The Miracle Pill

by Peter Walker

  Some pioneering doctors’ practices have tried solutions like prescribing people membership of a local bicycle share scheme, or suggesting they try their local Parkrun, the fast-growing, non-competitive social running movement we’ll hear more about later in the book. Boyd says the social prescribers’ most common solution is for people to simply walk more: ‘It’s free, and you can combine it into your day. It’s whatever works for that individual, and that’s why it has to take the form of a conversation – what would help someone do the sorts of things they want to do? That’s why you can’t fit it into a ten-minute GP’s conversation when you’ve already dealt with their acute issue and any medication issue.’25

  A similar lack of time and resources affects hospital doctors in helping patients with lifestyle advice. The NHS has a group support programme to help people with diabetes, particularly type 2, which covers physical activity, as well as diet and other areas. But according to Martin Whyte, a combination of mixed availability and limited motivation means only around 5 per cent of his patients take part.

  Others are prompted to take action themselves, Whyte notes: ‘You often get people who come in with a heart attack and type 2 diabetes. They have the heart problem and the diabetes diagnosed at the same time. They might have been inactive or overweight, but they felt healthy and thought they were – it can be a big shock for people. Some get depressed but for some they want to turn their life around. I’ve had people at my diabetes clinic where the transformation is amazing. But if it’s based around something like a gym or running, you have to ask – will it last in the long term? There are huge pressures and forces at play, and I don’t think the NHS is the place that can fight against them. We see the net results, which is the presentations through the front door, or in the clinics. And it’s huge.’

  It seems that the response has to begin with politicians, not doctors. As Phil Kelly sits in his office, he again ponders one of my questions, this time whether the looming crisis in the NHS will eventually force government ministers to start making bold choices. Eventually he replies: ‘No, is the short answer. You may say, we will get so close to the point of cataclysm and then we will draw back. But what of many points so far was not cataclysmic? What are we waiting for? The short-term reward from not providing playing fields for schools, or not having a reasonable public health approach to diet in children – there’s too much to gain from ignoring it. We’re all guilty of short-termism. And the official response so far is a bit weak.’ Kelly sits back in his chair, sighs, and then grins: ‘Of course, you could have just caught me after a bad ward round.’

  For a slightly more hopeful note on which to end the chapter, let us return down the corridor to Whyte’s office, where he is describing what he says is perhaps the biggest individual success story he has seen in his diabetes clinic. It was, Whyte recalls, a middle-aged man with type 2 diabetes.

  ‘By this point he had been coming to the clinic off and on for several years. He was on all sorts of medication, and he was overweight,’ Whyte explains. ‘With this clinic, when patients come in, they get blood taken and we get immediate results, which I see before the patients – it helps us understand how they’ve been managing their diabetes for the previous few months. Anyway, this time there was a sudden, massive improvement in this man’s readings. He told me he now wasn’t taking any medication either.

  ‘I said, “That’s incredible – what happened?” He said he’d got a job as a postman. It was just through walking on the delivery round, especially up and down hills, that everyday activity dramatically transformed his diabetes. It stuck in my head – it was such an amazing thing. I thought: if only everyone in the clinic could get a job as a postman. It was profound. Medicine works, but it’s much better to do it without medicine.’

  As we will see in the next chapter, for most people it is, sadly, not that simple. Without something like a job which guarantees daily movement, you are significantly more reliant on the built environment around you, one which often seems to conspire to make physical exertion as difficult as possible.

  If there is a message for this chapter, perhaps for the entire book, it is that for all the wonders achieved by modern medicine, without concerted, significant, interventionist action at a national political level, the sorts of universal health and social care systems many millions of people take for granted could effectively be gone within a generation. The hugely optimistic example of Martin Whyte’s revitalised, drugs-free postman simply demonstrates the overriding need to help make lifestyles built around activity a more normal thing. Multiply his example by the millions, and so much of the problem goes away.

  Next steps:

  Type 2 diabetes is the chronic medical condition perhaps most closely linked with inactive living, and many people do not know they could be at risk. Diabetes UK has an excellent, and very simple, web questionnaire, which uses factors like your waist size, height, weight, family history of diabetes and ethnicity to instantly assess your likely chances of developing it. Search for “Diabetes UK risk score” to find out yours.

  5 Towns and Cities on a Human Scale

  It is over an hour into a chat I had promised Jan Gehl would take considerably less time, but the Danish architect, now eighty-three, is still animatedly explaining the ideas he pioneered about the way towns and cities should be designed for the needs of their inhabitants, and particularly the ways in which these people can move around under their own power.

  Leaning forward in his chair in the light-filled meeting room of his eponymous architectural practice in Copenhagen, where he is still a regular presence despite officially being retired, Gehl puts one hand vertically on the table, the downward-facing fingers closed into a stationary block, to indicate a slab of a building. ‘This is easy to communicate in still photos, and easy to study,’ he tells me in his precise, lightly accented English. Gehl then starts wiggling the hand’s fingers to show people walking around: ‘This is much more complicated to study. And this is complicated to communicate. But it is very important. And that is what I’ve been involved in – making the people who use cities visible for politicians, and for my fellow colleagues around the world.’

