Every four years, the American Society of Civil Engineers (ASCE) issues grades for the nation’s infrastructure, and if the federal government were a high school student, it would tear up the report before bringing it home. In 2017, as in 2013, America’s overall infrastructure score was a D+, but it could have been worse. The rail network, despite high-profile failures of the Amtrak line in the busy Northeast Corridor and the New York City subway system, got a B. Seven systems, including hazardous waste, levees, ports, schools, and wastewater, received modestly better grades than in the previous assessment. Parks, transit, and solid waste did worse, while others, such as aviation (D), roads (D), drinking water (D), and energy (D+), retained their miserably low scores.1
It’s not surprising that the ASCE does not grade social infrastructure, which is only now becoming a common concept. But it’s strange that the ASCE refrains from scoring the nation’s health and food infrastructures, which are as essential to our well-being as any other vital systems. As anyone who has been treated in an urban public hospital, visited a fallen industrial town or destitute rural community, or shopped for fresh produce in a low-income neighborhood knows, the places that make healthy living possible are also in disrepair. No one questions the urgent need for investments in the nation’s outdated systems for transit, electricity, energy, and storm protection. But are the dire health problems that stem from shoddy social infrastructure any less pressing or dangerous?
Consider, for instance, the largest American public health crisis since the HIV/AIDS epidemic: opioid addiction. Since the late 1990s, the United States has experienced a dramatic increase in the sale, use, and abuse of prescription pain relievers, such as codeine and hydrocodone, as well as street drugs like heroin.2 The results have been devastating.3 Hundreds of thousands of people have died and countless communities, particularly in small towns and rural areas, have been ravaged. The addiction crisis has taken a financial toll as well. One 2016 study estimated that the opioid epidemic had already cost the US economy almost $80 billion.4
The most serious consequence of the opioid crisis is an alarming rise in overdose deaths. In 2016, sixty-four thousand Americans were killed by overdoses—triple the number of 2000—with the vast majority of deaths linked to opioid abuse.5 To put this in perspective, it means more Americans died of overdoses in a single year than during the entirety of the Vietnam War.6 And the problem appears only to be getting worse. Health officials believe it likely that, absent a drastic intervention, five hundred thousand Americans will die from opioids in the next decade alone.7
There is no single cause of the epidemic, but there’s growing evidence that an important and often overlooked factor is the loss of social cohesion and social support.8 In 2015, the Princeton economists Anne Case and Angus Deaton identified a historically unprecedented increase in the number of white Americans dying in middle age.9 This was due largely to fatalities from drug and alcohol abuse as well as suicide, which Case and Deaton would later term “deaths of despair.”10 The economists, who had been influenced by the French sociologist Émile Durkheim’s classic account of suicide as a consequence of profound social disruption, argued that these fatalities were tied to large-scale economic and social changes. In addition to facing a decline in job opportunities, white people with little education were experiencing a loss of traditional rituals and social institutions that had long served as sources of support. Marriage rates are down. Divorce remains common. Families are fragmented. Local government agencies are strapped for resources. Libraries and childcare centers have fewer open hours. Churches are scrambling to meet new challenges and demands. “These changes left people with less structure when they came to choose their careers, their religion, and the nature of their family lives,” they write. “When such choices succeed, they are liberating; when they fail, the individual can only hold himself or herself responsible. In the worst cases of failure, this is a Durkheim-like recipe for suicide.”11
How does a loss of community result in more people using painkillers? Intriguingly, there’s a growing body of neurological research showing that opioids are, chemically speaking, a good analog for social connection. In one recent lab study, subjects were given naltrexone, a chemical that blocks the body’s ability to produce its own, naturally occurring opioids.12 Without these chemicals, individuals felt more socially disconnected from other people. This reminds us that taking synthetic opioids, of the sort currently wreaking havoc on struggling American communities, can soothe physical pain, psychological anguish, and the agony of social disconnection as well.
Today, much of the evidence that social isolation and opioid addiction are linked is anecdotal, based largely on users who say that they turn to drugs after losing a job or a sense of belonging. One heroin addict in the Rust Belt city of McKeesport, Pennsylvania, told the sociologist Katherine McLean that the city’s drug problems stemmed directly from a shredded social fabric. “There is no sense of community here,” she said. “Not one, not one iota of community here…. So, left to your own devices, somebody that’s drinking and drugging is gonna continue drinking and drugging. Nothing else, cause there ain’t shit else to do.”13
But anecdotes are not our only evidence. There’s new empirical work that establishes a clear connection between the strength of a community’s social ties and its ability to withstand opioid abuse. In 2017, a study by the Harvard graduate student Michael Zoorob found that communities with strong social capital—as measured by things like the density of civic organizations and the rates at which citizens voted—were more likely to be insulated from the opioid crisis than comparatively fragile communities.14 This remained true even when Zoorob took into account factors such as income, education level, and the rate of painkiller prescriptions. Such a finding may indicate that people in stronger communities are less likely to become addicted to drugs or, possibly, that socially isolated people who use drugs are more likely to die from them. One of the most intriguing ideas in Zoorob’s study is that overdose deaths—not unlike deaths from heat waves—may be higher among people with weaker social networks. Among the many reasons: if someone overdoses while they’re alone, there’s no one there to find them and call 911.15
While restoring a broken social infrastructure is a critical long-term project, many cities and towns in the United States are asking what they can do right now to reduce the rate of overdose deaths. To answer this question, it’s worth looking at another country that once faced a similar problem: Switzerland.
