By Pete Choquette, AIA, LEED AP, WELL AP and Lauren Wallace, LEED Fellow, LFA, WELL AP
Within the last month, in a span of fewer than three months, the United States surpassed 100,000 deaths from the COVID-19 pandemic. Not a day seemingly goes by without another 500 to 1,000 lives being lost. We find ourselves appalled at the almost cavalier way some of our leaders seem to be approaching this unprecedented loss of life and the continuing and unremitting danger being faced by our physicians and nurses as well as all the other workers who are continuing to try to hold together an increasingly fragile supply chain to deliver all of our basic needs. More to the point, it’s been stunning how badly they have done in educating the public about this virus and the absence of critical thinking about several structural inadequacies in our society that have been highlighted by this pandemic.
Your Health and Wellness: 10/20/70
To begin, I want you to think about all the aspects that influence your health and wellness as one big pie chart. Roughly speaking, 10% of that pie is your genetics. Genetics tell us your predisposition towards cancer, diabetes, heart disease, etc. that is encoded in your DNA that you inherit from your mom and dad and grandparents. Generally, there’s not much we can do about our genetics, so let’s set that aside in this discussion. The next 20% of the pie is our access to healthcare, mostly the acute health care that’s needed anytime we become ill or injured. How quickly can we get to a physician? How skilled are they? How good are the treatments they can prescribe or the diagnostic and surgical tools they can wield? In 2018, the United States spent 17.7% of our GDP on health care, according to the Centers for Medicare and Medicaid Services. That’s over $3.6 trillion, annually, toward a small 20% slice of the pie that makes up our overall health and wellness.
So, what’s the rest? Roughly 70% (depending on the study you’re reading) of your health and wellness is determined by your environment and your lifestyle choices. As a rule, with some notable exceptions in recent history, we in the United States have reasonably good environmental factors: access to clean air, clean water, etc. Our lifestyle choices leave more to be desired, though. These include some of the obvious insurance industry questions: do you smoke, drink to excess, or use narcotics or other controlled substances? But they also include our activity levels as well as our nutrition, which are areas where the United States struggles greatly relative to many other developed countries. Our food staples include, among other things, far more sugar than the foods consumed in places like the Pacific Rim or Europe, and our activity levels also fall well below that of our international counterparts.
As a consequence, according to the CDC, a staggering six in ten American adults suffer from a chronic disease either because of genetics, environmental factors, lifestyle choices, or some confluence of the three. Four in ten American adults suffer from two or more of those chronic diseases. And, according to an Emory University study in 2007, the American rates of chronic disease were notably higher than in Europe. But it’s not just adults that suffer from these issues with chronic illnesses (remember this concept, you will need it later). Roughly one in four children in the United States also suffer from at least one form of chronic illness and one in twenty has multiple chronic conditions. The most common reason is the high rate of childhood obesity in the United States (20%, according to the CDC), which primarily traces back to nutrition and activity levels. Young and old alike, Americans are simply not that healthy to begin with on average. While many people believe that we have a technologically advanced health care industry in the United States led by the best practitioners, we’re still being outpaced by countries that spend less on their health care systems and have lesser levels of medical sophistication.
Consequently, we’re shoveling money into a public health system that’s ultimately destined to fail. Long before “bending down the curve” of COVID-19 was a thing, health policy experts were trying to “bend down the curve” of escalating healthcare costs in the United States. Between 1970 and 2018, the cost per capita of healthcare in the United States (adjusted for inflation) rose from $1,832 per person to $11,172 per person due in no small part to the ever-escalating rate of chronic illnesses in America. When we participated in the IWBI’s first Well Accredited Professional training at the Cleveland Clinic for Wellness in 2015, the doctors there posited that the only way to make America’s current healthcare system economically sustainable was to leverage better environmental factors and champion better lifestyle choices to drive down the rates of chronic illness in the United States. Without a focused effort to accomplish these end goals, higher morbidity and higher healthcare costs would be inevitable.
