Healthy Cities

Welcome to this week’s blog. If you’d prefer to listen to an audio version, click here for the podcast.

For two years I had managed to successfully avoid catching COVID. However, a couple of weeks ago, in common with what is now estimated to be more than half of the UK population, I finally succumbed. Thankfully in my case this appears to have been a mild bout of the virus: a nasty cough, a couple of days of feeling wobbly, but nothing that would otherwise differentiate it from a bad cold. As a consequence, I managed to continue working through the illness (albeit from home). Would I have done this in 2019? The bar of what it takes to be ill and off work has I believe been raised. It is one thing to crawl downstairs and open your laptop, and another to get on a train and go into the office. Does this spell the end of sick days? Does this spell the end of ‘sick buildings’? How important will public health be to the future of cities? In this edition of Futures /Cut, I ask in a post-COVID world, what might change and what are the real drivers of health in our buildings and cities?

First, let’s size up the workplace debate. The average number of sick days per year is about 5 per person. In the UK, this equates to 141 million lost working days. This might sound like a lot, but before the pandemic this figure had been falling consistently for the past 30 years. Breaking this down a bit further, about 30% of these lost days was due to ‘minor illnesses’ (colds etc), and another 20% was due to musculoskeletal issues. Within these numbers there are variances by type of workplace, grade, sector, and gender, with managers, private sector employees, those that work in small businesses and men all likely to take fewer sick days.

As discussed in previous blogs, the sick day decision for about half of workers is fairly binary. If you’re a bus driver you’re either driving the bus, or you’re not. What will be interesting to observe is whether office workers now armed with a WFH option will continue to work at home on some days that would otherwise have been spent on the sofa. The past 2 years of technological improvements has given the majority of these workers remote file access, video calling on tap, and most importantly, a cultural understanding that the majority of meetings will have some remote attendees. The last point certainly didn’t exist in 2019 for most office workers, and so being sick at home meant being cut out of meetings. If this new model prevails, then there will be a direct productivity boost due to the enablement of ‘working-at-home-sick-days’. However, it is the indirect benefits that might prove to be the greater gain for society.

We have all learned a bit more about the spread of viruses over the past couple of years. It’s a fairly simple formula. The more contact you have with other people, the greater the chance of infection and transmission. The area of our lives that is shown to create the most contacts is the workplace, and the number of working days is exponentially influential. In an office of 10 people, if all people come in 5 days per week, this has been shown to create 7 times more contacts than if everyone comes in only 2 days per week. Of course, contacts are not bad things! In most scenarios, in fact the density and frequency of contact can be a fantastic enabler of both economic activity and social gratification. It’s just when you have a communicable illness that the same doesn’t apply.

We all know colleagues who when afflicted with a terrible cold are happy to swig a Lemsip and then proceed to come into the office and cough all over everyone. Many in my experience wear this as a badge of honour (‘I’m too important to take a sick day’). However, cultural acceptance of coughing near other people has taken a bit of a nosedive recently. If coming into the office with a cold becomes denormalised, enabled by the option of working from home, it is not the individual productivity gain that will be realised, but rather the herd productivity. Fewer contacts with ill people could radically reduce the transmission of bugs in society, which would make our offices, trains and cities safer and healthier places to be in the future.

Culture is a big thing to shift, and there is a lot of inertia in the status quo. However, it strikes me that there is significant opportunity to shift the dial. 90% of people report occasionally going to the office with cold or flu symptoms, and 33% report always going to the office when ill. A third also admit to not considering their co-workers’ health in such situations. There are quite significant regional cultural differences with workers in some countries much more likely to stay at home and limit their own transmission. A survey of UK workers last summer suggested that 67% intended to keep wearing masks at work. Fast forward to today and that intention appears to have evaporated. It will be interesting to watch whether mask wearing remains for those with symptoms going forwards. Mask wearing simply didn’t exist in the UK pre-pandemic; but has long been a common feature in Asia, where familiarity with illnesses like SARS has instilled a greater willingness to take precautions.

