Public health and regulation of the built environment

The Health of Towns Association was formed in London in 1844 following the publication of Edwin Chadwick’s Report on the Sanitary Conditions of the Labouring Population.¹ The Association was an important lobby group which supported the sanitary reforms which culminated in the first Public Health Act of 1848, the direct progenitor of public health legislation in Australia. Its stated aim was to:

… substitute health for disease, cleanliness for filth, order for disorder, economy for waste, prevention for palliation, justice for charity, enlightened self-interest for ignorant selfishness, and to bring to the poorest and meanest – Air, Water, Light.²

Nineteenth century sanitary reforms created a durable system of governance of what at first was a narrow but pressing set of hazards in the built environment; local authorities were vested with responsibility for building standards and town planning, the control of noxious trades, water supply, sewage disposal, the management of burials and mortuaries and vermin control.

Over the last 150 years the public health infrastructure, especially in developed countries, has grown in both size and complexity. Some of the major components of this infrastructure, as it applies to the built environment, are summarised in Table 1. The evolution of this infrastructure is shaped by population growth, technological innovation, community expectations, environmental and resource constraints and importantly the national and international experience of regulatory and system failure, and disaster.

Table 1.  Regulatory response and responsibility for hazards in the built environment

Responsibility for managing these hazards is now dispersed across government.³ Public health professionals have less involvement in the day-to-day management of these hazards than environmental scientists, traffic engineers, building-safety experts and professional urban planners.⁴ Regulatory oversight is similarly fragmented and in this situation it is easy for those working outside of the health system to lose sight of public health regulatory objectives.

There is however a strong justification for continued regulation of the built environment for public health, and for a more explicit role for public health agencies and professionals in defining or redefining public health objectives, in setting standards and in regulatory decision making.⁴ This role would or could include:

1. An insistence on fidelity to the technical merits of policy proposals.⁵ Public health is not a self-evident virtue, and there is an active critique of the over-involvement of government in the everyday lives of citizens. At times there is a need to take a strong position, supported by evidence, to impose some controls on a new consumer product or to contest a policy proposal. By adherence to technical merits we mean a close examination of the feasibility, effectiveness and efficiency of proposed regulations. The recent technical and policy debate about the health effects of unflued gas heaters in Australian homes demonstrated the need for robust public health arguments to inform important decisions about energy use and sustainability.⁶

2. Enabling the consideration of a much broader range of health impacts of urban planning, transport or building proposals. As Table 1 demonstrates, the regulatory framework for the built environment has been shaped largely by concerns about safety and injury prevention and communicable disease risk, and not by concerns about chronic disease prevention (cancer prevention and tobacco control are an exception). In many cases, these concerns can be addressed by an extension of current practice: for example, while pedestrian safety will be a normal inclusion in any development proposal, explicit consideration of the extent to which a proposal encourages walking could easily be appended.⁴

3. Proposing regulatory solutions to contemporary public health problems. The obesity epidemic and its links to sedentary lifestyles and, perhaps, to an urban form which predicates reductions in levels of physical activity have thrown open a debate about regulatory intervention for health in land use and urban planning. Prescriptive requirements for the location and number of fast food outlets and fresh food retailers and the mandating of urban residential densities have been proposed. A more promising approach may be an ongoing review of existing ordinances for pedestrian and cycling throughways, zoning, and lot size and layout. With this caveat in mind some examples of regulatory responses to contemporary public health responses are set out in Table 2.

4. Being advocates and advisers in the public debates around climate change, sustainability and urban planning and the excesses of consumerism. The interactions between humans and their environment is complex and public health officials are well placed to provide a balanced perspective on acute and contingent health risks. Urban planning decisions in particular have the potential to shape ordinary lives over decades and the precautionary principle has special application to the health evidence used for or against specific proposals.

Table 2.  Examples of regulatory proposals directed at reducing risks of chronic disease

Our society has a vast fixed investment in public health infrastructure in the built environment: sewers, water treatment plants and storage facilities, road surfacing and engineering, public transport, building design and construction, consumer and product safety measures, fire prevention and waste disposal – all measures which underpin our health. In general these provisions do their work silently and are well accepted by the public. At the moment of their imposition there may be suspicion or alarm – there was a furious 20-year debate in Sydney about the building of the highly visible and ornate vents for Sydney’s sewer system⁷ - but, in time, if appropriate, these provisions will gain acceptance. The complexity of modern government should not deter public health officials from seeking out new regulatory approaches to the built environment for disease prevention.