Americans Are Likely More Vulnerable to COVID-19
Granted, the death rate per capita in the United States has been lower than most developed nations, spare Germany. Still, we suspect what we’ll discover at the end of this crisis is that the average American was statistically more likely to be vulnerable to COVID-19. One of the stupidest things, frankly, that was witnessed in the early days of this pandemic was the national media and the general public’s uncritical recitation of the “fact” that coronavirus only affected old people. We never knew a virus or other pathogen to check someone’s ID to see their chronological age. The far more accurate thing to say is that coronavirus disproportionately affects those with pre-existing health conditions, which include chronic health conditions. “Comorbidity” began to enter the country’s lexicon quickly as an April 22, 2020 study of 5,700 COVID-19 patients admitted to New York City area hospitals published in the Journal of the AMA confirmed that 94 percent of the patients had a pre-existing chronic health problem and 88 percent had two or more. The three most prevalent chronic conditions were hypertension (56.6 percent), obesity (41.7 percent), and diabetes (33.8 percent). Indeed, with the help of the Yale School of Health notes that over 15,000 “excess deaths” in the early days of the pandemic in the United States may have been COVID-19-related deaths misdiagnosed as deaths due to those existing morbidities.
A Wake-Up Call for Public Health and Wellness
When the current crisis is over, and we have a vaccine and/or therapeutic treatments to deal with this virus, the focus will inevitably turn toward lessons learned from the pandemic. We must learn our lessons after COVID-19 and not only make our healthcare system stronger but also invest in the built environment improvements and advocacy that curtail the chronic illnesses that have made COVID-19 such a deadly potion. It seems inevitable that the economic recovery from the current pandemic will include some form of federal infrastructure program as a part of a Keynesian stimulus approach. Such federal infrastructure programs should emphasize and prioritize infrastructure that promotes health and wellness. This will mean public investments in amenities that improve activity levels and promote greater fitness in communities. Safe bike lanes and sidewalk improvements in urban and suburban areas should be considered a part of the post-COVID-19 health and wellness strategy. Improved and expanded parks with hiking trails and sporting facilities ranging from pools to basketball courts should also be tactical weapons in our war on chronic illness. One of the more interesting observations of this quarantine era was on April 2 when the New York Times used cell phone GPS tracking data to show which areas of the country were not honoring stay-at-home orders. You don’t have to squint that hard to see some correlation with the USDA’s 2016 map of food deserts. Improving access to healthy foods in poor urban and rural areas alike ought to also be a goal of the post-pandemic strategy.
Building-level investments in health and wellness ought to also be incentivized. At Epsten Group, we believe in certification programs that focus on health and wellness advances that have been vetted by healthcare practitioners and scientists across the world. And by participating in these certification programs, facilities have a letter of attestation to prove that they have incorporated these design ideas, behavior influencers, and policies. New hospitals and community clinics are a natural fit for pursuing certifications in programs like the IWBI’s WELL Building Standard and the LEED Healthcare Rating System. Still, other facilities can also be designed and built with health and wellness in mind. And in the same sense, senior living communities can look to the Fitwel Communities rating system for guidance on design measures and policies to increase health and wellness for their programs. When certification isn’t a great fit, we can look to these rating systems to apply some of the more important health and wellness strategies as a start. Offices and schools can integrate improved air and water filtration, provide ample access points for clean drinking water, emphasize active vertical circulation and furnishings, and even include cafeterias and dining halls mindfully sequenced to promote better nutritional choices, as well as healthier food prep and hygiene. All of the above can easily dovetail with sustainability-related goals to reduce water and energy consumption, curtail vehicle miles traveled by traditional internal combustion vehicles, and provide larger green spaces for mental health, public recreation, all with microclimate and carbon sequestration benefits, with the end game of contributing to a healthier, more prosperous, and more just world.