  Gehl cheerfully describes himself as ‘an anti-modernist and anti-motorist’, someone who has spent more than half a century rejecting the idea that the urban domain should be seen through the prism of monolithic tower blocks and offices, and the highways snaking around them. Instead, he believes, towns and cities need to be focused on the everyday movements and interactions of human beings, travelling at human-powered speeds. Gehl’s philosophy is summed up by the hugely evocative, almost poetic title of the 1971 book in which he presented his ideas: Life Between Buildings.1

  When he first qualified as an architect, Gehl tells me, it was 1960, perhaps the heyday of modernism, when towns and cities were being reshaped according to a template in which near-universal car use was assumed as the default. At the time he was a true believer. So what changed? It was, Gehl tells me, meeting his wife, who is a psychologist.

  ‘I was meant to start with all these high-rise suburbs and freeways,’ Gehl recounts. ‘But she and her friends, they kept saying, “Why are you architects not interested in people? Have you thought about why your professors go out at four o’clock in the morning to take photos of their various monuments? It’s to be certain there will be no people in the foreground to distract the students during the lectures. Because we know, of course, that if there are people in the foreground, they will start to look at them. Because the biggest interest of people is other people.” ’

  Gehl and his wife went to Italy for six months to examine the street layouts and piazzas of the Renaissance-built towns and cities and see how they helped the natural flow of pedestrians. He then returned to Denmark to study the psychology of housing. ‘I had this joke that when I was at university we heard nothing about people, and so I had to go back to forget everything they told me,’ he says. ‘We had to sit down at square one and start to see how
people used architecture, how people used cities, and gradually accumulate knowledge about what were the important factors. Many of my colleagues thought I was crazy. They said, “You’re ruining your career!” ’

  Gehl’s colleagues need not have worried. He is now regularly lauded as one of the most influential urban thinkers of the modern era, with expertise that has been sought by cities as disparate as Sydney, Moscow and New York. His programme to make Sydney greener and less car-dominated, with pedestrianised streets, bike lanes and a new light rail system, saw him become only the second Dane to receive the key to the city, its highest honour, after Jørn Utzon, another architect, who designed its famous opera house.

  Perhaps the city which best epitomises Gehl’s philosophy is his own, where decades of human-friendly planning mean more than 40 per cent of all commuting trips in Copenhagen are now made by bike. Gehl opens his laptop to show me a photograph: in 2017, to mark the city’s 850th anniversary, Copenhagen’s council put up posters of the ten residents judged to have most shaped it over that period, with Gehl among them. ‘They had the founder, and king this and king that, and Hans Christian Andersen,’ Gehl recalls with obvious delight. ‘And then me – they said I was responsible for Copenhagen today. I rushed all over the city to see the poster on bus stops.’

  Gehl has a mischievously dry sense of humour, telling me that because of his age he has to turn down most invitations to appear at overseas events: ‘I say now that if they want me for sure they just have to hand me a medal. That’s my principle. If they want to do something in that direction, I come.’

  But his pride in his work is obvious: ‘I can say, after fifty years, that now we know how to make nice cities for people. I have had the chance to formulate the principles, to study the subject, to find out how things work, what you can do, and be able to do it in a number of places. I am able to see life here in my own city, like in Melbourne, Sydney, in Moscow, with these ideas being realised and used, and see that they have a tremendous impact on the quality of life. It is a privilege to be as old as I am.’2

  Before looking at what all this means in practice, let’s take a step back to consider why it matters so much. The ideas for which Gehl has battled are central to perhaps the most important element of the modern world’s unspoken war against everyday activity. It is one thing for governments and anxious health officials to urge people to move more in their lives. But when so much of the built environment makes this task, at best, much less convenient than it should be and, at worst, virtually impossible, it’s no wonder so little changes.

  This chapter is about activity in the public realm, whether on roads, in squares, streets and other spaces, as well as inside communal buildings and, perhaps most importantly, the way we travel to, from and between all of these. It is a story, in many ways, about infrastructure, which might appear at first a somewhat technocratic, even dull, subject, but holds an enormous influence over vast areas of most people’s lives.

  One thing is clear: if someone is to meet the universally recommended 150 minutes of moderate exertion a week as part of their routine life, rather than formal exercise, then both practicality and the mechanics of energy expenditure dictate that a good proportion of it will come from time spent outside the home. And for many people, a significant proportion of this will involve active travel, whether walking or cycling.

