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How built environment practitioners play a key role in public health

During the second AfriSam SAIA Sustainable Design Awards webinar, Professor Tolullah Oni, a public health physician-scientist and urban epidemiologist, discussed how trans-disciplinary urban design can help build better African livelihoods and cities.
Professor Tolullah Oni, public health physician-scientist and urban epidemiologist. Image source:
Professor Tolullah Oni, public health physician-scientist and urban epidemiologist. Image source:

“Practitioners of the built environment should consider themselves as public health practitioners as well. This is because the work that they do has both an immediate and long-lasting impact on the health and wellbeing of the people in the communities, settlements and urban areas within which they work,” said Oni.

Entitled "Breaking down the silos", the webinar, chaired by Cape Town-based sustainability specialist and the head of School, Architecture, Planning and Geomatics, Dr Philippa Tumubweinee, investigated the potential impact that multisectoral collaboration in urban planning can have on health in Africa.

Cracks in societal systems

“The Covid-19 pandemic laid bare the gaping cracks in our societal systems, highlighting the need for a more health-aligned societal reset,” explained Tumubweinee. “By driving fair and equitable urban planning, we can protect people’s health and the planet in the long term. A conversation such as this puts a different spin on how we think about sustainability, and more importantly, it highlights a pressing topic which many in the industry may not have considered.”

Oni explained that, at best, the failure to fully address the adverse implications of the built environment is a missed opportunity to enable and promote wellbeing and health in communities. At worst, she said, it actively contributes to risk and transmission of disease.

Renowned for her services and academic achievements in the health sector, Oni promotes an understanding that health is everyone's business. This ethos is underlined by the belief that when issues around health are brought up, in reality, we are inadvertently talking about diseases.

Spaces where health is undermined

“When talking about health, we often automatically begin envisioning hospitals, clinics and the diseases which people have. In reality, this is rather considered as the absence of health,” she said. “We know that more than two-thirds of the factors and exposures that influence health lie outside of the healthcare sector. We subconsciously act as though health is the responsibility of only the healthcare sector, but in reality, the spaces where health is undermined is all around us, and the current pandemic has highlighted the need to address this.”

While it is quite obvious that people being treated in a medical facility are there as a result of a manifestation of something gone amiss in their bodies, we often don't consider that the person was most likely exposed to the illness either in their immediate environment or beyond their borders.

Treating diseases instead of people

After attaining her PhD and focusing on diseases such as HIV and TB, Oni explained that it was while working in South Africa a few years ago that she became interested in treating diseases instead of people. This was after realising that she and her team simply sat in the clinic and waited for the diseases to present themselves, instead of focusing on the root cause of the diseases.

Often patients with HIV and TB have other underlying health conditions such as diabetes, obesity, or blood pressure issues. She advised patients to either eat better or to be physically active by walking more, however soon concluded that in specific areas, the latter would be equally as detrimental to the patients’ safety through either injury or acts of violence.

Environmental exposures

To address this problem, she argued that consideration needs to be given to the environmental exposures and limitations of people that emanate from their homes and immediate environments, as well as their broader communities and even the intersections between their homes and places of work or learning.

“We needed to look at how these environments influenced health, and most importantly, how we can intervene in those spaces to create health,” she said. “To tackle a disease, we can't look at the disease without first looking at its root causes.”

On the topic of behavioural choices and the role that practitioners in the built environment can play in impacting people's behavioral choices, Oni said that when diseases such as emerging epidemics like obesity and hypertension are discussed, certain words are associated with these diseases such as choice, behaviour and lifestyle.

Considering determinant factors

“We tend to focus on the act of the individual, and a lot less on what the definition of choice is,” she said. “Choice implies options, while the term lifestyle implies true choice. To imply lifestyle means that the person has access to both the healthy and unhealthy choices, and sways more towards the unhealthy option.”

And while many diseases may be considered equally impactful across all demographics, it is truly the poorer and deprived communities in high-density unhealthy environments that bear the brunt of disease infection.

She suggested that for building practitioners to be enablers of health, they should not only focus on instilling good practices, but consider determinant factors that could potentially contribute to the deficiencies and overall health of occupants. She offered these tips:

Importance of partnerships

“Not one person can do everything, and partnership is important to reduce the deficits in health,” she said. “Partner with someone who can offer expert insights and concrete data regarding the problems at hand. This will allow you to tailor your design to address these. Secondly, it's important to do your research and make sure to measure the influence and impact of your initiatives. Lastly, meaningful engagement with the people that you are trying to influence is a critical part of doing anything impactful.”

Oni referred to her partnership with the Western Cape Department of Human Settlements on addressing the issue of meeting the health needs of communities in the region. She said the initiative started by simply getting all stakeholders across various sectors together to discuss the issues at hand and look for opportunities to integrate health into their spaces.

“We are currently operating together to upgrade some informal settlements, taking into account key priority health interventions that will inform what is rolled out and where it will be rolled out. From this we will be able to look at the impact that it has had, which will allow us to continuously improve.”

Follow a systems approach

Oni urged built environment practitioners to upskill themselves to address complexities and to follow a systems approach to understand the follow-on impact of their projects. This, she believes, will allow for consideration of the long-term effects of their actions as the impacts will mostly only be visible in the distant future. Further, she advised that they consider an understanding of planetary health, meaning the connection between human health and the ecosystems and environments that they depend on.

“We must realise that waiting for diseases to occur is simply not a viable solution to the problems at hand, and that prevention is certainly better than a cure. When integrating health into sustainable design, we can address many of the underlying health issues impacting the communities, and the surrounding environments, in which we serve,” concluded Oni.

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