So, is this debate about viral transmission the defining feature of healthy workplaces and cities in the future? Well, it could be. We seem to be entering into a more positive phase for COVID; however, the spectre of the next variant, or another virus looms menacingly in the shadows. If we face another serious outbreak, managing the public health impact whilst keeping our economy going will be of paramount importance. In that regard, selective non-pharmaceutical interventions to reduce contacts with ill people are going to remain exceptionally important. However, we need to be careful not to be blinded to other bigger issues. Other than in the last couple of years, transmissible illness has not ranked highly on the continuum of health issues in the Western world and beyond. For instance, the leading causes of death in the UK firmly remain with non-transmissible complaints such as heart disease (19%), dementia (12%), cancer (8%), diabetes (7%) and even accidents.

So what are the real drivers of healthy buildings and cities?

Healthy Buildings – At its most basic definition, a healthy building is one you should feel safe in. There are two big contributors to this: the building fabric / construction, and the way that it is operated and managed on a day-to-day basis. We have become much more rigorous in both areas in recent decades. The presence of toxic materials like asbestos has been significantly removed, and an industry has sprung up around safety at work, and policies are much better embedded in practice. Nevertheless, new unknown or unappraised threats like the cladding materials at Grenfell continue to pose unexpected and potentially serious health challenges. This is however a very simplistic and lacking-in-aspiration view of what a building should do to promote good health.

Some buildings (typically offices) have attracted the epithet ‘sick’, due to the increased incidence rate of unexplained, often acute illnesses, presented by those who use them regularly; including fatigue, coughs, irritation and nausea. Most typically these conditions are due to poor ventilation, poor lighting, noise and overcrowding – all things within the influence of the landlord and the facilities manager. Interestingly, they are also most likely to be associated with open plan offices. Whilst these symptoms rarely result in long term illness, they can nevertheless be significantly impactful on personal comfort and productivity.

However, even the elimination of these factors doesn’t get us to a point of positive promotion of wellness. If health and wellbeing is going to be a deciding factor in building selection in the future, it doesn’t just need to eliminate bad things; it needs to make a positive impact on health. Typical interventions seen in high quality buildings include activity-based work settings and bespoke / customisable environmental settings; on-site exercise space, in-house cafeteria, outdoor and green settings, and dedicated relaxation spaces. However, much still rests with the employer and the business culture: avoiding long periods of sitting down, removing unnecessary back-to-back meetings, taking proper breaks, providing healthy food and promoting walking meetings are not usually choices of the individual, but rather the corporate culture.

Healthy cities – Spinning out one level further, what makes a healthy city? Whilst there’s a large range of contributary factors, most are in some way correlated with wealth. Wealthy cities are empirically healthy cities. In wealthy cities there are typically lower levels of deprivation and homelessness, better environmental conditions, better healthcare, and higher educational attainment, (which is associated with positive health behaviours).

However, even within wealthy cities, those on the lowest income tend to suffer poor health outcomes disproportionately. This includes for instance higher exposures to air pollutants. Lower income households are more likely to be located close to sources of emissions, such as factories, ports and busy roads. Your location within a city (highly correlated with wealth) remains one of the biggest single health influencing factors.

Beyond location, the built environment has a significant role to play in health. Access to green space is associated with more exercise, fewer pollutants, less noise and better access to sunlight. Housing is another strong contributor, with over 20% of homes in the UK failing to meet the Decent Homes Standard (more in the private rented sector), due to hazardous conditions, poor repair, lack of modern facilities or lack of thermal comfort.

Another significant consideration is how we move around. It has been shown that that those the rely most on cars, undertake least physical activity. For instance, those that live in rural locations walk less than those that live in cities, where amenities are more likely to be found within walkable distances. Whilst it has fallen significantly, transport still contributes 35% of all nitrous oxide emissions, with emissions from vans still growing. The de-leading and now the electrification of cars will certainly help, however they are still a big contributor to particulate matter (including from breaks and tyre wear). Over the past year, many people have shunned public transport, due to concerns over catching something nasty. However, public transport and cycling remain a vital component of healthy cities in the future, with huge variations in usage across the UK.