  Currently, this overriding need for human-speed movement happens in an environment shaped by humanity, largely around the needs of motor vehicles. The world has now passed the point in which a majority of people live in towns and cities, with the estimated global urbanisation rate now around 55 per cent.3 In the UK, even though considerably less than 90 per cent of land is built on,4 83 per cent of the population is urban.5

  Unlike other areas of modern life which have helped push out everyday movement, the urban status quo is deeply problematic for a number of reasons. While no one is really suggesting that people do away with labour-saving appliances in the home, when it comes to the takeover of virtually all human-powered travel by the motor vehicle, it is a different story. This is not to say cars should not exist, simply that they are not necessarily needed for the countless millions of tiny journeys they undertake every day. Such mass car use causes enormous damage in a series of areas entirely separate from activity, everything from choking air pollution to dangerous, socially disconnected cities, plus of course a significant role in the global, existential threat of the climate emergency.

  Directly relevant to this book, however, is the fact that the hegemony of cars hugely restricts the ability of people to walk and cycle, which are where the real gains can be made in terms of both energy consumed and exertion levels reached. To look back to the study we saw in the first chapter about the activity levels of various home tasks done manually or by machine, it found that washing dishes by hand, something that many people still do now, burns up around 110 calories per hour. In contrast, a hypothetical brief walk to a job uses about double that, while stair climbing goes beyond 250 calories an hour. The study didn’t include cycling, but if I take the estimated calorie count from my borrowed wrist-worn fitness tracker, the near- twenty-minute ride from my home to my temporary writing base – some of which is, admittedly, up a relatively steep hill – involves an outflow of just under 180 calories. We are suddenly over 500 calories an hour. That is a lot of energy expended.

  Active travel has another advantage. It is the very definition of incidental activity, that concept so beloved of public health advocates, where movement becomes a part of life which is happening anyway. When I cycle for transport, the calories burned and other associated health boosts are hugely welcome. But they’re not the main reason I do it. I cycle around a city because it is reliable, rapid and has the happy ability to deliver me to my destination within a minute or so of when I expected, often with a smile on my face.

  The 40 per cent gain

  It’s worth immediately stressing that whether or not they are a secondary concern, the health dividends of active travel can be enormous. In earlier chapters we saw the many benefits of walking, particularly at a brisk pace. This remains true when people do it for everyday transport. One UK study from 2017, using data from the huge and ongoing government-backed Biobank public health project, tracked more than 250,000 people across the country over five years. When other variables were factored out, it found that people who walked to work had almost a 30 per cent lower chance of suffering from heart disease in that time.

  That said, the benefits really start to multiply if you get on a bicycle. The same Biobank study concluded that those who commuted by bike had even lower odds of heart disease, with the risks cut by 50 per cent. The cyclists also saw the same reduction in risk for cancer, and had an overall 40 per cent lower chance of dying during the study period. In contrast, for people who commuted by foot, there was no measurable benefit with cancer or overall mortality rates.6

  The 40 per cent reduced mortality statistic is particularly resonant, as it exactly matches the findings of the Danish study into cycle commuting I quoted at the very start of this book as an example of the wonder-drug qualities of regular activity. That Danish research was published in 2000,7 and for years was routinely wheeled out as the go-to academic paper for vividly illustrating the marvels of activity. And now its findings have been replicated, precisely, in another country.

  You could spend a long time reading similar scientific paeans to the benefits of cycling. The reason why it appears to be so health-bringing is the fact that riding a bike almost invariably pushes you into the realm of moderate, or even vigorous, exertion. The threshold for moderate is a mere three METs, and while the calculations for what constitutes such an effort on a bike varies between riders, it’s generally seen as pretty leisurely, even below 10mph. To reach the six METs needed for vigorous activity is not a huge amount faster, with some tables suggesting even as little as 12mph could do it. And if you suddenly find yourself sprinting for a green traffic light, or riding up a st
eep hill, the MET total is suddenly into ten or more.

  Even if your bike-riding approach is notably sedate, you have to try fairly hard to not reach at least a moderate level, particularly when climbing any sort of incline. As one public health academic half-joked to me, the difference between walking and cycling is that with the former, anyone can have a lazy day and stroll at about two METs, whereas if you went that slowly on a bike you would probably fall off.

  To try to find out how strenuous a fairly regular cycle commute can be, I decided to enlist the help of a test subject: me. In non-coronavirus times, I make the three-and-a-half-mile trip between my south London home and Westminster maybe four or five times a week. No one would mistake this for sport or exercise. I use a heavy, practical bike, with hub gears and a huge basket at the front into which I can throw my bag. I ride in office clothes, which not only saves the effort of bringing in a change of outfit, but spares me having to experience the single, generally pretty grimy, men’s shower in the media enclave of the Houses of Parliament.

  Because my borrowed fitness watch only arrived after lockdown, the commute had to be replicated using what was then my government-sanctioned daily exercise. I tried to make it as accurate as possible, riding at a pace that didn’t make me overly sweaty, even putting my work bag in the basket. The watch has built-in GPS and so measured the distance and speed, as well as tracking my heart rate over both journeys. The results were illuminating, not least in highlighting the point about how useful a cycle commute is for getting you somewhere roughly when you expect it. The outward trip ended up taking me seventeen minutes and twenty-two seconds. The return was quicker – by precisely three seconds. That’s predictability.