Why Health Equity in the Built Environment Matters

Why Health Equity in the Built Environment Matters


Inequitable access to health care costs the U.S. $135 billion each year. This is in addition to the nearly unfathomable loss of 3.5 million life years associated with premature deaths. Michael Crawford of Howard University shared that W.K. Kellogg Foundation data during a recent HKS webinar on Health Equity & Access that explored the high price of health inequity.

The webinar was part of the firm’s quarterly Limitless panel series, conversations between HKS leaders and experts in other industries about ideas that influence design, examined through the lens of justice, equity, diversity and inclusion.

For the most recent installment, HKS convened research, nonprofit and health care professionals to discuss equitable access to health care, and the intersection between health equity and the built environment.

Data to Address Health Disparities

Crawford, Associate Dean for Strategy, Outreach & Innovation at Howard’s College of Medicine, opened the webinar with a keynote address on the roles of digital technology and the built environment in addressing health disparities.

He presented information on life expectancy gaps for residents of major U.S. cities. Referencing data for Washington, D.C. zip codes, he said, “Two kids grow up in the same city, five miles apart. One has an expectation to live 27.5 years longer than the other child. How does that instill hope?”

Crawford described efforts by Howard University’s 1867 Health Innovations Project to improve health equity and access through digital health solutions and non-tech solutions for medically underserved communities. A pilot project involving the use of mobile phones to connect with people who have sickle cell disease has shown promising results for medication adherence but has also revealed limiting factors such as insufficient Internet access, he said.

This research, and the experience of dense urban populations during the COVID-19 pandemic, have identified needs for spaces where people can receive care, isolate to reduce disease transmission or access health information on the Internet using mobile technology. Transportation, green space and adequate housing are additional assets for creating health equity.

“These are items we are focusing on…as we think about the architecture community and what role you can play in terms of being able to facilitate greater access to tech solutions, or to build solutions that promote a community health and wellness mindset,” Crawford said.

He emphasized that the most valuable asset is the community itself.

Crawford said that listening to diverse community voices “leads to an equitable health design that can facilitate and promote health and well-being. I think it’s critically important in terms of how we design facilities.”

Understanding Community Needs

HKS Design Researcher and Senior Medical Planner Kate Renner moderated a panel discussion that followed Crawford’s keynote. The panel featured Ginneh P. Baugh, Vice President of Impact & Innovation for Purpose Built Communities, an Atlanta-based nonprofit community development organization; Robert Goodspeed, Associate Professor of Urban and Regional Planning at the Taubman College of Architecture & Planning, University of Michigan; and Kate Sommerfeld, President of the Social Determinants of Health Institute and Vice President of Community Relations and Social Investments for Midwest health system ProMedica.

Like Crawford, the panelists highlighted the importance of community involvement in projects to tackle health equity and access.

Forming a deep history with individuals and listening closely to what they have to say can take time, but provides “incredibly rich data,” said Baugh.

One thing to keep in mind, she said, is, “Who are we designing for?”

Health care spaces, for example, should be sized based on the number of anticipated patients plus the expected support network for people in the community.

“Who’s waiting with you for dialysis, or how many people need to be with that new mom?” Baugh asked.

Other community norms can come into play. Baugh recalled a clinic designed with a small waiting room that had people lined up down the block—but not people from the neighborhood. A community health worker knocking on doors learned local residents did not want to be seen waiting for an appointment outside the clinic.

Sommerfeld said that to design the best community health solutions, public and clinical data should be balanced with “voice and lived experience.”

While cross-sector partnerships with hospitals, universities, government and financial institutions can supplement insights from community members, she said, “make sure that residents are at the forefront.”

Working in partnership with the community can help identify evaluation metrics, strategies and uncertainties for urban planning projects, Goodspeed said.

He described a multi-year collaborative project on mobility that showed the importance of public transit to reaching places like the dialysis clinic or other medical clinics. By interviewing stakeholders and holding public workshops, researchers were able to pinpoint specific locations in the region, which they used to draw new transit maps to serve health care destinations.

Make sure that residents are at the forefront.

Health and the Built Environment

Panelists agreed the built environment provides rich opportunities for innovation in addressing health inequity and access.

“Housing is a health issue,” said Sommerfeld. “We’re seeing more and more payers start to invest in things like affordable housing across the country.”

If a child is in the emergency department many times a month struggling with breathing issues, paying to replace moldy carpet to improve the air quality of the family home is both cost effective and best for the child; evidence is mounting across the country for these types of interventions, Sommerfeld said.

Goodspeed noted the documented relationship between eviction and a host of mental and physical health outcomes. Housing stability is “a fundamental driver to health,” he said.

Families who live at the same address for three years benefit from a ripple of positive health outcomes related to children’s consistent school attendance and family members’ ongoing connections with neighborhood health providers, said Baugh.

Panelists also described how the built environment can improve food access, a key contributor to health equity.

To eliminate a food desert in Toledo, ProMedica’s Social Determinants of Health Institute “took a very bold leap to go ahead and open and operate a grocery store,” said Sommerfeld. The system has now helped five other health care organizations and nonprofits launch grocery stores to provide more equitable access to healthy food.

Baugh mentioned a neighborhood in South Atlanta that has been looking into accessory dwelling units (ADUs), small homes that can be installed in a backyard to provide additional income for residents. Local families can build wealth by owning or renting an ADU; the units also help increase the neighborhood population to the point it can support a grocery store.

Institutional changes, such as zoning codes that allow ADUs, can drive change for neighborhoods and individuals, Goodspeed said.

At the conclusion to the panel, Yiselle Santos Rivera, HKS Director of Justice, Equity, Diversity & Inclusion, remarked that the discussion had underscored the overall importance of innovation, collaboration and trust.

“We have to pay attention and we have to be intentional,” Santos Rivera said. “These, to me, are at the core of how we create a more equitable, just and inclusive world.”