2020 was a year that made the invisible, visible.

Air quality was a topic that so many in Australia had previously taken for granted. The year commenced with one of the most horrific and devastating bushfire seasons in living memory leading to many in our community rushing to purchase air purification devices or downloading the latest and greatest air quality apps on our phones. It ended as different parts of Australia navigated a global pandemic and public health interventions. This included a COVID-19 outbreak in the southeastern suburbs of Melbourne, where experts have found that air flow and ventilation (indoor air quality!) is likely to have played a role in the spreading event.

But as we enter 2021 with the horrors of the last year firmly in our minds, we need to remember equity and how it can – and should – drive our health interventions in the future.

Across 2020, we saw the most vulnerable populations of Australia impacted the most from the disasters:

• Rural and farming communities who were already vulnerable after periods of drought were at the frontlines of the bushfires that ravaged Eastern Australia. The research has already established significant mental health impacts associated with natural disasters; however, access to mental health services in regional and rural areas is a significant barrier (Usher et al. 2020)
• Particulate matter from smoke is a direct impact from bushfires. Vulnerable populations such as the elderly, people with cardiorespiratory diseases or chronic illnesses, children and people who work outdoors are most impacted by this.

As the global COVID-19 pandemic took hold, the vulnerabilities and health inequities across our local communities were exposed even further. It has become increasingly clear that it is those who are most vulnerable are the same individuals who suffer the most.

• During the pandemic, over 75% of deaths (685 of 909) from COVID-19 in Australia were in residential aged care, a population that was already highly vulnerable. This doesn’t account for the other deaths from our elderly population who are likely to have been socially isolated.
• Public health restrictions as a result of the COVID-19 response impacted our vulnerable communities the most. During the first phase of the second lockdown in Victoria, the community saw the rapid lockdown of public housing towers in Melbourne. Individuals in these towers included recent migrants, individuals with deeply troubled backgrounds and those already suffering from mental health issues and addictions. This lockdown came with very little notice and left many of the most vulnerable members of our society without sufficient access to food, medication or services. This was found to be a “deeply traumatising” event for many residents.
• We also saw schools closed for in-person learning for a period of time. The evidence has shown that school closures across the world have the greatest impact on disadvantaged children including higher incidences of dropping out, less access to food and healthy nutrition, and longer term impacts of future earnings.
• In the USA, statistics have found that Black Americans were 37 percent more likely to die than whites, after controlling for age, sex and mortality rates over time. Asians were 53 percent more likely to die; Native Americans and Alaskan Natives, 26 percent more likely to die; Hispanics, 16 percent more likely to die.

These events and figures make clear that a focus on building health is not enough. Rather, we must expand our notion of health to include equity if our buildings and organisations are truly going to have an impact. But how do buildings fit into this idea of health equity and what does healthy and equitable building look like?

The design and operation of our buildings, spaces and organisations can contribute to health disparities or they can promote a more equitable environment. Our buildings and spaces don’t exist in isolation but are part of a community.

• Accessibility and universal / inclusive design: Individuals living with disabilities account for approximately 15 percent of the world’s population, and often experience poorer health outcomes and discrimination (World Health Organization, World Report on Disability, 2011). Further, these individuals can experience adverse effects as a result of environments or products poorly suited to their use (Cieza et al 2018). Neurodiverse individuals – or those with variation in the brain related to learning, attention, mood, sociability and other mental functions, including those with autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD) or dyslexia – are an integral component of the workforce. It is critical to consider how workspaces can be designed to support the diverse learning needs of these individuals. Accessibility codes and standards often provide only minimal or limited guidance on specific strategies to accommodate people of varying abilities, and typically only basic accessibility is established, neglecting further consideration of more comprehensive accessibility and actual usability (Story’s Principles of Universal Design, 2011). Universal design expands beyond basic accessibility to emphasise inclusion and equality, and can represent a way to improve well-being and quality of life for individuals who may otherwise be restricted in their abilities to fully participate in certain activities (Crews & Zavotka 2006). The seven principles of universal design are covered in C13 of WELL v2 and outlined further in the Community Research Digest
• Housing equity: Across the United States, European Union, Japan and Australia, more than 60 million households are financially stretched by housing costs (Woetzel et al 2014). With a lack of access to affordable housing, an estimated 235 million urban families live in substandard housing, which exposes them to mould, dust, water leaks, lead-based paint, poor air quality and temperature extremes, leading to poor health outcomes like asthma, infectious disease, cardiovascular events and children’s nervous system damage (Taylor 2018). Further, affordable housing shortages lead to homelessness, which increases stress, substance use and morbidity in adults and mental health issues and depression in youth (Kottke et al. 2017). When developing new residential projects, it is important for developers and governments to consider the housing needs of the entire population. An allocation of units to individuals with low incomes is only part of the solution. Housing equity also needs to consider annual housing costs (defined as rent and utilities) paid by affordable unit tenants and the maintenance of these costs over time. Further, a key issue with housing equity is diversity of housing stock. Provision of lots of one-bedroom apartments will not solve access and equity issues for families. Therefore, consideration needs to be given to housing variability with enough units that contain two or three bedrooms. These considerations are covered in C16b of WELL v2
• New mother support: Although the World Health Organization recommends exclusive breastfeeding for the first six months and breastfeeding with complementary foods until age two for the health of both mother and child, we know that rates of breastfeeding tend to decrease significantly when mothers return to work and lack of workplace accommodations contributes to shorter breastfeeding duration or leads to a drop in milk supply, resulting in early weaning. In addition to social and policy-based support, buildings and workplaces can provide safe, private spaces with essential amenities (Shealy et al 2005). Moreover, we are seeing more offices provide lactation rooms (as required by C09 Part 2) that promote a comfortable, calm and private space, optimise thermal and acoustic comfort and maximize accessibility needs to support the needs of each individual (York & Lee 2016)
• Responsible labour practices: Buildings and spaces are unfortunately areas where modern slavery can take place. Modern slavery refers to the various situations in which a person is recruited, transported or compelled to work through force, fraud or coercion, and may include traditional slavery (or involuntary servitude), human trafficking, forced labour, bonded labour, sex trafficking and the worst forms of child labour. The Global Slavery Index estimates that in 2016 there were over 40 million victims of modern slavery worldwide, including 24.9 million in forced labour. Modern slavery is not only a violation of human rights; it is a global public health issue. Building operations and supply chains – specifically in the areas of construction, cleaning, security, maintenance and catering – are at risk; however, investigation, disclosure, reporting and planning of these supply chains can have a huge impact in reducing significant health disparities within these workforces.

While these interventions focus on buildings and space, we also know that organisational and human resource policies can have a substantial impact on health equity in our buildings: diversity and inclusion practices (C12 of WELL v2), how employees are encouraged to volunteer in their communities (C11, civic engagement), support for victims of domestic violence (C18 of WELL v2), childcare, family, and bereavement support (C10 of WELL v2), and a focus on stress management planning (M05 of WELL v2) are all just some ways that organisations can show leadership in creating more equitable environments.

How else can buildings, spaces and organisations remove health disparities and create a more equitable environment? Let us know by contacting IWBI at healthquity(at)wellcertified.com.

By Jack Noonan, Vice President, Asia Pacific, International WELL Building Institute (IWBI)