Beginning in the 1970s, Switzerland saw an alarming number of its citizens become addicted to heroin.16 Initially, the Swiss responded to this in the same way the United States has traditionally responded to drug use, with tougher law enforcement. Courts issued stiffer sentences for drug users and dealers, while police dispersed people who took drugs in public places. But the problem only got worse. In addition to seeing more young people take up the needle, the country also witnessed a frightening increase in property crime, HIV infection, and overdose deaths.
In 1987, increasingly desperate, authorities in Zurich tried the opposite approach. Instead of facing harsh penalties, addicts would now be allowed to use drugs openly, but only in a specific area of the city, Platzspitz Park. Fans of the television series The Wire will recognize this strategy as similar to the one deployed in Baltimore’s fictional “Hamsterdam.” As in Hamsterdam, this approach did little to stem the problem of addiction and created intense spillover effects, such as increased crime in areas around the park. Meanwhile, legalization did little to stem the number of overdoses.
Switzerland is not an especially progressive country. Swiss women, for example, only gained the right to vote in 1971. Yet, a country of bankers is nothing if not pragmatic. Stymied, authorities struck on a plan that was both radical and full of common sense. What was killing people, authorities realized, was not heroin use per se, but using heroin alone, under unsafe conditions. The Swiss government ultimately decided that the best way to protect users was to give them the drug. However, the heroin would be administered only in clinics where the addicts could receive proper supervision, and the drugs would be pharmaceutical-grade, free of any unknown and potentially fatal additives. Doses were large enough to allow users to function and not suffer withdrawal, but modest enough to prevent them from getting high. The program was run like any other medical facility and the users treated like any other patients. People even had to purchase health insurance to participate.
The Swiss found that once heroin users didn’t have to worry about how they’d get their drug, they were often able to take on the larger problems that had led to their addiction in the first place. Social workers were able to build trust with users, helping them get jobs and counseling. By reducing the stigma of heroin, and creating physical places where drug users and counselors could meet together without the threat of punishment, the Swiss government was able to reintegrate its users back into society.
In all cases, recovering from substance abuse requires the support of a community, be it family, friends, therapists, or twelve-step groups. Addiction experts refer to these kinds of social connections as elements of “recovery capital.”17 The heroin maintenance zones that the Swiss government established were not merely sites for drug injection. They were social infrastructures, places where addicts, counselors, and medical providers interacted regularly, under conditions that, though not exactly salubrious, were as healthy as possible.
Between 1991 and 2004, overdose deaths in Switzerland dropped by 50 percent.18 While many still overdosed at the supervised injection sites, not a single person died.19 Meanwhile, fewer people were choosing to start taking heroin. The number of new users dropped 80 percent between 1990 and 2002; in turn, HIV rates plummeted. The program also had positive effects for nonusers. Most notably, the country saw a 90 percent drop in heroin-related property crimes.20 In a national referendum held in 2008, Swiss citizens overwhelmingly voted to maintain their public health approach to opioid addiction. It’s now part of national law.
It’s also an international model of effective, if still controversial, social infrastructure, and one with a proven record of saving lives. Australia and the United Kingdom have run successful experiments with safe injection clinics. In 2014, Vancouver, Canada, an early leader in clean needle distribution programs, became the first North American city to open a fully legal heroin and methadone maintenance facility as well. The program made an immediate impact.21 Within two years of opening, the rate of fatal overdoses in the immediate vicinity of the clinic dropped by 35 percent; in the rest of the city, deaths dropped less than 10 percent.22 In Vancouver, as elsewhere, opponents of the legal injection sites predicted that they would encourage more people to try heroin, yet subsequent studies have shown that this hasn’t happened. As in Switzerland, cordoning off a safe yet tame zone for users made the drug less appealing, and there are far fewer new users there than in comparable places.23
US cities have been reluctant to adopt the Swiss model for opioid maintenance, but some places are inching toward the idea. Boston, which was one of the first American cities to experience a spike in lethal opioid overdoses and has been unable to reverse the problem, has allowed a sparsely populated corridor on the edges of the South End, Roxbury, and Newmarket neighborhoods to develop into the city’s “Methadone Mile.” It’s not a legally protected drug safety zone, but the area, which overlooks Interstate 93 and has little commercial activity, now hosts an open-air drug market, homeless shelters, addiction clinics, and the Boston Medical Center, one of New England’s largest safety-net hospitals and trauma centers. The thick concentration of services has attracted opioid addicts from all over New England, including some who are looking for treatment and others who just want a safer place to shoot up.
The city is struggling to keep up with the demand, but recently it opened what the journalist Susan Zalkind, in an article on the “infrastructure of the opioid epidemic,” calls a “no questions asked ‘engagement space’” that operates like a library, without requiring names or identification from its patrons. The clinic aims at getting addicts and drug abusers off the streets and into therapeutic programs, as does its neighbor, the Supportive Place for Observation and Treatment (SPOT), which monitors drug users to prevent overdoses and protect them, particularly women, from assault.24 Both programs achieved early successes. Within a few months of opening, Zalkind reports, SPOT staff had initiated 3,800 interactions with about five hundred users, 10 percent of whom went on to seek treatment, and prevented more than one hundred hospital trips. The addicts Zalkind interviewed told her that they’d made new friendships in the corridor. “You just know if something happens, you know that you have certain people that regardless are going to have your back,” one man told her. There’s a community, and a level of trust that’s unusual among opioid users on the streets.
Not everyone is enthusiastic about the project, however. There’s little question that Methadone Mile promotes the health and safety of opioid addicts, but social infrastructures designed for sick and vulnerable people, some of whom have criminal records, do not fit neatly into larger residential or commercial areas. Walk near the corridor, Zalkind writes, and you’ll notice that “people tend to walk toward the area in a determined march and away in a foggy stupor. Men with backpacks may whisper ‘brown’ and ‘that hard’ in your ear as you pass, and you’ll see a large number of people wearing lanyards with medical IDs hanging around their necks.”25 It’s easy to appreciate the benefits of building designated drug use and treatment zones if you live in another part of the city. Inevitably, though, people who live and work close to them complain.
