The Topography of Wellness: How Health and Disease Shaped the American Landscape

By Sara Jensen Carr; Charlottesville, Virginia:
University of Virginia Press, 2021; 288 pages, $34.50.

Reviewed by Pollyanna Rhee

In 2016, Karen DeSalvo, the acting assistant secretary for health at the U.S. Department of Health and Human Services, noted that public health was in a new era where “one’s zip code is a better indicator of health than genetic code.” DeSalvo’s link between health and place underscored a pervasive and uncomfortable fact about living in the United States today: Racial and class-based segregation is both common and harmful for people’s physical and mental health.

Under these conditions, health is often a luxury rather than part of our common good. At the same time, our current era is marked by constant data gathering and quantitative assessment of our cities: Where is the most livable place? Which is the healthiest city? What is the walkability index of this locale? We have more information than ever about our cities. But does all that data actually help us? And how did we get to this point?

Landscape and Public Health

Sara Jensen Carr, ASLA, an assistant professor of architecture at Northeastern University, tackles that final question in The Topography of Wellness: How Health and Disease Shaped the American Landscape. Instead of thinking about health as a matter resolved through a simple yes or no question—are you sick or not?—the book examines how landscapes responded to and shaped ideas about health, wellness, and politics over the past two centuries of American life.

Over the course of eight chapters that progress thematically and chronologically, Carr offers two related interventions. The first part of the book, titled “Infectious Terrains,” consists chiefly of a revisionist history of the American built environment from the 19th to the middle of the 20th century. Familiar and canonical figures such as Andrew Jackson Downing, Frederick Law Olmsted, Daniel Burnham, Le Corbusier, Frank Lloyd Wright, and Lewis Mumford undergo reassessment through the lens of dominant ideas about health and disease in their times. The second part, “The Chorography of Chronic Disease,” begins in the 1950s and presents a critical analysis of recent work and initiatives linking public health with the environment over the past half century.

Throughout, landscape—parks, bike infrastructure, public housing projects, and suburbs—is interlocked with the history of public health, including deadly miasmas, germ theory, and our current focus on wellness and lifestyle choices, as well as increasing concerns around climate change.The Topography of Wellness’s narrative pinpoints urban landscapes as a central platform for thinking about the health and wellness of the nation’s inhabitants, as well as the undeniable political and social stakes of such endeavors. Artful landscapes, such as Olmsted’s parks, provide leisurely and charming spaces throughout the country. The designer also saw them as lifesavers for the poor that allowed them to convalesce in urban nature before returning to productive labor.

At its core, Topography of Wellness argues that health “was the medium through which cities were shaped and municipal governments imposed order.” In using “wellness” as her central term, Carr acknowledges its breadth, but explains the choice as one rooted in its present resonance as a term connoting healthy behavior and lifestyles and her objective to interrogate its uses. Wellness and the associated phrase “well-being” not only imply an individual’s happiness but have taken off as terms for marketing products. The process of commodifying both landscapes and health through wellness has a contemporary feel, but Carr wants to show its long-standing presence.

The Importance of Place

Throughout the historical and current examples, landscape emerges as an often underexamined but ubiquitous presence in assessing health. As cholera epidemics swept through the United States at regular intervals in the middle of the 19th century, sanitary surveys revealed stark disparities in death rate by place. Some commentators saw tenements as “perpetual fever-nests” due to their inhabitants’ behaviors, whereas others viewed the poor as “victims of their environment.” Attempts to expand access to healthy spaces often revealed attitudes that presented some segments of the population as more deserving of health than others.

The shifts Carr traces map onto larger trajectories of American social and cultural history, especially as citizens, institutions, and governments have grappled (and continue to grapple) with deep inequalities. Calling for interventions in the landscape in the name of health offered a way of advancing political objectives. Responses to 19th-century epidemics in rapidly growing cities depended on assumptions that modern vices contributed to their spread. Urban playgrounds furnished children with dedicated spaces but had moral justifications. Playgrounds encouraged activity rather than idleness and kept children separated from the influence of criminals and other bad actors on city streets. Even imaginary worlds showcased health. Hygeia: A City of Health, a utopian text by the British physician Benjamin Ward Richardson in 1876, provided detailed descriptions of a city with “the lowest mortality” despite a lack of training in design. Notably, he omitted details about human activities. Realizing clean cities free from disease was such an aspiration that it may as well have been a fantasy.

