There is a public health parable, ‘The river story’, originally told by sociologist Irving Zola (cited in McKinlay).
“Standing on the shore of the river I hear the cry of a drowning man, I go into the river to rescue him, pull him out and resuscitate him, just as he starts to breathe another call for help, I go in, pull them out and resuscitate them. These calls for help continue. Near exhaustion, it occurs to me that I’m so busy jumping in, pulling them to shore and applying artificial respiration that I have no time to see who is upstream pushing them all in..”¹.
The story recognises that health is a continuum, determined by many factors. We cannot tackle ill-health only in a reactive response. It identifies that health promotion and prevention strategies need to be implemented to stop people from falling into the river, teaching them to swim if they do, and finally have services available to pull them out.
The overarching topic, Health by Design, the theme of my blogs, stemmed from my professional and personal experiences in healthcare. This, in turn, led me to focus on the notion that good health and wellbeing, should not only be an objective of those on the inside of the health facility. I have concentrated on health facilities to date, however equally important in promoting good health is where we live. Returning to the parable, the health care facilities would be located downstream and housing would be located upstream. Depending on the quality, the house would be located somewhere between teetering on the edge of the river or up on the hill with views over the river. Architects can play a role ensuring that our homes are spatially and structurally safe, secure and affordable to prevent the residents from ‘falling in the river.’
The World Health Organization (WHO) describes health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’². It’s a common misconception that individual behaviours (drinking, smoking, poor food choices etc.) are the main cause of ill-health. Health is more complex and it is a combination of behavioural, biomedical and social factors that influence our wellbeing. Under the social model of health, housing sits under the umbrella of general socioeconomic, cultural and environmental conditions as seen in Fig.1 below. The Australian Institute of Health and Wellness states: ‘There is a gradient in the relationship between health and quality of housing.’³. Often, however, the individual has little influence over the quality of their house. Shelter is and should be, an essential human requirement, and it should be a basic right to have one that is functional, maintainable, livable and healthy.
Sharing the responsibility
The profession of architecture is more closely related to the health profession than realised. Architects’ own statutory code of professional standards and conduct states,
‘An architect has a fundamental and overriding obligation to serve and promote the public interest’ and ‘An architect has a responsibility, where possible, to contribute to the quality and sustainability of the natural and built environment and the health and safety of the general public.’.⁴ the Doctors code of conduct states; ‘Doctors have a responsibility to protect and promote the health of individuals and the community.’ ⁵ The responsibilities and goals between Architect and Doctors are very similar.
Similarly the Australian Institute of Architects website under ‘About Architecture’ outlines their definition of what architecture is, and focuses predominately on how architecture influences our quality of life. Architecture ‘has a significant role to play in improving social inclusion and therefore health outcomes in our communities’⁶. Many who are not in the architecture or design industry see architecture purely as built forms and good and bad design in terms of aesthetics. Often the motivation to study architecture is largely influenced by beauty and the abundant building porn in print and social media. Few view architecture from a health perspective. However, as Tanya Ring from the Office of Government Architects described:
‘Good design isn’t about just; looking good; or us liking the style of it. It’s how the design delivers overall functionality and how it protects the wellbeing of its occupants’
Housing and our health
The relationship between housing and health is well researched and documented. It shows that health quality of individuals/communities is linked to three housing factors; safety (design /structural form), affordability and security. Poor quality housing can lead to physical and mental illness due to factors such as indoor air pollution, temperature extremes, inadequate ventilation, poor planning and social isolation. In addition, poor housing design choices can cause further difficulties for people who are already unwell due to other unrelated illness or trauma, or when their health needs change due to ageing. Inadequate ventilation and temperature extremes, for example, can cause respiratory illnesses such as pneumonia, the spread of airborne infection, allergies, asthma and dehydration.
A colleague who is a hospital in the home nurse recently observed that when visiting people who were housebound with an illness many spend most of the day either in their bedroom or living area. He had noted how many houses he visits have little natural lighting, limited views to nature and poor natural ventilation. These conditions did nothing to support their mental health. Another observation was that due to safety concerns people often would not open windows and doors, and due to their economic situation was such that they were unable to afford cooling and heating. The air quality and internal temperature was therefore uncomfortable and not conducive to improving their already compromised health.
TIME, MONEY, quality
There is the saying, ’form follows funding’ and you don’t need to look far for this to ring true. Most architects and building designers are constrained by, clients’ needs and demands, time and budgets. Tanya Ring explained the project management triangle which comprises, time, money and quality. She suggested that ‘architects need to advocate for the quality’. This emphasis will ensure that occupant’s quality of health is not negatively affected but hopefully positively affected by their built surrounds. This means writing quality into a brief, or if money talks then promote the economic benefits of quality. For example, long-term robustness, longer life, and fewer maintenance requirements.
A study by the City of Melbourne ‘Understanding the quality of housing design’ showed how ‘badly-designed places impose costs on their occupiers, their neighbours and society. At a time of scarce resources, design costs are in effect social costs.’⁷ The study identified the following common design issues;
a. small apartment sizes,
b. lack of apartment choice,
c. dominance of car parking,
d. poor lighting,
e. poor natural ventilation,
f. visual privacy,
g. poor building layout and poor apartment layout,
h. limited flexibility and adaptability,
i. poor environmental performance,
j. limited communal space and facilities, and
k. Lack of storage and utility spaces.⁸
Selling the dream
Developers and real estate agents are selling us the dream for financial gain, we are told what we want to live in, and how we want it designed and good quality, as the City of Melbourne study showed, is not a high priority. For the status quo to change, the focus of housing delivery needs to start changing from a commodity to livability. Is this difficult to achieve in our society? Does there need governing policies to set design standards, such as the Office of the Government Architects design code ‘Apartment Design’?⁹ And would implementing more housing design standards lead to the planning approval of only quality projects?
Do we actually want their housing dream? The Nightingale project is a good example of architects playing a role in providing safe, affordable and high-quality housing. Architects drive the project and they maintain a focus on creating livable buildings. The Nightingale model focuses on affordability, sustainability, transparency, deliberate design-buyer engagement, and community contribution. The difference is the developments are owner-occupied focused, not profit driven and for investment purposes.¹⁰ This is what ‘Architecture,’ is or should be; ‘playing a significant role in improving social inclusion and, in turn, health outcomes in our communities’.
Quality promotes health
High quality does not have to be synonymous with a high cost. High quality is a result of good and often simple spatial and structural design choices. HealthHabitat formed by the late architect Paul Pholeros, medical officer Dr Pail Torsillo and anthropologist Stephan Rainow, is a company with the goal of improving the health of disadvantaged communities through improving housing conditions. It developed from the observation that despite improved health facilities in remote Aboriginal communities, the health of the people was not improving. They highlighted that it was a combination of living conditions and access to healthcare that was affecting the people’s health.¹¹ They have since developed a guide ‘housing for health’ which outlines design strategies to reduce safety issues and promote healthy living practices. While these specifications may seem quite simplistic, they do have real life health implications if not implemented in the design. Some examples include;
Installing insulation – maintains comfortable environment prevent illness to thermal exposure
Selecting materials appropriate for the environment robustness decreases maintenance issues
Appropriately located electrical fittings – decreases incidents of electrocution and fire a national survey of 7000 houses surveyed showed only 10% have safe electrical systems
Separating toilet and laundry from washing areas – infection control
Functioning shower/washing facilities – deceased the incidence of childhood disease and infection.¹²
We all deserve to live in a safe, affordable and secure home, it’s good for your health. Architects should not underestimate the part they play in promoting and protecting health. Even if they are not directly involved in the design and construction of projects, for example, estate housing or apartments, they can be advocates and lobby for the improvement of quality through the implementation of design standards or guides, be involved with restructuring the housing market, continue to emphasise the importance of good evidence-based design in education and in the industry. This all plays a part in preventing the people upstream from falling into the river.
1 John B. McKinlay “A Case for Refocusing Upstream: The Political Economy of Illness” McKinlay, J.B. (1981)
https://www.healthyshetland.com/site/assets/files/1176/river_story.pdf Accessed 23/05/2018
2 World Health Organisation. WHO | Frequently asked questions.
http:// www .who.int/suggestions/faq/en/ Accessed 22/05/2018
3 Australian Institute of Health and Welfare. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW p5. https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true
4. Architects accreditation council of Australia. Architects’ Model statutory code of professional standards and conduct. Part A.3.Statement of Professional Standards. http://www.aaca.org.au/wp-content/uploads/2010/09/JCOC2003.pdf Accessed 22/02/2018
5. Medical Board of Australia .Mar 2014. Good Medical Practice. A code of conduct for doctors in Australia. About the code 1.4. http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx
6.Australian Institute of Architects. About Architecture. http://www.architecture.com.au/ Accessed 22/05/2018
7. City of Melbourne. 2013. Understanding the quality of housing design. p11 https://participate.melbourne.vic.gov.au/application/files/6514/1274/9459/Understanding_the_Quality_of_Housing_Design_Final_February2013.pdf
8. ibid p26
9 .Western Australia. Department of Planning. Department of Finance. Office of the Government Architect. 2016 Apartment Design. Volume Two of State Planning Policy No. 7.3 Residential Design Codes. Guidance for multiple-dwelling and mixed-use developments. https://www.planning.wa.gov.au/dop_pub_pdf/WAPC_Apartment_Design_Policy_DRAFT_.pdf
10. Nightingale. Nightingale housing. http://nightingalehousing.org/ Accessed 22/05/2018.
11. Healthhabitat. 2013. Housing for Health- the guide. http://www.housingforhealth.com/the-guide/safety/electrical-safety/
Tanya Ring. Architect. Office of the Government Architect. Face to Face interview
Darren. Registered Nurse. Face to face interview
Fig1. Australian Government. Australian Institute of Health and Welfare. Australia Health 2016. Chapter 4 Determinates of Health. 4.1 Social determinants of health. https://www.aihw.gov.au/reports/australias-health/australias-health-2016/contents/chapter-4-determinants-of-health. Accessed 22/05/2018
1 “Western desert remote hosing.” Iredale Pederson Hook. Accessed May 36, 2018. Http://iredalepedersenhook.com/?portfolio=western-desert
2.3.4 Personal images
5. Abraham, Craig. 29 August 2016. “High-rise apartments are bad to live in and bad for society, says respected architect.” The Age. https://www.theage.com.au/national/victoria/highrise-apartments-are-bad-to-live-in-and-bad-for-society-says-respected-architect-20160829-gr39nf.html.
6. n.d. “Apartments Docklands_Newquay.” Accessed May 25, 2018. http://www.newquay.com.au/live/.
7.Future Melbourne Team. 2016. “The grass isn’t greener in the outer ‘burbs.” City of Melbourne. March 11. Accessed May 2018. https://participate.melbourne.vic.gov.au/future/grass-isnt-greener-outer-burbs.
8-11. N.d. Breathe Architecture. Accessed May 2018. http://www.breathe.com.au/the-commons-1/y06x89qorgl21jp2ayk8yikrrprz0m.
12.13.. n.d. Health Habitat. Accessed May 25, 2018. http://www.housingforhealth.com/.
14. Personal image
15. “Housing for Health- the guide.”
16 n.d. “tjuntjuntjarra community housing.” Iredale Pederson Hook. Accessed May 36, 2018. http://iredalepedersenhook. com/?portfolio=tjuntjuntjarra.