Boston officials and leaders of the nonprofits and medical facilities that are working on Methadone Mile have been trying to do outreach with residents and small business owners who are worried about problems spilling over from the drug corridor. They are adding security and experimenting with designs that separate the therapeutic and medical facilities from the rest of the city. Fortunately, old industrial cities like Boston tend to have abandoned or undeveloped land where drug safety zones will not stretch into anyone’s backyard. If it works, it’s scalable: across the country, there are hundreds of places where a Methadone Mile could go. It’s too early to assess the Boston project, but the evidence thus far suggests that it’s reducing the risk of overdoses and helping people get into treatment. It’s sparing the city the cost of managing overdoses in public hospitals. Most important, it’s saving lives.
As devastating as the opioid crisis is, it’s not the only—or the biggest—threat to public health in the United States. Indeed, in many poor and segregated African American neighborhoods, the most urgent problems stem from the absence of basic goods and services that other Americans take for granted, including the most fundamental form of market activity: selling healthy food.
Consider Englewood, the neighborhood on the South Side of Chicago where so many people died in the heat wave, and where life expectancy is far below the city average. Abandoned homes, boarded storefronts, and empty lots with tall grass and weeds the size of trees actively discourage people from walking around the area, and there are frighteningly high levels of violent crime on the broken-down, depleted city blocks. “We’ve lost so many people here that I had to stop counting,” said Cordia Pugh, who has lived in the neighborhood for nearly five decades. “It was just too much.”
Pugh worries about drugs, gangs, and guns in the neighborhood, and she still gets rattled by the sounds of conflict in the streets. But for decades, the most frustrating daily problem she and her neighbors faced was the lack of fresh meat and produce in the neighborhood’s markets and corner stores. “I’m a fourth-generation farmer,” Pugh explained. “My father’s father’s father was a farmer, from Mississippi, and we just kept on doing it. It’s our heritage. With the Great Migration, which my family did in the 1930s, we took farming up North. We moved to Chicago when I was six, in 1959, from the place that’s now Ford Heights. And I’ll tell you, that was as rural as Mississippi. We had hog farms, cattle farms, all kinds of vegetables. You wouldn’t have known you were out of the South.” There were plenty of good food options in Englewood when Pugh’s family first moved there. “Back then it was still a mixed neighborhood,” Pugh recalled. “We had all kinds of shops and grocers, and there was a lot going on. I did Girl Scouts and the Boys & Girls Club in the neighborhood. I went to the YMCA after school. I did the Cadets [a music and marching program]. All right here. But in the 1970s things started falling apart here. All the white people left. There were riots after Martin Luther King was killed. The city disinvested, and all those programs for kids evaporated.” The groceries disappeared too.
By the 1980s, Pugh told me, Englewood had become “the heart of Chicago’s food desert”—the term that the US Department of Agriculture uses to describe urban areas where people have limited access to supermarkets, supercenters, or large grocery stores. The USDA reports that about 13 percent of low-income census tracts are food deserts, and in these areas, the absence of healthy food can be just as dangerous as the presence of gangs and guns.26 According to the US National Academy of Sciences, living in a food desert is associated with obesity and a host of chronic, diet-related diseases. It makes residents, including children, more likely to drink soda and consume processed foods that are high in salt, sugar, and chemical preservatives. It’s linked to diabetes and cancer. And, for people like Pugh, it makes each ordinary meal an occasion for regret about the sorry offerings on the table instead of joy.
There are not many upsides to living in a place like Englewood, but one of them, Pugh told me, is that so many lots are empty—there’s at least one open property on every block, and most have several—that the neighborhood is ripe for agriculture. “It took some time to see it,” she explained, “but after a while we realized that Englewood could be farmed just like Mississippi.” It’s an ideal place not only for developing community gardens but for urban farming, potentially on a large scale.
She wasn’t the only one to see the possibility. In 1992, Les Brown, who founded the Chicago Coalition for the Homeless, began advocating for an urban job-training program organized around farming. It was a bold idea, but a premature one, since the concept of urban farming was not yet established, and few shared his vision for transforming Chicago’s empty lots into sites of agricultural production. He persisted, as did one of his colleagues, Harry Rhodes, and in 1998 their organization, Growing Home, acquired land for a farm in Marseilles, Illinois, seventy-five miles from Chicago, which they used to train production assistants. Brown died in 2005, but that year Rhodes worked with an Englewood community organization and persuaded the City of Chicago to let them use a vacant property for an agricultural site in the neighborhood. The lot turned out to be located at the crossroads of three distinct gang territories, and it was polluted with PCBs. But after four years of remediation, which involved bringing in truckloads of new soil, building good relationships with nearby residents, and persuading the city to amend a local zoning ordinance, Growing Home opened the Wood Street Urban Farm in Englewood. It was Chicago’s first organic urban farm. Two years later, it opened the Honore Street Farm nearby. “Our goal,” Rhodes told me, “is to turn Englewood from a food desert to a food destination.”
Rhodes understands that it will be a long, difficult process, and he vividly recalls how bad things were when the farm project began. “Before we got to Englewood most people didn’t have access to fresh produce,” he explained. “They got their food from corner stores, Walgreens, or the gas stations in the area. People who really wanted fresh food would go to Whole Foods in the South Loop or the food co-op in Hyde Park, but most people didn’t have the time or the money to do that. It wasn’t hard to see why so many people had unhealthy diets. It was just hard to get good food.”
