Defining Ethical Placemaking for Place-Based Interventions

Abstract

As place-based interventions expand and evolve, deeper reflection on the meaning of ethical placemaking is essential.

I offer a summary account of ethical placemaking, which I propose and define as an ethical ideal and practice for health and for health justice, understood as the capability to be healthy.

I point to selected wide-ranging examples—an urban pathway, two long-term care settings, innovations in refugee health services, and a McDonald's restaurant—to help illustrate these ideas.

Known under many names, placemaking is a practice—really, several practices—targeting neighborhoods, parks and paths, features of landscape, housing developments, long-term care facilities, and hospitals. Although it has deep roots, it may, indeed, be the “new frontier”¹ for public and global health. As place-based interventions expand and evolve, deeper reflection on the meaning of ethical placemaking is essential. What, more precisely, might the World Health Organization mean when it says “people need good [emphasis added] places to live”?^2(p40) When people set out to “improve” a place, what considerations should guide them? These are empirical and profoundly ethical questions. In public and global health, place-making initiatives aim principally at addressing health inequities.^1,3 Yet how exactly should we understand the moral wrong of these inequities, and what should place-based efforts generate or support? What other ethical considerations call for attention?

I offer a summary account of ethical placemaking (developed but undefined by geographers⁴), which I propose and define as an ethical ideal and practice for health and health justice, understood as the capability to be healthy. I suggest that health justice demands the creation and sustenance of places that nurture care; allow for bodily integrity, mobility, and autonomy; and promote equity. I point to selected examples—an urban pathway, two long-term care settings, innovations in refugee health services, and a McDonald's restaurant—to help illustrate these ideas.

THE IDEAL OF ETHICAL PLACEMAKING

Place “is no fixed thing.”^5(p286) It concerns the material environment; how we move in, absorb, shape, and are shaped by it; and how we as social agents interact with and within it, gather and attach particular meanings to it, and forge relationships and identities.^5,6 The emphasis on place has surfaced with the paradigm shift toward “ecological thinking”^7,8 and the reckoning with our identities as ecological subjects: creatures whose prospects hinge on “interdependence and [emphasis added] locatedness.”⁹⁽¹²⁸⁾ Our vulnerability comes from our need for care across the life span as well as the fit between our bodies and our social and physical environments. Advances in social epidemiology and other fields have shown the dramatic extent to which societal determinants, including place-related factors, help to account for variability in health.^10,11 With this enriched conceptualization of persons, grounded in our social and ecological interdependence,¹² what constitutes ethical placemaking for health and health justice?

Ethical placemaking calls, first, for nurturing relations of care and interdependence. Ecological subjects are not so much self-reliant as embedded in relationships and, most importantly, those that help sustain us over time given our shared and variable fragility. Placemaking should support societies’ obligations to provide the conditions in which people can care and be cared for.^13,14

The scope of placemaking to support care relations should be wide. Workplaces with meaningful family leave policies and a cultural norm of support may have potential to address the adverse health effects of caring for loved ones; schools with nutritional support programs for families may help parents better care for children and prevent childhood obesity; and innovations in long-term care might promote the health of elders and direct care workers.

Given the growth of the aging population, innovations in long-term care are compelling. In the United States, the Green House Model offers an alternative to traditional nursing homes (http://thegreenhouseproject.org). Central to the approach—which uses small buildings designed like homes integrated into existing neighborhoods that house at most a dozen residents—is the idea that the conditions in which elders come of age and their caregivers work and the quality of long-term care are inextricably linked. Evidence is just emerging but suggests that this model has health benefits.¹⁵ Designed by nurses to resemble a real European neighborhood, Hogeweyk Village in the Netherlands nurtures relations of care for people with dementia (http://www.hogeweyk.dementiavillage.com/en). Hogeweyk has a market, café, salon, theater, sidewalks, and ample green space. Different models are tailored to appeal to specific social and cultural groups. Staff spend time with residents, interacting as neighbors might, and simultaneously provide skilled care. Family members are integrally involved.

A shining example of a place-based intervention in public health organized around interdependence is New York’s Giraffe Path, a six-mile trail from Central Park to the Cloisters designed to reconnect broken links between communities. By “re-stitching” or “weaving” the frayed social and material fabric within and between neighborhoods, this project responds to the harms done to health by severing ties between people and places through urban development policies.¹⁶

Ethical placemaking also aims to ensure bodily integrity for ecological subjects. This is the broadest and most difficult-to-define element. I opt to use the term bodily integrity instead of security, common in current discourses around health, food, and water for its military and protectionist connotations. Relations of care are key, but beyond these foundations, bodily integrity requires access to health care services, green space, and nutritious food; freedom from violence and threats of violence; and protection from exposure to unsafe work conditions, weak infrastructure, and industrial pollutants. It could even be extended to concerns such as noise in intensive care units that can thwart recovery.