Mental health – the new frontier

Whilst this discussion has focussed on physical health, there is no doubting that mental health has been rising steadily up the public health, government, corporate and social agendas. Poorly designed buildings and cities can be significant contributors to poor mental health, including anxiety, depression and psychosis. Depression is 20% more prevalent in cities than in extra-urban locations, and psychosis is 77% higher. Notably, studies have shown that living in cities during childhood increases the prospect of poor mental health later in life, and big cities drive larger effects.

Contributing factors include limited access to green space, noise and air pollution, crime and social inequalities. Where these factors are less prevalent (in high performing cities) the contribution to poor mental health is decreased.

Another contributing factor is lack of community ties and cohesion. Those with a weaker self-reported ‘belonging’ to their neighbourhood are more likely to feel lonely, particularly women, and loneliness is strongly correlated with poor mental health. Lack of belonging is greater in transient communities (where for instance there is a higher percentage of short term rented stock) and where people feel less able to have a voice in local decision making.

So what should we in the property industry do about this? Some concluding thoughts…

Whereas COVID has dominated our psyche over the past two years, it is important to see the wood for the trees. Containing transmissible illnesses has only a limited role to play in improving health in the UK. We have adopted many new behaviours during the pandemic, some of which have been positive for our health (not commuting 5 days per week) and some of which have been detrimental (sedentary working on endless video calls for longer hours). On balance, it strikes me that the future of our cities shouldn’t be about hiding away from society to protect ourselves. To do so would unwind many more social and health benefits than it would deliver. Whereas many health factors are related to wealth, inequality and the economy, there are also many ways in which the built environment can influence positive health outcomes in the future.

The first is to recognise that health and wellbeing will form an increasing part of the battleground in the war for talent. Health needs to step beyond being a hygiene factor (avoiding bad things) in building design and instead be seen as a vehicle to create value. In this context there is need to consider the individual as well as the herd. This includes an explicit consideration of neuro-diversity in the workforce. Taken together with viral transmission and sick-building syndrome, it is increasingly difficult to champion open-plan working from a health perspective. As with other factors there is both a need and opportunity for offices to show a positive differential over the home office in the future. A trip to the office should combine health benefits like access to exercise and green space. Provision of sensibly-priced, healthy food, not often delivered in city centre sandwich bars or office canteens, needs to be a level above what employees can cook in their own kitchen.

Secondly, we need to design our cities in a way that promotes greening and walkability. My personal passion sits with the eminently deliverable opportunity to turn our cities green. Planting trees in particular is a quick win with multiple health, aesthetic, natural and value benefits. Creating high quality open spaces appears harder. Particularly as our cities densify the opportunity cost of open spaces becomes higher, and we need to be more innovative around where we put this space. Moving parks onto roofs, in replacement of roads or even within buildings provides new opportunities to restore natural balance and improve health. The trend towards moving cars out of cities and prioritising walking and cycling is only likely to increase, and this will need some rethinking about the accessibility of pedestrianised assets.

Finally, for policy makers and large-scale developers there is an opportunity in both town planning and scheme design to mitigate health inequalities. Whilst a common baseline of good health is paramount, a secondary objective should be to minimise the health inequalities created by real estate. Increasingly there will be commercial and regulatory pressures to level the playing field. This starts with giving residents a genuine voice in local planning, and developers minimising the quality variances across large sites. Critically, if cities want to become and remain attractive places to both live and work, the non-physical elements of schemes, such as sense of place, access to open space, secure tenure, human scale proportions and easily accessible amenities and services that promote community interactions rise up the chain of importance. There’s an exciting opportunity in the next decade to take learnings from the pandemic, to refuse to accept that living in a city means taking a trade-off on wellness, and make health and wellbeing a priority in design.