“Englewood was obviously struggling in 2006,” he said. “But a lot of families were doing okay. They had block clubs. The housing stock was filling. Things were starting to change.” Then the Great Recession started, and the wave of foreclosures that swept through Chicago’s African American neighborhoods hit Englewood especially hard. “It happened so fast,” Rhodes recounted. “One foreclosure after another. Before we knew it, every block had at least three or four houses that got boarded up. Even today, a decade later, there are blocks where half of the houses are empty. There are more empty lots. And there’s a lot more violence too.”
Today, thanks to a decade of labor by civic organizations like Growing Home, there are already more than eight hundred identifiable community gardens and urban farms in Chicago, and they deliver tangible benefits to the people who are fortunate enough to live near them.27 According to the American Public Health Association (APHA), which recently issued a policy statement and review of the scientific literature on how access to nature affects health, community gardens do more than provide shade and reduce the temperature in overheated urban environments.28 They foster interactions within and across generations, resulting in less social isolation as well as more cohesion, civic participation, and neighborhood attachment. They reduce stress levels for people who visit or frequently walk by them. They help children develop positive feelings about nature and facilitate scientific learning. And they provide healthy food: more than five hundred gardens or farms in Chicago produce fruits or vegetables, many in places where fresh food is hard to find. The city, which has more than twenty thousand empty lots, most of them concentrated in poor and segregated areas, could use many more small-scale green spaces.29 But that won’t happen without the resources that Chicago’s political and philanthropic leaders have devoted to other vital infrastructure, including the impressive green roof on its own City Hall.
The 21,000-square-foot, $2.5 million City Hall roof garden is one of the grandest and most expensive green roofs in the world. First planted in 2000, it features about 20,000 plants of more than 150 species, each of which helps reduce heat and absorb rainwater in storms. Chicago reports that, on hot days, the roof temperature on City Hall is approximately 30 degrees lower than on comparable buildings with conventional roofs, and that this reduces energy costs by thousands of dollars per month.30 The massive roof is an impressive piece of green infrastructure, exactly the kind of project that cities will need to build out at scale as the world confronts climate change. It’s aesthetically pleasing and ecologically responsible. It’s inspiring not only to international visitors but also to local developers, dozens of whom have planted gardens on the roofs of other Chicago buildings. It is not, however, a work of social infrastructure. It does nothing to help people in Chicago neighborhoods connect with one another on a regular basis. It doesn’t give people who are surrounded by asphalt better access to parkland or clean air. It doesn’t make those who are vulnerable to extreme weather any safer, nor does it make the places they live healthier. To do all of that Chicago would have to invest in less glamorous but far more accessible green spaces: community gardens and urban farms.
Pugh, who had a long career in the private sector before moving into philanthropy, told me that one motivation for getting so involved in Englewood’s farm and garden movement is establishing proof that the concept works. In addition to her own garden, she has developed two urban farms, the Hermitage Community Garden and the Englewood Veterans Gardens, in partnership with Growing Home. The new green spaces yielded much more than fresh produce. “The farms and gardens are giving people a peaceful place to go,” Pugh explained. “Young people. Old people. We even get people coming from other neighborhoods, because they get so much pleasure from being outside, working the land with other good people. And we need that, because you can’t have a community without a community space.”
The farms and gardens are not just community spaces, Pugh added. “They’re safe havens. Even the gangbangers respect what we are doing.” They have parents and grandparents in the neighborhood, after all, and they appreciate fresh food too. “When there’s a conflict they tell everyone to stay off our block now. They know we’re doing something good here. And there’s a good chance that their relatives will be out here too!”
“When we first got to Wood Street there was a turf war among gangs right there,” Rhodes told me. “And we were building just as everything else was getting boarded up, so we had some kids vandalize our property, breaking windows and the like. But we were working closely with community groups and residents, and after a while people came to see us as a local resource. They saw that we had something to offer. And since then it has been pretty peaceful here. The gardens are just beautiful places. We’re trying to build new ones too, because it’s clear that the neighborhood needs more.”
Englewood is still far from a food destination, but Growing Home is helping to end the food desert. Its two farms are producing a steady supply of fresh produce, and they now run a weekly farmers’ market with cooking classes. Recently, two other community organizations built farms on empty lots nearby, and Kusanya, a locally owned nonprofit café, opened there too. The neighborhood, long stigmatized as a den of urban violence, is slowly gaining a reputation as a special place for urban agriculture. This change in its status has already affected local economic development. In September 2016, a shopping center with a Whole Foods, a Starbucks, and a Chipotle opened in Englewood, leading journalists to call it a “food desert no longer.” This was perhaps premature, since not everyone can afford the fare at these establishments. But Englewood residents waited in long lines to shop in the Whole Foods on opening day, lured partly by the high-end grocer’s pledge to offer reduced prices on staple items, including fresh produce, and partly by its commitment to hire scores of local residents.
Growing Home has also maintained its original commitment to job training and economic development. “When we spoke with people in the community, we learned that helping to break the cycle that led from poverty to prison and back was incredibly important here,” Rhodes told me. “So we set up a program for people who’d just left prison, giving them fourteen-week jobs as production assistants and then helping them get full-time jobs when they finished.” Once that was set, Growing Home formally added community development to its mission. “It makes a big difference to have a place that produces good food and helps to make all these social connections. We now see a lot of ways that we can help make Englewood a healthier place.”
It took years, and an enormous amount of hard labor in the long-neglected urban soil, to persuade public officials that they could use infrastructure funds to support urban farms and community gardens. “When we first started the city kind of laughed at us,” Rhodes recalled. “‘A farm in Englewood! Right.’ Now they can see that this is a good idea. We’re about to get a new site next to the farm on Honore, and for that one the city will actually do the environmental cleanup, cap it, fence it. That’s a lot more support than we had a decade ago. It would be nice if the support was more systematic. But they see the difference we’re making, and maybe we will get that someday.”
