By Sandro Galea
December 5, 2018
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This piece is part of an ongoing series by Boston University’s Dr. Sandro Galea on the intricacies of health care and public health.

At last, Amazon made its decision. After a yearlong search, in which dozens of US cities competed to host Amazon’s second headquarters, the company announced it will build new locations in New York City and Arlington, Virginia. In a statement about the move, Amazon founder and CEO Jeff Bezos said, “These two locations will allow us to attract world-class talent that will help us to continue inventing for customers for years to come…we look forward to becoming an even bigger part of these communities.”

The search took as long as it did, in part, because of the complex political and economic maneuvering necessary to close a deal of this size, and there have been plenty of cynical motives attributed to Amazon’s search for new homes. But there is something more fundamental at play here than just tax breaks and land values.

Put simply: place matters. In his statement, Bezos says he looks forward to becoming part of a community. This suggests he understands the power of place. He sees that moving Amazon to a new city means engaging with that city’s existing social and physical networks. The neighborhoods where we live and work, the transportation networks that carry us where we need to go, the safety of our physical environment, the schools we can access, the people we interact with each day—these factors are central to who we are, and what we do. There is no escaping their influence; even a company with the wealth and power of Amazon must take place into account when making its decisions. For Amazon to succeed, it must be in a place that facilitates success.

It is equally true that, to be healthy, we must be in a place that facilitates health. Where we live—the design of cities, towns, and neighborhoods, their density, the social cohesion of communities, and the basic services and public goods that are maintained in an area—are core to our ability to live healthy. When neighborhoods are socioeconomically stable, services robust, transportation clean and efficient, and local government responsive to community needs, health thrives. When these conditions are wanting, health suffers.

Consider, by way of example, the problem of asthma in the US. According to the Centers for Disease Control and Prevention, asthma rates climbed by 28 percent between 2001 and 2011. In 2011, an estimated 18.9 million adults and 7.1 million children had asthma. Asthma is especially common among kids who grow up in crowded urban neighborhoods located near major roadways. Such neighborhoods are disproportionately likely to be home to low-income communities of color. In many cases, this is the legacy of a time when such communities were deliberately cut off from the rest of the city, a separation enforced by the very traffic lanes that can now make people in these places sick. In this way, asthma risk is shaped by the political and economic policies that create health divides.

Such divides have long been a focus for those who study the health of populations. These gaps can be stark, even between communities that are close to each other. In Oakland, CA, people living in zip code 94621 have a life expectancy is 74. For people living in zip code 94611, representing the affluent Piedmont neighborhood, life expectancy 84. In Boston, where I live, there diabetes rates are five times higher in some neighborhoods compared to others just a few miles apart. In Seattle, there is a twenty-year difference in life expectancy for neighborhoods nearly adjacent to one another. The list goes on.

These data illustrate a core truth: We cannot talk meaningfully about health unless we talk about place. If we live in a place that is not conducive to health—one near a noisy, pollution-spewing bus depot for example, or in a food desert that lacks nutritious food—then we cannot be healthy, regardless of the individual choices we make about our health. If a child is forced to breathe exhaust each day, there is little she or her family can do to prevent her from developing a respiratory illness like asthma. In the end, it is place that decides her health. It is no exaggeration to say that our zip code matters more for our health than our genetic code.

As part of its move, Amazon has committed itself to investing in place, by funding community infrastructure and donating space for education and tech startup incubation in New York. Hopefully, it will build on these steps, to deepen its investment in the communities it will soon call home. This investment could take the form of improving public transportation, creating green spaces, building more affordable housing, or ensuring all its workers have the economic stability that creates healthy places and healthy people.

This will not just help ensure Amazon’s imprint on its community will be a positive one, it will help ensure the company will have a well of productivity and talent to draw on. Health is ultimately a means to an end, a tool that allows us to pursue our aspirations in life. When we are healthy, we are energized, resourceful and primed to innovate. When companies invest in place, they invest their own success by cultivating a workforce with the capacity to perform at the highest level, all while contributing to the broader wellbeing of society.

Place is a ubiquitous influence on our health. It is like the water in a goldfish bowl. If the water is dirty, a fish cannot be healthy, no matter how much exercise it gets or how nutritious its food happens to be. In the same way, place is central to our own ability to live healthy lives, shaping our health far more than our individual choices. It should be an imperative for all of us who understand this to work to make the places where we live, work, and play are as healthy as we can make them.

Sandro Galea, MD, DrPH, is Professor and Dean at the Boston University School of Public Health. His latest book, Well: What we need to talk about when we talk about health, will be published in May 2019. Follow him on Twitter: @sandrogalea

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