Comprehensive neighborhood interventions aspire to address these concerns (https://www.policylink.org/focus-areas/promise-neighborhoods-institute). Responses to “changing therapeutic geographies” offer other examples.¹⁷ Recognizing the layered vulnerabilities of people fleeing war, especially their protracted mobility and eroding health, humanitarian and local actors have reorganized health service delivery, moving it outside camps and dispersing it across state borders with the aid of Global Positioning Systems and vans loaded with medics and supplies. A specific example, developed by the United Nations Refugee Agency and partners, is the “Blue Dot” hubs, which provide health services for refugees and others displaced.¹⁸

As ecological subjects dwell and evolve, so too should their capacities for determining their actions and the conditions of their actions. Ethical placemaking should contribute to autonomy, not interpreted in terms of individual self-reliance but in the relational sense that perceives individuals as originating and persisting within relations of care and interdependence and as flourishing given ongoing opportunities for self-directed thought and action.¹⁹

The United Nations Habitat calls for creating an “enabling environment,” one that builds “on [refugees’] capacity.”²⁰ The founders of the Hogeweyk believe that elders with dementia can exercise agency and limited autonomy in the right environs. The Green House Model promotes autonomy through providing more private space, control over bedtimes and waking times, and resident and care worker participation in governance. Generally, place-based interventions that engage those dwelling there can promote autonomy.²¹

Ecological subjects require stability and, at the same time, the opportunity for flowing, generative movement. We may or may not be deeply rooted, but we dwell within and navigate around places vital to our sustenance: homes, workplaces, care settings, markets, and so on. Ethical placemaking should attend to threats to health such as hypermobility, entrapment, isolation, and fragmentation.

Efforts to create reception conditions for refugees that ensure shelter but also foster stability and integration shine as instances of placemaking. Part of the City Life Is Moving Bodies (CLIMB) Project, the Giraffe Path is celebrated as “a victory for the city’s entire circulatory system.”²² This project is an example of an explicit effort to establish “systems of connection” and promote flowing movement among fractured and displaced communities with a walking and biking path and the restored High Bridge, allowing for passage across the Harlem River. Hogeweyk protects yet does not restrict, offering abundant outdoor access. Integrated palliative care services ensure that residents do not have to relocate, allowing for continuity of care and relationships. Family members need not navigate new terrains of care and transportation as needs change.

Equity is at the moral center of place-based interventions for health. As noted, most placemaking efforts in public health target entrenched health inequities and the particular social and physical conditions underlying them. The inspiration for the Giraffe Path was the plight of residents who endured health inequities under urban land use and development policies of sorting, intentional shrinkage, and serial displacement, policies linked to the AIDS epidemic, addiction, asthma, posttraumatic stress, and obesity.¹⁶

When remedying or preventing injustice is an explicit aim, we should understand ethical placemaking in terms of responsible placemaking. This highlights the social responsibilities owed to oppressed communities. To the extent that societal determinants (such as racist norms, the profit motive, specific policies, or exposure to toxins) contribute to health inequities, societies have obligations to remedy them out of concern for the equal moral worth of people everywhere. More generally, though, place-based interventions should be understood as efforts to promote health justice, or the capability to be healthy for all people.²³ Given the importance of place for health, in other words, governments and other agents (the for-profit sector, lenders, and ordinary individuals) have responsibilities to create the conditions necessary for all people to be and endure in at least a minimally good—but, optimally, flourishing—life. Placemaking and remaking are the innovative edge of the necessary social interventions.

THE PRACTICE OF ETHICAL PLACEMAKING

Ethical placemaking rests on an intertwined set of moral capacities: recognition and responsiveness. It calls for contextually sensitive explorations of particular habitats and the ecological subjects dwelling in and around them. Thinking ecologically and ethically about place, then, requires attention to whatever is threatening the requisite conditions for care, bodily integrity, mobility, rootedness, and equity in particular places and, often, the relations between places. Attentiveness to this specificity is a threshold capacity for ethical placemaking and the grounding of a partner moral capacity: responsiveness.

Responsiveness is a capacity for being vigilant “to the possibilities for abuse that arise with vulnerability”^24(p135) and seeking fitting remedies for harms done. This makes it an especially vital capacity for work aimed at addressing injustice. Another interpretation casts responsiveness as a virtue that, when cultivated, helps us adapt our moral agency and character “to anomalies, challenges, and disturbances within our situated experience.”^25(p14)

These moral capacities are especially important for placemaking that occurs amid asymmetries of power and pluralism. Just as inequities structure access to good places, they create barriers to equitable participation in the processes for shaping places. This can serve to generate, perpetuate, and exacerbate existing inequities. Responsiveness demands that the processes involved in placemaking consider power inequities and strive to be egalitarian. Because places are not fixed but fluid, responsiveness means continuing to show concerned attention over time as conditions evolve. Public health educators, along with faculty in schools of architecture and planning, might consider how best to nurture these capacities.

CONCLUSIONS

For the light and the view of the neighborhood bustle, elderly Korean residents of Flushing, New York, walk from their apartments to a nearby McDonald's restaurant to “keep track” of one another and call family and friends abroad. A church offered them space in a basement and a van for the mile-long drive. They winced at the prospect:

We’re grateful for the offer. But we are not schoolchildren or government workers. We want to see our friends when we choose.²⁶

Although much placemaking is intentional, the example highlights that it is often, perhaps mostly, the result of a confluence of unintended actions:

In the end, it is what people do in place, day to day, that makes places what they are, and . . . the interactions between people as agents in and across different places that constitutes those places.^4(p8)

It also underscores the need to reimagine (sometimes from the perspective of the ecological subjects there) existing places as having potential for health and health justice and when this potential is being realized, to let them be and resist social, economic, and other policies and practices that threaten them.

The McDonalds is an emergent place, one found yet transformed and organized around care and connectivity, rootedness and generative mobility, autonomy, and if not actual equity, a leveling of the playing field between the community and a transnational corporation (following a threatened international boycott after the restaurant management tried evicting the elderly Koreans).

Intentional placemaking should be based on available evidence about health hazards and organized around the nurturing interdependence and relations of care, supporting bodily integrity, autonomy, stability and flow, and promoting equity for the sake of health and health justice; that is, the capability to be healthy. This ethical ideal and practice should serve more than the public health community; it should inspire architects, designers, and developers to understand their work as having import for health, ethics, and justice.