plastic detreitus washed up on its banks

Slum living - our health and our environment go hand in hand

The Royal Institute of British Architects (RIBA) has published A Guide For Assisted Living. It is a ‘how-to’ for designers, healthcare workers, architects and anyone else “who may have to take decisions on the appropriate design, specification, construction and adaptation of ‘assisted living enabled’ buildings.

As we are all aware, we are an aging population. The Western world has coaxed life-expectancy out to new extremes and so rates of chronic disease have increased. This week’s edition of The Lancet has given over its pages (actually its website, I cannot say I have seen a copy but presumably one mirrors t’other) to the staggering burden of diabetes across the globe. The well-worth-a-read editorial cites a 2011 study that shows the worldwide burden of the disease is 347 million cases, as of 2008.

The RIBA guide recognises that the growing chronic disease burden threatens to overwhelm the ever-more scant healthcare resources:

The changing demographic means that traditional arrangements for supporting those with long term conditions will not be sustainable even in the medium term.

By incorporating the built environment into provision of care this strain on support will hopefully abate. How we plan our towns and cities, how we design our homes and building materials can all contribute to care and support.The built environment is key to health and care and this guide is another welcome example of architects getting to grips with the benefits their work can have.

Go back through history and see how this role of the built environment in disease and health ain’t nothing new. Edinburgh’s Old Town was built to such a plan as to course and channel wind through its streets. The blustery gusts of the Scots’ capital are infamous and intentional because this was a time when we all believed in miasma. That is, disease was spread by bad smells. So a draft whipping away odor from one’s nose logically prevented disease spreading. This is, we now know, dead wrong.

Skip forward to the mid 19th century and a pet subject of Extra mural: the building of the London sewer system. The intercepting sewer was of course a singular moment in the city’s history. The first of its kind, it meant cholera was rid from the streets of the metropolis when European cities would be routinely racked by this water-borne bacteria. Beyond the pipes and pumps keeping shite separate from water, the sewer system meant housing improvements. The building work, which lasted decades, required much of the appalling, ramshackle housing of the London rookeries had to be pulled down. In their place modern, hygienic, sanitary homes went up.

In the 21st century the RIBA guide speaks to modern Britain’s healthcare needs. We are no longer plagued by acute infections and instead must deal with the chronic non-communicable diseases. However the developing world still has to contend with the infections all but banished from the West.

The fundamental importance of water, hygiene and sanitation to health was explained in a series of articles published last year in the journal PLoS Medicine. To labour the point – sewerage, water safe to drink, roads; these things save lives. Too many people live in slums worse than those of the London of old, without access to that basic human right – drinking water. Pneumonia and diarrhoea, cholera and helminths, TB and measles; the pathogens and diseases that we no longer fear are common.

A potential solution to the misery of slum living that is being talked of more and more is the One Health concept. As more than 60 per cent of diseases are zoonotic – transmitted from animals to humans – the concept of human health cannot be viewed as distinct from animal health. Health systems cannot be blind to the interaction of people with their environment. If it is cholera in Bangladesh slums or H1N1 influenza transmitting from horse-shoe bats to people in insanitary wet markets of southern china – how we live and interact with the environment is fundamental to health.

Dr Laura Kahn of Princeton University is a leading proponent of and sometimes teaches a course on the One Health Concept. A clear line can be drawn, says Dr Kahn, between the growth of a city and its burden of disease.

[They] grow organically without a thought to the impact on the environment, to the destruction of the ecosystems to make way for shanty towns. The resulting disease that occur are so largely because there is no foresight in how to reduce the risk.

The place of civil engineers and urban planners are key, she continues. It is in the next generation of these professions that a focus on One Health must be fostered. The fact is that disease will always be a burden when it is allowed to flourish. By taking more care and greater artifice in planning and building our built environment we can change that. Like refrigeration took away the perfect conditions for food to become poisoned with microorgansims, so we must look to our cities to stop our surroundings becoming poisonous.

Image by Jonathon McIntosh


The Lancet, . (2011). The diabetes pandemic The Lancet, 378 (9786) DOI: 10.1016/S0140-6736(11)61068-4


Danaei, G., Finucane, M., Lu, Y., Singh, G., Cowan, M., Paciorek, C., Lin, J., Farzadfar, F., Khang, Y., Stevens, G., Rao, M., Ali, M., Riley, L., Robinson, C., & Ezzati, M. (2011). National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants The Lancet, 378 (9785), 31-40 DOI: 10.1016/S0140-6736(11)60679-X


The Lancet Infectious Diseases, . (2011). One health for 7 billion The Lancet Infectious Diseases, 11 (6) DOI: 10.1016/S1473-3099(11)70128-1


Cairncross, S., Bartram, J., Cumming, O., & Brocklehurst, C. (2010). Hygiene, Sanitation, and Water: What Needs to Be Done? PLoS Medicine, 7 (11) DOI: 10.1371/journal.pmed.1000365


Bartram, J., & Cairncross, S. (2010). Hygiene, Sanitation, and Water: Forgotten Foundations of Health PLoS Medicine, 7 (11) DOI: 10.1371/journal.pmed.1000367


Mara, D., Lane, J., Scott, B., & Trouba, D. (2010). Sanitation and Health PLoS Medicine, 7 (11) DOI: 10.1371/journal.pmed.1000363


Hunter, P., MacDonald, A., & Carter, R. (2010). Water Supply and Health PLoS Medicine, 7 (11) DOI: 10.1371/journal.pmed.1000361


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: