Why does place matter?

And what does sanitation have to do with it?

Humanity has radically transformed its physical environment through the processes of modernization, urbanization, and industrialization (Peterson, 2017). The changes have impacted our social relationships and to a certain extent, “the world we make tells us how to live in it,” (Purdy, 2018). The way we live, our markets and our governments, reinforces the changes we’ve made and continue to make to our world. In this sense, our environment, or “place”, is composed of both social relations and physical resources; and it is a combination of both as well as the interaction between individual and place that is important for health:

“Access to goods, services and other assets may be dependent partly on the geographical disposition of facilities and their jurisdictions but also on social networks and social power, interventions of various “actors” and degrees of regulation which produce “layers” of resources accessible to different members of local populations in different ways” (Cummins, Curtis, Diez-Roux, & Macintyre, 2007).

An understanding of how a place is architected has profound implications for guaranteeing a population’s physical and mental health, for pursuing environmental sustainability, and creating a just and equitable society.

One significant way in which place matters for health is the relationship between sanitation and disease. It has been suggested that it is sanitation that makes long-term urbanization and high-density growth possible (Sahasranaman, n.d.). In the 1850s, beginning with Edwin Chadwick’s role in recognizing the relationship between sanitary conditions and epidemic diseases, sanitation provision became interlinked with the role of city and its responsibility in ensuring public health for its growing populace. When it comes to constructing place, the provision of sewerage in cities became a fundamental part of the city-building process, in Canada and elsewhere (Brace, 1995). Urban planning and design has its origins in public works, and specifically in sanitation.

The estimated population density in inner London in 1850 was 16,000 people per square mile, having tripled between 1800 and 1850 (Wikipedia). It was a city whose population was growing faster than its infrastructure, an example that can be seen in developing countries today (Sahasranaman, n.d.). Many cities in developing countries now have much higher population densities than London in 1850 and yet, they still lack sanitation systems that adequately protect their populations from fecal-borne diseases. While one might imagine that lack of a sanitation system might be sufficient to deter urbanization and high-density growth, there are other significant advantages in the urban context that confer health advantages (e.g. more wealth, more schooling, and greater access to health services) such that it is the interaction between sanitation and population density, between individual and place, that matters most significantly for health outcomes (Hathi, Haque, Pant, Coffey, & Spears, 2017). On average, living in an urbanized environment is advantageous, but it is less advantageous where sanitation conditions are poor.

Additionally, it is no longer sufficient to approach the design of place from a “pathogenic orientation” (i.e. by keeping risk factors for disease low), but instead necessary to integrate a “salutogenic orientation” (i.e. by leveraging the positive influence of the natural environment on human wellbeing) (Silva, Rogers, & Buckley, 2018). A city can and should be designed such that there’s not only an absence of disease, but a contribution to health and happiness. This needs to be a significant priority: it needs to be recognized that climate change has an impact on both physical and mental health, on issues from migration to the opiate crisis (Cimons, 2018; Preston, 2017). It has been said that “we can only be healthy if the environment in which we live is also healthy,” and we are seeing now how many ways there are to be unhealthy. Centralized sewerage was a solution in the 1850s to one kind of public health crisis, but we now know that traditional flush toilets are not a sustainable use of our water and energy resources. In Victoria, BC, the current water infrastructure produces one quality of potable water for various uses like drinking, irrigation, and cooking via an energy intensive process. Toilet flushing represents the highest percentage of water use in all residential and most commercial contexts (Anand & Apul, 2014). The question I’m asking now is how can sanitation be managed in such a way that there are salutary benefits? How can we transform our environment to improve the way we live in it?


Brace, C. (1995). Public Works in the Canadian City: the Provision of Sewers in Toronto 1870-1913. Urban History Review/Revue d’histoire Urbaine, 23(2), 33–43. https://doi.org/10.7202/1016632ar

Cimons, M. (2018). Drug Abuse Linked to Extreme Weather. Retrieved August 13, 2018, from https://nexusmedianews.com/climate-change-enters-national-conversation-about-opioid-addiction-16f0420718e3

Cummins, S., Curtis, S., Diez-Roux, A. V., & Macintyre, S. (2007). Understanding and representing “place” in health research: A relational approach. Social Science and Medicine, 65(9), 1825–1838. https://doi.org/10.1016/j.socscimed.2007.05.036

Hathi, P., Haque, S., Pant, L., Coffey, D., & Spears, D. (2017). Place and Child Health: The Interaction of Population Density and Sanitation in Developing Countries. Demography, 54(1), 337–360. https://doi.org/10.1007/s13524-016-0538-y

Peterson, J. A. (2017). The Impact of Sanitary Reform upon American Urban Planning , 1840-1890 Author ( s ): Jon A . Peterson Published by : Oxford University Press Stable URL : http://www.jstor.org/stable/3786777, 13(1), 83–103.

Preston, C. (2017). Depressed about climate change? There’s a 9-step program for that. Retrieved from https://grist.org/article/depressed-about-climate-change-theres-a-9-step-program-for-that/

Purdy, J. (2018). The World We’ve Built. Retrieved from https://www.dissentmagazine.org/online_articles/world-we-built-sovereign-nature-infrastructure-leviathan

Sahasranaman, A. (n.d.). The Outbreak That Enabled Urbanisation: London in “The Ghost Map.” Retrieved August 13, 2018, from https://www.smartcitiesdive.com/ex/sustainablecitiescollective/outbreak-enabled-urbanisation-london-ghost-map/212186/

Silva, R. A., Rogers, K., & Buckley, T. J. (2018). Advancing Environmental Epidemiology to Assess the Beneficial Influence of the Natural Environment on Human Health and Well-being. Environmental Science & Technology, acs.est.8b01781. https://doi.org/10.1021/acs.est.8b01781