They will if the American Public Health Association has influence in the emerging space where social infrastructure planning meets urban health. According to one of the main policy recommendations from the APHA report on nature: “Community gardens should be considered as a primary and permanent open space option as part of master planning efforts; gardens should be developed as part of land planning processes rather than as an after-thought in neighborhood redevelopment projects.”31
Policy makers have ignored this recommendation, but should know better. After all, modern infrastructure—for reliable power, clean water, fast transit, affordable food, and resilient structures—has done more to improve public health than any other modern intervention, including scientific medicine. “The early 20th century saw great changes in health and safety brought about through collaborations that today would be viewed as odd or unusual—[between] physicians and city planners, sanitarians and civil engineers,” write Charles Branas and John MacDonald, who expanded their research on mediating urban blight to see if it does more for public health than reduce violent crime. “Episodically treating small numbers of people, while ignoring the obviously unhealthy social and environmental surroundings within which people live, has stunted our treatments and moved the health of the nation forward at too slow a pace.”32 Today, as the world grows more urban and unequal, there’s an urgent need to build healthier places, and social infrastructure is the key.
Fascinating research by Branas’s team in Philadelphia shows not only that small green spaces in poor urban neighborhoods improve public health but also how they do. In a study led by Eugenia South, a professor of emergency medicine at Penn, the team found twelve people (eight men, four women, all African American, mostly older, and the majority with annual incomes under $15,000) who were willing to walk through an area within two blocks of their home with Garmin monitors measuring their heart rates continuously. They did two walks, separated by several months. On the first, the participants walked by untreated empty lots, the kind of urban blight that, as Branas’s earlier research showed, tends to attract crime. On the second walk, they walked by empty lots that had been converted into small, accessible gardens with trees and other vegetation. Heart rate, the authors note, is a clear and dynamic marker of stress response; tracking its variations as the study subjects walked by the treated and untreated lots would show whether being within view of well-maintained green places affects a crucial element of human health.
The results were unmistakable: When residents walked by the untreated vacant lot, acute stress caused their average heart rates to increase by 9.5 beats per minute—this despite the fact that the sites had long been in the area and were familiar to the study participants. A spike of 9.5 heartbeats per minute may not sound too dangerous, but to Branas’s team it was a worrisome number. It suggests that living near blighted urban spaces generates recurrent surges in stress and, with them, “inflammatory changes and dys-regulation of cardiovascular, neurological, and endocrine systems over a lifetime for persons repeatedly exposed.”33 Walking, which in most cases is precisely what people need to do to improve their health and fitness, can become instead a source of anxiety.
The effects were reversed when the subjects walked by lots that had been transformed into green spaces. “Our results indicate that in-view proximity to a greened vacant lot decreases heart rate, compared with in-view proximity to a nongreened vacant lot,” South and her colleagues conclude. “The reduction in heart rate suggests a biological link between vacant lot greening and reduction in acute stress.” More pragmatically, it indicates that “improvements to … physical conditions”—even inexpensive changes, like turning vacant lots into pocket parks—“may lead to widespread downstream health benefits.” Like the APHA, they urge governments to consider structural improvements to neighborhoods as “first-line solutions to difficult urban problems.”34 In Philadelphia, and around the world as well, the evidence that vibrant green places promote health by reducing stress, especially among the most vulnerable, is hard to ignore.
I’ve been concerned about the fate of one rapidly expanding group of vulnerable people, the elderly, since I began studying the Chicago heat wave. There are nearly six hundred million people aged sixty-five and above around the world today, and the United Nations estimates that “almost half of women living independently [i.e., not with family or in an institution] live alone.”35 These numbers are expected to rise dramatically in coming decades, as the population ages. According to a joint report by the World Health Organization and the US federal government, the total number of people aged sixty-five and over will reach 1.5 billion, or about 16 percent of the global population, by 2050.36
In another research project, which became the book Going Solo, I argued that the rise of people living alone is one of the most significant but least examined demographic changes in modern history. Although the rise of living alone results from many positive changes (including the increase in longevity and the rising status of women), it has generated one extremely worrisome social problem: a spike in the number of old people at risk of becoming sedentary and isolated, particularly if their mental or physical health diminishes. Public policies that provide professional caregivers can help address this problem. But there is another, far more beneficial and considerably less expensive way to help the elderly maintain their health and vitality: invest in social infrastructure, and build places that promote active lifestyles and frequent interaction in the public realm.
In the United States, branch libraries, particularly those that offer programs like video bowling leagues, book clubs, and karaoke sessions, play a significant role in helping old people remain active. Designated senior centers also draw people out of their private homes and into the social world, albeit a somewhat stigmatized one where they only encounter people in their age group. Thanks to Social Security and Medicare, the American elderly receive basic support for managing the financial challenges of old age, yet the United States does little to promote physical and social activity among the elderly. Parks, for instance, may occasionally host programming for older people, but they are rarely designed to meet the needs of an aging population; the same is true of most libraries and public housing facilities. Other countries, however, have made larger and more thoughtful investments in social infrastructure that help the elderly flourish. These projects get little public attention, but as promoting good health in the world’s aging population becomes a major social challenge, it’s important to understand how they work.37
I’ve spent years seeking out places that help old people maintain their physical health and social vitality, and one of the most remarkable examples is Singapore, where the life expectancy, 83.1, ranks third in the world. (Japan is first, at 83.7, and Switzerland is second, at 83.4. The United Kingdom ranks twentieth, at 81.2, and the United States is thirty-first, at 79.3.38) About 80 percent of Singapore’s citizens, and an even greater proportion of old people, live in publicly developed housing projects with privately owned flats, sold to residents with generous state subsidies. Most of these complexes offer residents easy access to vibrant common areas, including parks with exercise areas, generous meeting spaces, and affordable dining options at the outdoor “hawker centers” (or food courts) that typically occupy the ground level. “These places are busy all the time,” says Wei Da Lim, my host during a research visit with Singapore’s Centre for Liveable Cities, as we slurp laksa in a crowded hawker center on the ground floor of the Toa Payoh development. “Of course there are a lot of old people, because there are a lot of old people in Singapore”—today about one of eight people is over age sixty-five; by 2030, it will be one of five. “A lot of them live alone, and this is a place where they can always come and find people they know.”
