I gave a talk at the RSA recently as part of an event called “Healing People, Healing Cities”, hosted by RSA Fellow Silviu Pirvu of Optimal Cities.
The title inspired me to draw on something I wrote two years ago, in which I suggested that the “Do No Harm” principle, central to modern medical practice and embodied in the Hippocratic Oath undertaken by medical practitioners, does not seem to apply to the diagnosis and treatment of the health of our cities, neighbourhoods and local places.
This vacuum continues to inspire my thinking about how to develop and sustain places that support their inhabitants to live long, healthy lives and, in revisiting this, I began to think a little harder and beyond the simple – but critical – Do No Harm principle. It became obvious to me that good medical practice, manifested in continually updated diagnostic and treatment pathways, provides a powerful template for the development of healthy places.
It all starts with Hippocrates, an ancient Greek physician and philosopher who is known as the Father of Medicine. Hippocrates did three amazing things which underpin medical practice today:
Over the centuries, these Hippocratic principles have supported a continually evolving pathway of care for patients, which in best practice is defined by these principles:
Following this pathway generates its own dataset which, in best medical practice, will inform and improve care going forward through a refined understanding of what works and what doesn’t. This not only drives better treatment but also fosters prevention of illness in both individual patients and the wider population.
It's intuitive to me that Hippocrates and the implementation of modern medical pathways offer a clear, robust approach to the development of neighbourhoods, communities and places. You don’t need to be a genius to take each of the principles outlined above and recognise its applicability and potential benefit to the planning of cities and places. But most architects, planners and built environment practitioners don’t think like this.
I so often hear that it’s rigid “siloes” that are a cause of many of our planning challenges. But this is no excuse to avoid translational learning and practice development – in fact the medical profession is already on to this, recognising the importance of societal infrastructure in public health and patient care.
In the most recent edition of the medical journal Frontiers in Medicine, three members of the Faculty of Medicine at Imperial College London argued for the need to “teach medical trainees to see societal infrastructure as a clinical issue”.
In an article entitled “Infrastructure determines health: the clinical evidence”, the authors point out:
“Medical training traditionally focuses on detecting pathology through history-taking, physical examination, imaging, and laboratory testing. However, clinical outcomes are often shaped as much by the built environment as by biomedical factors. Problems such as inadequate housing, poor sanitation, unreliable transport, and unstable energy supply are all linked to increased morbidity and mortality. In England, more than 11% of households experience fuel poverty, contributing to excess winter deaths and exacerbating chronic illness.”
They add:
“Globally, the World Health Organization reports that 24% of all deaths are directly caused by modifiable environmental and infrastructural determinants. Taken together, these data establish infrastructure as a clinical determinant rather than background context. The question, then, is why curricula rarely make infrastructure a routine part of clinical reasoning.”
The authors argue that medical students are constantly taught to carefully review specific organ systems individually, but they are often not taught to systematically review environmental parameters like the quality of housing, access to transport, or energy security—"elements as important to the wellbeing of the patient as are laboratory tests or radiology reports.”
They also recommend establishing dedicated educational partnerships between medical schools, urban planners, housing authorities, and transport organisations. “These partnerships could offer structured clinical placements designed explicitly to illustrate infrastructure-driven health outcomes, providing trainees first-hand experience in systemic advocacy.”, they state. “Similarly, integrating emerging digital technologies into medical training can help clinicians map and visualize infrastructure-related health inequalities, facilitating targeted interventions and advocacy.”
Implications for the NHS and its increasing focus on Neighbourhood Health are significant. As the Kings Fund explains, Neighbourhood Health encompasses many different ideas, policies and approaches to delivering health and social care.
Key to its success is Prevention and Place-based care, both informed by the wider determinants of health and their influence on people’s wellbeing and risk of illness.
Place-based health and healthy placemaking are two sides of the same coin – the terms reflect the professional lens through which one is looking. Medical professionals and healthcare providers are demonstrating an encouraging willingness to see patient health through the lens of the built environment and embed this into their practice. It’s time for Built Environment leaders and practitioners to do the same.
This article was first posted on Listen to Locals.
Photo credit: Hippocrates. Line engraving, 1584, Wellcome Library, London. Licensed under CC BY 4.0.