Restricted Viewpoint

The second part of the book focuses on attempts to mitigate the effects of chronic diseases in 20th- and 21st-century urban spaces. As approaches toward health became more technical and professionalized at the start of the 20th century, a similarly restricted view of the relationship between health and cities emerged as well. Americans came to see epidemics and illness as a result of individual choices rather than a result of policy and structural forces. Rather than improving one’s surroundings, the task was now to improve one’s own self and free the body from disease. These ideas informed critics during the midcentury era of urban renewal, such as when Architectural Forum published an article in 1951 titled “Slum Surgery in St. Louis” and included photographs of blighted and so-called obsolete districts that threatened to spread across the city. In Victor Gruen’s 1964 The Heart of Our Cities, he considered the urban core to be a heart and advocated for the revival of the garden city to repair this “tired heart.” Like a human body, a city could have its diseases and pathologies in the form of blight surgically removed.

This limited perspective resulted in the minimization of social and cultural considerations. Writing in 1984, Kevin Lynch found the use of medical terminology problematic because it reassured people “living outside the city that their health would be preserved by stopping the contagion of blight.”

No Single Solution

If there is one overarching assumption, or perhaps aspiration, in these projects over time, it is the idea that a single intervention or design could be a straightforward solution to the problem of health without regard for social, political, or ideological context. Currently popular interventions such as incorporating landscape views in health care settings, tree planting programs, and smart cities designed with active livability in mind contain aspects of this assumption. This was the case even as the Centers for Disease Control began to address “social determinants of health” in the 1980s and 1990s. Carr looks especially at research linking rising obesity rates, increased stress, and the rise of hypertension to low-density sprawl and life oriented around the car. But vilifying sprawl and offering an alternative could also take a neo-traditionalist or even regressive turn.

In one of a few reassessments, Carr examines the New Urbanist principles of Andres Duany and Elizabeth Plater-Zyberk enshrined in their 2000 book, Suburban Nation: The Rise of Sprawl and the Decline of the American Dream, written with the urban planner Jeff Speck, Honorary ASLA. In addition to dismissing the work of landscape architects simply as people who “prettify” rather than improve the landscape while leaning on their own aesthetic preferences, Duany, Plater-Zyberk, and Speck reveal their own limited social vision. In their rebuke of modernist cities, Carr contends that the trio “uncritically doubled down” on “defining their superior traditionalism as European” or from the antebellum South. Since early in the 21st century, Duany and Plater-Zyberk have focused on post-Hurricane Katrina recovery projects in Biloxi, Mississippi, and New Orleans, stressing the healthful attributes of New Urbanist designs, positions that have not avoided controversy and charges that their nostalgic designs are accomplices to displacement of New Orleans’s Black population.

Health as Privilege

Health, Carr acknowledges, is a term with “value judgments, hierarchies, and blind assumptions that speak as much about power and privilege as they do about well-being.” Writing in the context of the COVID-19 outbreak in spring 2020, Carr concludes that ultimately there is “no green pill” that solves everything. But she notes that fact doesn’t keep urban critics such as Joel Kotkin from vindicating Southern California’s sprawling landscape of single-family homes as vital for minimizing virus exposures. Very often solutions are oriented toward bettering or justifying the lives of those who are already comfortable rather than toward more equitable approaches.

Near the book’s conclusion, Carr includes a rallying cry for landscape architects. She acknowledges that landscape architecture “is often victim to value engineering or dismissed as a decorative art.” But it can also create a path to reconnect the design and planning of cities with public health in mind. Landscape architects can reclaim their role by envisioning a more expansive and politically engaged set of tasks. Confronting intertwined issues of sprawling development, climate change, spatial inequities, and chronic disease transcends the traditional boundaries of the profession.

Nevertheless, embracing these challenges is a necessity. Instead of a solutions-minded focus, the essential takeaway here is the need to shift the perspective on health and wellness and its relationship to landscapes if we are to have a more equitable society. Although landscape architects may find the chapters in the second half most helpful for their focus on contemporary activities, Carr also admonishes landscape architects to consider the possibility that design practitioners have been “compliant in a system that exacerbates social inequity.” Landscape architects are political actors whether or not they want to be. Recognizing that fact means examining the assumptions behind health, cities, and design and understanding that the choices we make are anything but neutral.

Pollyanna Rhee is an assistant professor of landscape architecture at the University of Illinois Urbana–Champaign.