Toa Payoh is a typical Singapore housing estate: a series of high-rise towers, connected by stone walking paths and sidewalks, with small gardens scattered around the area and an expansive, open-air shopping center at the base. I visited five other housing complexes in different neighborhoods during my time in Singapore, and while their designs varied, each supported an extraordinary level of social programming, offered verdant green space for outdoor relaxation, and hosted commercial activity, from shopping to dining, that attracted people across generational lines. The common areas were heavily used, but the grounds were always clean and well maintained. People worried about crime, and a few complexes featured large signs where officials could report recent offenses. But the crime rates are low by almost any standard—at Toa Payoh, the “Crime Alert” sign was blank—and most criminal acts are petty. Old people looked to be at home in the public areas, whether they were walking, shopping, or, in a sight I saw often during long and humid afternoons, sleeping on a shaded bench.
The Singapore government engages in strict social planning, and it allocates units to achieve a mix of ethnicity and income level in each complex. But it is only beginning to grapple with the problem of what to do with such a rapidly aging population. I met with several city officials during my visit: the Centre for Liveable Cities is a research arm of the state, with tight connections to policy makers. Some worry that residents who age in place will grow isolated and estranged from their children and grandchildren, because the tight housing market makes it difficult for multiple generations to live in the same neighborhood. Others are concerned that large units designed for large families will be occupied by old couples and singles who won’t use the space, further intensifying the housing crunch in one of the smallest and most densely populated places on earth. There are limits to the government’s social planning, and it respects the rights of home owners to remain in their flats. But the housing agency is considering new developments that would help reintegrate elderly people with their children, whether in larger, multigenerational units or in new complexes that offer a mix of housing types for younger families and older singletons.
These ideas are not unique to Singapore. In Sweden, where a greater proportion of people live alone than in any other nation, I observed mixed-generation residential communities designed to bring people from different families together in active, socially supportive environments. At Färdknäppen, a cohousing project for people aged forty and above, everyone keeps their own private apartment but there are all variety of common spaces and programs, including a large kitchen and a nightly dinner that residents can cook and eat together whenever they choose.39 In the United States, some developers—and far more individual families acting alone to solve what feels like a private problem of caring for an elder—are experimenting with multigenerational housing types that allow younger and older members of a family to live in separate units on a common property. These projects, which come primarily from the private and philanthropic sectors, are hardly common. But they signal an emerging recognition that more and more people are looking for better places to live as they age.
Visiting Singapore was striking because government officials there are worrying about problems for the elderly that, thanks to the design and social order of their estate housing, they’re already solving better than most other places. Singapore is an unusually affluent and educated society, with an authoritarian government and norms of social intervention that no democratic nation shares. Yet the current model of urban planning that Singapore uses to improve the health and welfare of its older citizens works by promoting the same things governments around the world are beginning to advocate: busy food corridors, commercial strips with local vendors, neighborhood parks, and vibrant public spaces. In most societies, creating healthier places for old people doesn’t involve changing core values or systems of government. But it does require confronting two major social developments that few nations have been willing to confront honestly: there have never been so many old people, and there has never been such a dire shortage of housing that meets our current needs. Designs for the world’s rapidly aging, increasingly urban societies will, inevitably, involve the kinds of large-scale housing and commercial complexes that Singapore is already developing. In the meantime, however, there are a number of small-scale improvements to the places where we live that can help keep old people healthy.
In Placemaking for an Aging Population, the urban planning scholar Anastasia Loukaitou-Sideris, along with a team of policy researchers at UCLA, highlights innovative social infrastructures designed for older people around the world. The most common projects are for parks and green spaces, which can easily be rebuilt to encourage more active use by older residents and more interaction across generations. In China, for instance, the elderly have long used public parks for collective exercise, including fast walking, dance, and Tai Chi. But in the late 1990s and 2000s, as China prepared to host the 2008 Olympic Games, the government began urging its rising older population to be even more active. It built thousands of new parks in urban areas, and many feature low-impact exercise equipment designed for the elderly.
