How HKS Invests in Improving Health and Housing

Health is inextricably linked with where we live—from our individual units to our neighborhood designs. Over the past year, HKS has leveraged research to evaluate how this link defines local communities. One track of our HKS-sponsored grants program is called “Incubators,” where we empower practitioners to invest time and energy into meaningful research initiatives.

A Denver Incubator team approached health care by whether people have—or don’t have—access to permanent housing. And in Detroit, the Incubator team took stock of the city’s housing and disease prevalence, creating a roadmap for design strategies that have research-backed connections to better outcomes.

Housing is a social determinant of health, meaning that homes are one of many non-clinical contingencies on well-being. As a firm, we’ve long examined the home as a health issue. While homes may lack ventilation and clean water, those who inhabit them may lack access to health resources, and observing neighborhood-level trends unveils where we should first intervene.

­Our firm embraces a design continuum at different scales—from individuals and buildings to entire organizations and neighborhoods. That is, one research intervention may prescribe “nudging” individuals to take the stairs, but another may assess population-level statistics and inequitable access to resources, providing the building blocks to outline the next steps for our cities’ residential planning by way of optimized outcomes.

If Housing is Health Care What About the Unhoused?

Having a good home contributes to healthcare, so lacking one altogether may mean the opposite.

The number of days spent unhoused is tied to worse health outcomes. That is, permanent housing is better than the alternative. Point-in-time approximations show nearly 600,000 homeless people in the United States, and the total in December 2023 hit a historical apex.

And we must explore this issue at the local level—because homelessness is fundamentally local. Consider the fact that 75% of people who experience homelessness do so in the same county in which they lost their home. Our team in Denver, Colorado, used an HKS-sponsored grant to investigate the link between health and housing. They did so by finding opportunities where the design community may influence collaboration between community professionals to offer solutions that address the overall well-being of unhoused populations in downtown Denver.

The Denver team leveraged the concept of “Whole Health,” a comprehensive approach that explores well-being as a system of many parts, to explore local solutions for the unhoused.

A visual created by the Denver incubator team who studied health-centered approaches to homelessness

In the summer of 2023, Mayor Mike Johnston declared homelessness a crisis, calling to reduce point-in-time counts by 50% by 2026. To do that, one of the primary goals is to increase the annual number of households served in re-housing and supportive housing programs to 3,000 and reduce the average length of time residents experience homelessness to 90 days (down from 366 days) by 2026.

Over the past 10 years, there have been more than 17,000 street sweeps due to a camping ban enacted in 2012. One leader of the Denver Incubator team, Savannah Gregory, suggests that our approach to homelessness must include permanent supportive housing.

“Architects, designers and planners need to reevaluate their traditional roles only as the creator of place,” Gregory said. “They should expand their roles to help find solutions through legislation, planning and conversations to create healthy housing outcomes for all.”

Permanent Housing is Only One Component of a Health and Housing Paradigm

Given the broad spectrum of housing conditions in the US, uncovering problematic design elements is a critical step in creating healthier communities.

In cities across the world, many residents believe their homes are out of sync with their health. A quarter of New York City’s public housing residents believe their housing impacted their health negatively. Exposure to lead, carbon monoxide, extreme temperatures, or wastewater leads to poor health outcomes, and unfortunately this exposure often happens in the home. Indoor air pollution alone may account for 2 million excess deaths per year.

HKS has carved inroads through our novel approach to sustainability and health—applying what we’ve learned to residential design. In 2017, HKS launched a tool to help designers make healthy product choices. Our practitioners integrate tools to gauge material toxicity—or non-toxicity—in everything we design, including homes.

A broad review of studies that have addressed architecture health indices (AHIs) find major categories fall under air quality, lighting, acoustic indicators, thermal comfort, and are most associated with reducing communicable diseases and injuries. Health-ier cities may have a lower prevalence of communicable diseases, and their residents may report below average rates of cardiovascular disease, obesity, or asthma. And next-order considerations may include mental well-being and social cohesion, but as researchers have reported, few studies on AHIs discuss them.

