by Giulia Melis
SiTI, Politecnico di Torino, Italy
 
Since ancient times, we have known that the place where we live can impact our health. Cities have always been shaped and restructured according to the needs and priorities of the time.  The Roman Empire, for instance, created a model for the planned city: with its rigid morphologic and geometric rules, the typical Roman settlement provided basic facilities and infrastructure for its inhabitants, ranging from thermal baths, to aqueducts and sewers. During the Industrial Revolution, cities had to face a new challenge: overcrowding, industrial dumps, and bad hygiene conditions were helping the spread of infectious diseases, and working class suburbs were growing too fast, without any concern about the quality of life in those areas.

That’s how laws about urban décor, cleanliness and sanitation started to be discussed: the Public Health Act (UK, 1948) is one of the first examples. This Act linked the urban design of a city with the spreading of epidemic diseases, and tried to prevent it by moving industrial production out of the city core. This model lasted until recent decades, when deindustrialization and various crises meant the need for new paradigms.
Nowadays, modern cities are starting to wonder not only how to create a healthy environment to protect the spread of epidemics, diseases, violence etc., but also how to enhance the quality of life of their citizens and their wellbeing. The waves of New Urbanism are questioning our lifestyles, and starting to re-consider the social component of city life as fundamental for granting us happiness and fulfilment.

That’s why, as a group of researchers coming from the architectural and medical domain, we became interested in mental health in our cities. As urban planners, we were interested in understanding which urban features most significantly affect our daily life, in order to identify the most urgent and promising intervention opportunities towards less-stressful urban living. And as public health experts, we wanted to know if the effects are equally distributed among the population, or whether some groups are experiencing a higher burden?

The Research

We chose an Italian city, Torino, where a huge dataset on population health is available, and looked to see if the numbers confirmed our initial theory. While a lot of researchers have already presented evidence of the importance of urban trees and parks, which can have a profoundly beneficial impact on psychological wellbeing and general mental health, not many studies have analysed the urban built environment in its complex functioning. We therefore gathered data both on the structure of the city (how dense it is, where are the parks for recreational activities, which is the mix of functions in one area) and its services (is the nearest library placed within an accessible distance? is the area well-served by public transport? Are there public sport facilities? Cinemas, theatres? etc) and we looked for connections between this data and the consumption of antidepressant drugs in the city.

The Results

Our research suggests that good accessibility to public transport, as well as a dense urban structure (versus sprawl), could contribute to a reduced risk of depression, especially for women and elderly, by increasing opportunities to move around and enjoy an active social life.

Women (of all ages) and older people (age 50 to 64) were found to be prescribed fewer antidepressant drugs when they lived in places reached more quickly by bus or train, and in places with taller average building heights, compared with counterparts in more remote or sparse areas. That connection held up even when social factors were taken into account. This means that if everybody had the same level of education, same citizenship, and were all in employment, all living in a neighbourhood that had equivalent levels of crimes and social and physical disorder, there would still be differences in antidepressant consumption according to how well the area is served by public transport and to the density and liveliness of the neighbourhood.

Challenges and decisions with the method

Antidepressant consumption is quite a strong indicator in mental health. Taking antidepressants implies that you have recognised you have a problem, actively sought help from a doctor, received a diagnosis and a prescription for antidepressant medication, and started treatment. This is a long way from starting to feel that you may be stressed or depressed. We used this indicator in our research as we were looking for solid evidence, but by doing so, it is likely that our results underestimate the phenomenon of stress and depression in the city, thus setting the stage for further and more accurate investigations and reflections.
Of course the range of density that we were able to test was limited to that of a typical European city; this range does not include the extremes of US cities sprawl and high density (which are both known to have negative effects on health).

Also, this type of large-scale data analysis can’t pinpoint causal mechanisms. But it’s not hard to speculate why transit and density might reduce stress: the former relieves the need to drive everywhere (and to own a car); the latter enhances the potential for social connectivity. For older populations, in particular, both aspects help guard against feelings of isolation or loneliness. They also stand in contrast to remote suburban living that “can have a serious impact on mental health, particularly when it results in forgone trips”.

The Conclusion
There’s still a lot to understand about the key stressors of city life, but sound advice to urban planners could already be launched: in order to address health inequalities, urban policies should invest in the delivery of services that enhance resilience factors, above all a good public transport network, in a careful and equal manner, throughout the city.

Last winter I had an experience that changed the way I saw urban design.
 
It was mid-February. It was one of those days that was so cold that the city seemed to be blanketed in a mist of ice. Certainly not a day one wanted to spend outside for too long. I was on my bike, waiting to cross an intersection in downtown Edmonton. That winter was the first that I had decided to participate in winter cycling. I bought an old beater mountain bike and outfit it with some studded tires. It was the best decision I had made in a long time. Winter cycling is a lot of fun.
 
So, there I was waiting at the light, which seemed to be red for an eternity. To my right, there was a pedestrian waiting for the light to change as well. He wasn’t wearing a winter jacket, or gloves for that matter. He appeared to have mobility issues. He was pushing a shopping cart which I later realized was doubling as a makeshift walker. We looked at each other and had a moment of shared frustration as we were patiently waiting for the crosswalk man to appear. The delayed crossing allowed us time to share some small talk, so I decided to jump off my bike and stand with my new acquaintance, who I’ll call John.
 
The time finally came that we were given permission to cross. I walked with John as he slowly moved one foot behind the other whilst pushing his cart over the ruts in the snowpack made by vehicles. It was a visibly taxing process for him, and difficult for me to watch. The occupational therapist in me grew agitated with the lack of accessibility this man experienced. We neared the midway point in the intersection when the menacing stop hand began to flash, and quickly went to a full stop.  The lights had changed and we were stuck in the middle of the intersection. That’s when John said it.
 
“Sometimes I think this damn city is trying to kill me!”

John had made a valid point. While there wasn’t an explicit intention to harm him, by virtue of the way the infrastructure was designed, John was regularly put in harm’s way.
 
I have, on many occasions, uttered a similar sentiment. I primarily use cycling and walking to get around the city. I’ve cursed under my breath while waiting at signaled crosswalks that seem to take forever to allow pedestrians to cross only to give them a very short time to do so. On a regular basis, I dodged cars while attempting to use a crosswalk to get across Whyte Avenue and 102 street (Whyte Avenue is a pedestrian rich area in the Edmonton neighbourhood of Old Strathcona). I had a near miss almost every day. And I have the privilege of being an able bodied person that can quickly step back as an unknowing driver almost runs over my foot.

Reflecting on these issues, I was reminded of a workshop I took this past summer given by the Stanford Design Thinking School. I see the problems I identified as primarily an issue of design, or rather the lack of thoughtful design. Design thinking helps in creating services and products that put the user experience at the core of the design process. The foundation of the approach lies in the "empathy" step - empathizing with the user and caring about how they feel. Empathizing is done through observation of the user as well as qualitative interviewing. When something is designed with empathy in mind, the result is an experience that meets the user's needs.
 
Assessing John's experience, I'd argue that his perspective wasn't taken into account when designing that intersection. Having significant mobility issues made waiting for excessive periods of time without moving difficult. Add to that the severe cold. When he finally had the opportunity to cross, the ruts in the road created additional challenges for him. And to top it off, the time given to him to cross was certainly not enough, and left him stranded in the middle of an intersection fearing for his life.
 
John's experience with using that crosswalk was riddled with anxiety. Speaking with him afterwards, he stated: "Sometimes I feel invisible here". That really sat with me.
 
I was quite bothered by John's disclosure. To me, (beyond it being a matter of safety) it came down to dignity. John, and many others like him are hard-pressed to be able to navigate their cities with dignity. Something as seemingly trivial as pedestrian infrastructure has huge implications on how people see themselves. Having to dodge speeding vehicles on marked crosswalks (without adequate signalling to alert drivers) could communicate that that person's particular experience is not worthy of concern. Or that their safety isn't a priority.
 
So, why should we be concerned about dignity? While writing this piece, I was taken back to work I did as an occupational therapist while at the Centre for Addiction and Mental Health in Toronto.  Something I tried to be cognizant of was the concept of “dignity moments” – that I would make the utmost effort to support the dignity of my clients in every interaction I had with them. This was embodied in the way I spoke with my clients, the nuances of my body language, and the general demeanor in which I engaged with them. The reality was that most of the people I supported lived in abject poverty, had experienced significant oppression (i.e racism, gender-based violence, mental health stigma), and generally had negative experiences with numerous systems. The cumulative impact of these negative experiences took a toll on their sense of dignity.
 
I believe there is a lesson in this for cities. I’d be curious to see how built space would manifest if transportation engineers contemplated how to facilitate dignity moments for the people that used urban infrastructure.
 
It’s also important to recognize that people like John spend almost all of their time navigating and living in the urban environment.  I’d contend that the homeless are one group who most intensively access the built environments of our cities, so should have a voice in the process that goes into building the urban environment.

What would our urban landscape look like if we acknowledged that homelessness was a pervasive issue and that people did in fact live in public spaces?

We’ve seen the opposite; in cities around the world, measures have been taken to make public spaces inhospitable to the homeless. In London, a developer installed “anti-homeless” spikes to deter those looking for a place to sleep. In Tokyo, park benches were designed to make sitting and sleeping uncomfortable. And, if we’re going to explore how urban design influences our mental health, we need to acknowledge that the prevalence of mental health issues in the homeless is higher than the non-homeless populations. We have to build cities for everyone – not just the privileged.
 
I think that we have some way to go when it comes to improving the pedestrian experience in our cities. I believe that it should be at the top of our list of priorities. I think street vibrancy depends on it. I also strongly believe that cities need to be inclusive in their design; this requires that we acknowledge that not everyone drives a car (due to choice or affordability) - and that this should be reflected in the design of our streets and roadways. Design of our spaces governs our lives. It determines the way we move and the way we experience the world and accordingly influences how we see ourselves. More attention needs to be paid to this as we build our cities. While these issues may seem inconsequential to some policy makers, I am convinced that dignity lies in the details.