Loukaitou-Sideris and her colleagues report that Spain has built more specialized recreational areas for old people—they call them “geriatric parks”—than any other European nation. The province of Málaga has thirty-two geriatric parks, mostly set within larger green areas. They typically include balance beams, pedals, stairs, ramps, and turntables, as well as space for group activities, and they’re complemented by multigenerational exercise equipment in the adjacent areas. In 2009, London installed a similarly equipped “playground for seniors” in Hyde Park, and although middle-aged adults are welcome to share the area, children under fifteen are prohibited. Residents in Blackley, in Manchester, built their own senior park around the same time, but they opted for proximity to younger users, whose playground is on the nearest lot.40
The most ambitious attempt to promote cross-generation interaction through outdoor play comes from Finland, where the playground manufacturing company Lappset has been working with local governments to create “three-generational play spaces.” Lappset’s parks feature equipment such as crawlers, climbing frames, and swings that are designed to be accessible regardless of age. They require some risk taking and cultural adaptation, since middle-aged and old people can feel awkward and uncomfortable on recreational facilities long associated with early childhood. According to market research, the French are least inclined to jump in and use the playgrounds, while the Germans and Scan-dinavians show the most enthusiasm for multigenerational play. No matter their nationality, once older people start using them, the benefits come quickly: A study by researchers at Rovaniemi Polytechnic, for example, found that three months of exercising on the playground equipment improved the balance, speed, and coordination of a group of forty senior citizens between the ages of sixty-five and eighty-one, reducing their vulnerability to falls. One sixty-three-year-old told the BBC that when she started using the playground’s balancing equipment she felt like “an elephant walking on a narrow beam,” but that after three months she’d cut her time from more than a minute to seventeen seconds.41 The real payoff, however, came outside the playground, on the streets and sidewalks where she could walk with the power and confidence she’d had when she was young.
Old people, of course, are not the only ones who need easy access to parks and other recreational facilities for their well-being; we all do. Children’s need for open-air play spaces is particularly important: their physical health and social development depend on them. But in recent decades, as research by the renowned environmental psychologist Roger Hart and the scholars he has assembled at the City University of New York [CUNY] Children’s Environments Research Group establishes, children throughout the developed world have been steadily losing their outdoor play spaces. Even playgrounds, Hart argues, have become excessively constraining for developing bodies and minds. The CUNY team identifies several reasons for the decline in accessible spaces for outdoor activities: public divestment from parks and recreational facilities; rising concerns about violence; new regimes of continuous adult supervision; parental pressure for academic achievement; the emergence of professionally managed after-school programs; and, cutting across all classes and regions, the popularity of small-screen culture, with video games, apps, and social media as the dominant sources of youth entertainment. The effects of this loss include higher levels of child obesity and stress, and, Hart argues, diminished skills for participating in civic life.
This concern about the loss of civic skills may be surprising, since we rarely think of spending time on swings and slides or playing in sandboxes as preparation for democracy. But when Hart and his team go to the playground, they focus on behavior that most parents treat as secondary: How does a child decide when it’s time to give up a swing so that another can have a turn? What happens when the wait feels too long? When do kids include strangers in their games and projects, and when do they set boundaries? How do they manage disagreement and conflict? Context matters. Hart and his colleagues are not only interested in what happens in the schoolyard or neighborhood playground where children make regular visits. They believe that social dynamics among children change when they explore new places and encounter different people and groups. Kids are especially likely to develop interpersonal skills that will help them in civic life when they wander into “foreign” places and have to navigate the new social situation on their own.42 But that’s the kind of thing that happens less often now that parents monitor their children so closely, and they get little opportunity to roam.
One recent paper, by Hart’s colleague Pamela Wridt, draws on oral histories, childhood autobiographies, and archival research to show how access to public space varied among three generations of New Yorkers: those born in the 1930s and 1940s, the 1970s, and the 2000s. For those born in the 1930s and 1940s, the neighborhood sidewalk was the main play area. Victoria, an Italian American who grew up in the East Harlem/Yorkville neighborhood in the 1940s, recounts that on her street “the whole block was full of kids. Almost all the activity was done outdoors…. You went outside and on the sidewalk you drew [with chalk] a potsie, those little squares where you used to play jacks, [and] bottle tops.” Mothers allowed their children to play late into the evening, Wridt explains, “as they knew neighbors were keeping a watchful eye on their sons and daughters. Parents could also keep an eye on their children with great ease by peering out their tenement windows.”43 There were risks involved in outdoor play, from benign conflicts with other kids or adults to, more seriously, getting involved in a gang or being hit by a car, and reform organizations lobbied for the city to develop contained play spaces, like playgrounds, to better protect kids. But bad things rarely happened to kids like Victoria. The sidewalks were their safe haven, the place where they grew up.
Most New Yorkers born in the 1970s had a different experience. By then, Wridt shows, rising crime made parents reluctant to let their children roam freely on the streets and sidewalks, and supervised areas, including playgrounds and athletic fields, had become more popular. But when the fiscal crisis hit, the city cut funds to parks and playgrounds. Professional supervisors disappeared. Conditions deteriorated. Gangs and drug dealers took charge of public spaces. Reggie, an African American who grew up in East Harlem/Yorkville around that time, tells Wridt that racial conflict was common, and black and Latino children often found themselves targeted in places that lacked an adult presence. As a teenager, he still wandered the area with friends, going to outdoor concerts (“open jams”) in parks and playgrounds and building friendships through music and dance. But for younger children, these areas were gradually becoming off-limits, particularly after dark. A rising number of parents and caretakers were retreating from outdoor public spaces and forcing their children to hunker down indoors instead.
By the 2000s, children’s access to outdoor public spaces was even more restricted. Noel, a thirteen-year-old Italian American who is growing up in the Isaacs Houses, the same complex where Reggie lived, tells Wridt that as a young child her parents let her play in the playground within the Isaacs, but forbid her from going to other local parks. “Noel’s parents are extremely protective of her,” Wridt writes, “and invest an enormous amount of energy monitoring her everyday life.” Occasionally they let her join friends for movies or window-shopping on Eighty-Sixth Street, a more affluent commercial corridor near her neighborhood. And occasionally she goes to a professionally managed after-school or summer program in one of the commercial organizations that have become so common in middle-class and affluent communities today. But Noel says that her mobility is restricted, and as a result she spends most of her free time going where most people her age go. “I’m always on the Internet,” she reports, “instant messaging … not as much email, but instant messaging. The television is always on, and the computer is always on too. I text message on my cell phone.”44 It’s social behavior, to be sure, but it seldom involves physical activity or spending time in green spaces outdoors. It may well protect Noel from violence, but it exposes her to risks of other health hazards, from obesity to stress to attention deficit disorders, that were far less prevalent in previous generations.
