Health responsibility

Holding individuals & planners responsible for health, without passing the buck.


23 million Americans have diabetes today, compared to 2 million in 1960. The issue raises a contentious question. Did rates of the disease rise because of the personal failings of 21 million individuals? Or has something changed in our urban environment that have makes it harder to stay healthy?

Both positions can be skewed to seem absurd. I recently wrote a column arguing it is unlikely so many millions simultaneously suffered the same loss of willpower. The idea that we can blame the design of the neighbourhood, however, evoked a backlash online. Commenters argued individuals can always choose to be healthy no matter where they live. As one Reddit user put it, “I used to be Obese. I can't say I ever shook my fist ... and went ‘Damn you urban planning!!’”

My detractors have a point. No urban planner walks into people’s homes and prevents them from doing jumping jacks. The zoning for a neighbourhood may outlaw most useful destinations people might walk to, but planners cannot prevent anyone from going for an afternoon walk, or from driving far enough to buy vegetables. Yet clearly, planners can reduce the cost and willpower necessary to be healthy by designing places where walking and eating quality food is comfortable and convenient.

It would be easy to say that both individuals and urban planning are in part responsible for health. This answer, however, only dilutes responsibility and fails to push anyone to find solutions. We need a coherent way to hold all parties strictly responsible for their specific roles. As rates of inactivity and obesity continue to rise, we must stop allowing shared blame to abett inaction.

Happily, we need not develop a solution from scratch. Modern Western legal systems have already established how to manage shared responsibility on a related topic: safety.

When using a deep fryer, kitchen knife, or chainsaw, both the individual and the manufacturer are in part responsible for safety. The intrinsic purpose of these tools is itself dangerous, so the manufacturer cannot eliminate risk. The law is not vague, however, on how responsibility is shared.

A cook I once worked with dropped tongs into a deep fryer during the morning rush and, without thinking, reached her hand into the 190°C oil to pick it up. In this case, the fault fell clearly on the individual. She could not sue the manufacturer.

And yet, the manufacturer is responsible to ensure that nudging the contraption does not cause it to topple over. The distinction depends on whether injuries can be prevented without undermining the purpose of the device. The manufacturer was not responsible for my coworker's mistake, because preventing that kind of accident — perhaps by covering the oil with a metal top — would make it impractical to deepfry anything. It wouldn't be a deepfryer anymore. The manufacturer is liable when a product is a dangerous in a way not justified by its purpose. 

Even where the onus for safety is on the individual, the designer must make it relatively intuitive for a reasonable person to use it safely. When something dangerous is tempting (like standing on at the top of a step ladder), warning labels are required. In part thanks to clarity on who can be sued or punished for unnecessary danger, there has been 15-fold drop in deaths from accidents at work since 1910, and a three-fold drop in deaths from falling. 

Imagine an alternative planet, “danger world,” where only individuals, not manufacturers, are responsible for safety, the way individuals are soley responsible for living healthy today. Even with the most top-heavy deep fryer, the onus would be on cooks not to nudge it. You couldn't safely plug in a toaster in danger world without first reading a 10-page manual. Table saws would have no blade guard, rip fence, or off button, and so to cut wood without losing a finger would require highly trained hand-eye coordination. Plastic bags and choking hazards would be marketed as toys in the baby aisle. Lawns darts would still be for sale.

It is theoretically possible to be safe in danger world, but only if everyone becomes a safety expert in everything. Any person injured could be blamed for failing to apply due diligence, but since doing so for all appliances, tools, cars, and machines would take more time than available in a life, it would be effectively impossible to be safe on all fronts. Our real-world system makes much more sense: require the experts to be experts, not every individual. Make companies research and develop products to remove unnecessary potential risk, so that where individual responsibility takes over, it is as manageable as possible.

When it comes to urban planning, we live in danger world. Residents of the United States spend $66 billion annually on diet books, magazines, personal health coaches, clubs, and more, in an effort to turn everyone into health experts, yet rates of inactivity and obesity continue to rise. While over a third of Americans want to be in shape, as few as 5% attain even lax minimum standards of moderate physical activity, and less than 3% live an overall healthy lifestyle. Staying healthy is now only attainable by the exceptional few, often the wealthiest.

The design of many communities is clearly a major source of these problems. Decades of research has conclusively demonstrated that people who live near shops, services, parks, and transit are, on average, far more physically active and less obese. The location and zoning of many communities today, however, makes transit impractical and local shops illegal. We continue to build many communities where absolutely nothing useful can be accomplished by walking.

To fix these problems, we must start by asking: what barriers to a healthy lifestyle are intrinsic to the purpose of a house and its neighbourhood? If a problem is not essential — like a top-heavy deepfryer — then those who designed the community should be held strictly responsible for the bad health outcomes, not the individual. 

Are the above major barriers to health necessary to the intrinsic purpose of a home? Unlikely. It is possible to provide everything people seek in a suburban house — including privacy, quiet, safety, and a reasonable amount of space — while providing shops, services, and transit a few blocks away. Some people do want to live in communities with nothing but homes for miles, just as some people want cars without ABS breaks, and so we need to decide whether that desire is so intrinsic to the product that it outweighs the pressing health consequences. At the very least, such homes should come with warning labels outlining the substantial risk they create for diabetes, heart disease, kidney disease, stroke, cancer, and car accidents. I am absolutely serious on this point.

Once we are clear that the responsibility to design communities to support health falls squarely on urban planners, it will be necessary for the profession to develop expertise in how to better support health while still delivering the kinds of homes people want. As it stands, urban planners  can graduate without even learning about the issue, and many continue to design and approve communities where doing anything practical while being active is impossible. The profession is in a position similar to doctors in the 1800's, just as likely to hurt people's health as to help it.

As with deep fryers, individuals certainly do have responsibility for health, but it should start where expert designers can do no more to ensure their community offers options for being active and accessing healthy food. Arming planners with the necessary responsibility, authority, and education to support a healthy built environment will not be simple, but the first step is to recognize that they do in fact carry that ethical burden. Lifestyle diseases have been allowed to become the greatest source of illness and mortality in developed countries. The problem will continue to grow until we stop expecting every individual to make up for the failures of the professionals who build the communities where they live.


Photo by Raphaël Biscaldi on Unsplash