Healthy by Design? Reflections on The Topography of Wellness by Sara Jensen Carr

If the COVID-19 pandemic has demonstrated a unique ability to muddle our perceptions of time, it has also made us acutely aware of space and movement. Working from home, like so many others, I find myself counting down the hours to the words “HOT GIRL WALK” in my list of daily tasks. Lucky enough to live near Rock Creek Park in Washington, DC, I can be embraced by tree-lined trails in mere minutes, giddy with the departure from cityscape. Traversing my neighborhood, my path is facilitated by crosswalks and clean sidewalks; I pass two convenience stores, a large grocery store, and three coffee shops along the way. These details are just the elements of the landscape I notice in real time — I rarely take notice of the sewage system operating beneath my feet, the sanitation workers sweeping the sidewalks before dawn, or the ceaseless undercurrent of gentrification across DC.

My augmented appreciation for fresh air and neighborhood amenities during the pandemic, I’ve learned, has deep historical roots. As David Benjamin, associate professor of architecture at Columbia University, summarizes in an interview for the Washington Post Magazine, pandemics are a fundamentally “spatial problem.” Sara Jensen Carr’s timely and insightful book The Topography of Wellness: How Health and Disease Shaped the American Landscape examines this point further, arguing that throughout history, we have indelibly shaped our environments in the pursuit of wellness.

In Topography of Wellness, Carr, an associate professor of architecture at Northeastern University, historicizes the ways urban planners, designers, and health professionals have interpreted and shaped the ties between disease and landscape. She exhorts us to remember that our environments “inevitably inscribe themselves onto our bodies.”^[1] As we continue to weather the disruptions of COVID-19, Topography of Wellness makes a powerful case for collaborative strategies that conceptualize the body in space and, most importantly, in community.

Carr structures her analysis around historical approaches to six epidemics — infectious, social, and chronic — which have acted on conditions in the urban environment. The book is bisected to reflect the narrative of “epidemiological transition” long upheld by scholars of demography and public health, which posits that over time, degenerative, man-made diseases overtake epidemics of infectious disease as the primary form of morbidity and cause of mortality. In reality, however, Topography of Wellness invites us to consider early 20th-century epidemics of cholera and tuberculosis alongside chronic diseases like cancer and obesity. Rather than separating infectious and chronic disease into distinct eras, Carr challenges us to see the ways the manipulation of landscape has consistently remained central to conceptions of wellness.

Beginning in late-19th century America, at the crucial juncture of the Industrial Revolution, Carr outlines the ways urban planning, public health, and medicine have diverged as specialized fields increasingly supported by empirical evidence and isolated in epistemological silos. She draws on a vast breadth of sources and stories, from advocacy for playgrounds by tuberculosis experts to Olmsted’s notes on the planning of Central Park to emerging models of rigorously curated “Smart Cities” (described here by Bloomberg CityLab). Each chapter adds to Carr’s central insights on the formation of urban, suburban, and “natural” landscapes, controlling built environments, and perniciously unequal access to “healthy” spaces.

Over the course of the 20th century, Carr demonstrates, actors in planning and public health have cast the urban environment as alternatively healthy or degenerative relative to heavily romanticized, pastoral conceptions of “nature” and the spacious, automobile-dependent suburbs. Public health officials in the early 20th century linked high population density to social ills and moral degeneration as well as infectious diseases, each addressed by planners with the insertion of green spaces or by fleeing from the city outright. In recent decades, conversely, urban density has been heralded as “greener” for its efficiency and concentrated resources, while the isolation of suburbia is associated with the degeneration of both physical health and social participation.

Within these distinctive landscapes, the focus of planners and designers has progressively turned to control of the built environment. Attention to individual units within the city, like the optimized neighborhood designs proffered by New Urbanists, has mirrored increasingly biomedical views of physical health that abstract the human body from its environment and partition wellness into ever more granular metrics.

This confluence of perspectives across design and medicine, Carr illustrates, is also deeply rooted in the consumerist lens applied to wellness in America. With the advent of services that quantify wellness in the body and landscape through the use of metrics like body mass index and neighborhood “walk scores” (calculate yours here), wellness has become progressively commodified. Carr identifies this phenomenon as hypercapitalism, a Marxist term that describes a form of social organization in which commercial interests invade “every aspect of human experience.”^[2] While Carr does not discuss her use of hypercapitalism in detail, she cites incisive examples of products and models that, in putting a price on better health, reinforce a “healthism” in American society, which makes health outcomes the responsibility of the individual.^[3]

America’s obesity epidemic, Carr observes, is exemplary of this pathological emphasis on individual behavior. While obesity is known to be the product of many entangled factors dependent on the body and its environment, from genes to grocery store access, obesity is ultimately still viewed as the result of individual choices – much like infectious diseases in the Progressive Era and today.

Over time, Carr shows us how differing interpretations of disease causation and “healthy” landscapes aided in the construction of this extant, thoroughly American approach to wellness that presumes choice over one’s environment, blames individuals for failing to thrive in that environment, and thus fails to create an equitable “public realm for wellness.”^[4] In the absence of a social healthcare system, Americans have been conditioned to search for quick, purchasable routes to healthier living.

Throughout Topography of Wellness, crucially, Carr engages with the amplified impact of the modern American landscape and profit-driven healthcare on poor and minority communities. In the 20th century and today, neighborhoods already grappling with inadequate access to healthcare as well as poor infrastructure have been razed to make room for desirable green spaces and wealthier, whiter populations, as was the case for Seneca Village in the creation of Central Park. Carr’s most challenging guiding question, which she leaves us with in the conclusion, asks: in shaping the American landscape, whose health values have we been espousing and prioritizing? In approaching health as an amenity, rather than an organizing ethic for policy and long-term planning of the landscape, vulnerable populations have not only been repeatedly displaced, and their choices among neighborhoods and in health provisions constricted, but also blamed for health outcomes created by systematic oppression — not, Carr underscores, from personal choice.

The latest in a long line of communicable crises, COVID-19 has become as unavoidable as air and as pivotal to the landscape as those who inhabit it. As Carr observes in her conclusion to Topography of Wellness, the failure of the US public health response to COVID-19 is also a failure of architecture and design. The pandemic has exposed the inadequacies of both domestic and public spaces, particularly for populations already suffering from worse health outcomes. Scattered solutions newly ingrained into the pandemic landscape, like HEPA filters and UV-sanitized surfaces, fall short of achieving a sustainable and accessible strategy for built spaces that prioritizes health.

Moreover, as David Benjamin argues, chasing the “fetish” of a sterile environment ultimately isolates us from the biodiversity of life and our intrinsic connection to the world around us.^[5] To keep up with the “messiness” of human existence, as Carr puts it, maybe our built spaces should be a little messy, too. After finishing Topography of Wellness, I was inspired by the innovative projects of the MASS Design Group, with designers like Michael Murphy embracing the benefits of letting fresh air and sunlight refresh the built environment, treating it less like a machine and more like a living, breathing organism that can adapt with us over time. After all, Carr shows us, time is a critical dimension of both landscape and wellness. In considering the evolution of the urban landscape over time, Topography of Wellness encourages us to challenge the inevitability of the environments we inhabit today and work towards a more just, sustainable future.

Margo Williams

Margo Williams is an MPhil student in the History and Philosophy of Science and Medicine at the University of Cambridge. She works on the histories of health advocacy movements, modern healthcare systems, and medical racism.

• Margo Williams

  https://nursingclio.org/author/margo-williams/

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