Our Detroit Incubator team, led by Betsy Williams and Nikola Gjurchinoski, gathered that the prevalence of various ailments—from asthma and obesity to cardiovascular disease and cancers—may vary significantly city by city, and often, block by block.

“Detroit is a place known for innovation, strong community organizations, highly ranked hospitals, Detroit-focused research institutions and . . . a renewed commitment to exceptional planning and design,” Williams said. “There is great potential for health to be a driver in this design momentum and innovative spirit.”

The incubator team gathered data and information, looking at existing evidence, frameworks, case studies, and held conversations with local partners such as non-profit organizations and healthcare providers to inform which health outcomes to prioritize—and therefore, which design elements to target first.

Based on its research, the team identified nine key evidence-based health outcomes impacted by housing design. For the scope of their HKS-funded research, however, the team focused on the two most critical outcomes for the city of Detroit—obesity and mental health. A gap analysis revealed asynchronies between the community, providers, and housing developers. At one scale, the team investigated the average dwelling unit, analyzing how unit features—from operable windows to envelope and wall design—may impact health outcomes.

A visual created by the Detroit incubator team, led by Betsy Williams and Nikola Gjurchinoski

Public health research continuously reveals the nominal risks that extrinsic health variables—our behaviors, the environment, and other variables outside our biology and clinical care—play in community mortality rates. Lifelong cigarettes use takes about 10 years off the average lifespan. Cities that lower driving speeds see fewer fatal car crashes and real effects for injury-related mortality. Increased caloric consumption of trans fat poses significant risks to overall mortality.

The Housing Crisis is Often Framed by Affordability, but What About Health

Despite the push for greater affordability, public rental housing is itself considered a risk for all-cause mortality. Those in low-income neighborhoods, including public housing, are termed “marginally housed.” Research suggests  that the marginally housed are significantly more likely to not only suffer worse health outcomes, but to overutilize the emergency department, rather than receive care through other means, such as primary doctor’s visits or urgent care centers. For instance, one study found that 40% of respondents who were marginally housed received care through the emergency department over the past year.

The physical and social realities of low-income neighborhoods pose health risks. In many areas, large clusters of public housing developments create segregation, concentrations of poverty, and because of the physical state of many public-housing buildings, the health of residents is compromised.

Our firm elevates community health through health-conscious decision-making. That means we approach population health through a mixed model of connected service points. From our urban designers to residential architects, our firm integrates how we see housing typologies as layered with proximal community amenities, by combining traditional site analysis with geospatial analysis and nature of place research.

“In every instance where these collaborations have occurred in authentic and inclusive ways, we’ve uncovered data points that were used as key drivers to inform positive community impact and design strategies that inform program and other design decisions,” said Alexander Briseno, AIA, Office Design Leader in our Atlanta studio.

Health inequities and the affordability crisis all reveal the fragilities of our communities. But we can take concrete steps toward resiliency. After the COVID-19 pandemic began, we introduced our Community-BLOC concept, a resilient community paradigm with principles like net positive design, digital infrastructure integration, and flexible mobility. The Community-BLOC ensures sustainability and adaptability during pandemics, but also emphasizes inclusivity, health, and education as cornerstones for community resilience, offering a blueprint for designing healthy communities amid crises.

While HKS research delves into the intricate relationship between health and housing, our practitioners actively examine the implications for each scale—from individual units to entire neighborhoods. Investigating health outcomes linked to housing conditions, like homelessness and substandard housing, guides the firm’s efforts in creating healthier communities.

HKS Research operates by a “design to outcomes” framework, where the work we incubate, ideate, and prototype will—once fully realized—integrate with the project processes of our designers, architects, and planners. That’s the model we use as a research-based firm.

Our design research is how our firm progresses toward informed outcomes. The research program at HKS is both a sandbox of creativity and a model for investigating the most pressing issues facing our communities. In the past year, we’ve spent a lot of time thinking about the link between health and housing. Research is a paradigm where there are always more questions than answers, but it is also the paradigm of interlinking the decisions we make—in partnership with our clients, stakeholders, and communities—with intentionality and a legacy of rigorous research.