Noel’s parents are choosing to keep her out of their neighborhood’s degraded public play spaces, but by some measures they and their fellow New Yorkers are better off than other American families, because at least they have a local option. In the United States, the United Kingdom, and most other industrial countries, access to nature and outdoor play areas varies by social class, sometimes dramatically. In Los Angeles, for instance, where good weather should entice children outdoors in all seasons, nearly half of all low-income households lack immediate access to a park or playground. And, as Billi Gordon, a UCLA neuroscientist who studies the relationship between obesity and stress reports, many who do live near an outdoor play space are so close to a freeway that they stay indoors to avoid the dirty air.
Los Angeles didn’t have to be this way. In 1930, with a commission from the chamber of commerce, the landscape architect Frederick Law Olmsted Jr. published Parks, Playgrounds and Beaches for the Los Angeles Region, an elaborate proposal to build a network of parks, playgrounds, beaches, and forests for Los Angeles County. According to the City Project, a civic organization that advocates for equity in access to green space, the Olmsted Report “recognized that low-income people often live in less desirable areas, have fewer leisure opportunities, and should receive first consideration in parks and recreation.” Its recommendations included “doubling public beach access,” “greening the Los Angeles and San Gabriel Rivers,” and “integrating forests and mountains within the regional park system.”45 Although the plan was well received, Los Angeles power brokers killed each of Olmsted’s key proposals. Worse, in subsequent decades the city’s growth machine used racially restrictive covenants and constricting zoning laws to make Los Angeles even more divided and unequal than it was when Olmsted tried to fix things. Today, the city has some of the most lavish private estates, beaches, and country clubs in the United States, and residents of Los Angeles’s affluent neighborhoods live amid some of the world’s most beautiful natural sites. But in the impoverished neighborhoods, parks are in short supply.
They’re also financially strapped. Los Angeles’s refusal to invest in healthy, accessible green spaces did not end in the 1930s. Today, after decades of massive urbanization, Los Angeles County estimates that the parks it does support face roughly $12 billion in deferred maintenance costs, while the system needs some $21.5 billion for improvements. Los Angeles, like many American cities, is politically fragmented, and dozens of small municipalities have raised their own funds for parks, playgrounds, swimming pools, and senior centers because the public resources are insufficient. But that merely compounds the city’s environmental injustices. After the Los Angeles city controller conducted a series of audits, it formally declared what everyone already knows: “that more high quality recreation programs are available in wealthy communities than in low-income communities, and the policies and formulas for distributing public funding exacerbate rather than alleviate inequities.” Local leaders have been aware of this problem for decades; yet, as the City Project concludes, “the City has failed and refused to implement the Controller’s recommendations to improve parks in every neighborhood.”46
Recently, however, Los Angeles voters expressed their over-whelming frustration with the city’s disinvestment from parks, beaches, and open spaces. In November 2016, they passed Measure A, a 1.5-cents-per-square-foot parcel tax to help build and maintain city parks, with nearly 75 percent of voter support. It’s a modest measure, to be sure, with projected returns of less than $100 million per year. But it has no expiration date, so it promises to deliver a steady supply of new resources to the city’s parks and public spaces. For now, though, whether the funds go to the people and places that need them most remains an open question, and the history of Los Angeles suggests that directing public investments in outdoor amenities to poor minority areas will always require a fight.
The research on environmental inequalities leaves little doubt that race and class shape who has access to nature. But poor people are not the only ones who suffer when they live far from green social infrastructure; middle-class and affluent people also need time in verdant settings, and those who cannot get it pay a high price. That, at least, is the conclusion of a fascinating paper by a team of British researchers headed by the geographer Jamie Pearce. Pearce and his colleagues wanted to know which environmental characteristics help drive health disparities in the United Kingdom. They developed a “Multiple Environmental Deprivation Index,” which incorporates a wide set of ecological “disamenities,” and measured census wards across the United Kingdom.47
At the national level, the new index confirmed what Pearce’s team expected: on average, impoverished neighborhoods had far fewer ecological amenities than wealthier ones. The effects are readily apparent. Mortality records at the census ward level show that environmental deprivation has a significant effect on health, even after controlling for a ward’s age, sex, and socioeconomic status. The relationship is straightforward too: the more physical environmental deprivation, the worse the community’s health. This finding was important to Pearce and his collaborators, because until recently some scholars, including Richard Mitchell, an epidemiologist who was part of Pearce’s team, had wondered about “confounds,” such as social class, that might better explain why environmentally deprived people fare worse than those in greener surroundings. Here, using reliable and comprehensive national data, the British researchers showed that environmental deprivation matters, period.48
The real surprise from Pearce’s study, though, concerns the effects of environmental deprivation on the health and longevity of people in more affluent districts. In previous studies, mainly conducted in the United States, epidemiologists had found that the impact of environmental deprivation on health was “disproportionately detrimental” in low-income neighborhoods. But in the United Kingdom, Pearce discovered, “the effect of multiple environmental deprivation was greatest among the least income-deprived populations.” In London, for instance, affluent people who live in densely populated neighborhoods, such as Islington and Clerkenwell, that are coated with asphalt and far from open green spaces face greater health risks than their peers who live in places like Knightsbridge or Bayswater and enjoy easy access to all of Hyde Park.49 In the United Kingdom, at least, even wealth cannot protect people from the dangers of a poor environment. To stay healthy, everyone needs some green.