What If You Could Build It?

By Joe Flower


This article appeared in:
The Healthcare Forum Journal, May/June 1996, Vol. 38 #3
International Copyright 1996 Joe Flower All Rights Reserved
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Three years ago in these pages, Dr. Trevor Hancock described a vision of the ideal healthy community. It was culled from the dreams of thousands of people at the scores of "visioning workshops" he and Len Duhl had led for the World Health Organization around the world. The ideal healthy community that rose from these workshops was:

... small and compact. There are no high-rise buildings, and all the activities of daily life are located physically close to each other . . . people walk, bicycle . . . The center of the community has a square, a green, a market, or community garden. It is a social center, with outdoor cafes, lots of street life and activity, and different age and ethnic groups living together harmoniously. The place is green, with lots of trees and flowers . . . There is water -- a river, lake, or fountains -- and the water is always clean and accessible for recreational activities, including walks along the bank, swimming, fishing, and boating. It is an environmentally friendly place as well . . . recycling and pollution control are routine . . . the industry is non-polluting . . .

In these and other workshops, people have repeatedly sketched such a community, along with the hidden parts -- the strong families, sustainable economy, sense of belonging -- which are the marks of true community.


Could you build it?


What if you had empty land not far from a major city, a budget that was big enough to build a whole town, and a name on the door that would magically attract the best talent in the world, from architects and town planners through educators and health professionals?

What would it be like to try to build a truly healthy community, right from the bare dirt?

It's not a hypothetical question. If your travels take you to Orlando, turn east from I-4 on the Irlo Bronson Expressway. Turn right at the first light. The town is called Celebration. The first citizens move in this summer. The Walt Disney Company is making a serious attempt to build a real, functioning healthy community.

News reports have mentioned the gee-whiz high-tech aspects of Celebration Health, the 60-acre health campus that Florida Hospital is building in the town. Time Magazine dismissed it inaccurately as "a cross between a full-service gym and a hospital." Dismissive or dazzled, the news reports uniformly missed the fact that health arises not just from medicine but from the way people live, from the health of the community, of families, and the environment -- and that Celebration, and Celebration Health, are an ambitous attempt to build health in a whole new way.

For this project, unlike most, Disney has vigorously looked outside its own ranks for expertise as well as for vision. When Chris Corr, then a vice president of Disney Development, was looking for the latest and most powerful ideas in health, the list of experts he called included Kathryn Johnson, CEO of the Healthcare Forum. At her suggestion, Corr showed up at the 1993 founding meeting of the International Health Futures Network (IHFN) in San Francisco to talk about Celebration. A former state legislator with a background in real estate development, Corr quickly grasped the central concepts of "healthy communities." Clem Bezold, one of the founders of the IHFN, calls Corr "one of the most innovative business leaders I have ever dealt with."

By 1994, Corr had become a Healthcare Forum Healthy Communities Fellow with a unique action project. He and his colleagues enlisted the IHFN, as well as Johnson and Leland Kaiser, former Surgeon General C. Everett Koop, and Stanford University's Dr. Ken Pelletier, for visioning sessions to answer the interesting questions: Is it possible to build a truly healthy community? What would it take? The answer was a qualified yes: the future residents are the only ones that can truly build the community -- but there is a lot that a town planner can do to encourage it. It is one of Kaiser's favorite lines: "The future of health care is habitat redesign" -- and here was a chance to do it.

The Disney team turned to Florida Hospital, the largest not-for-profit in Florida. According to Bezold, Florida Hospital was in the midst of a deep organizational shift from being a "hospital" to a new role as a world-class healthcare provider in a managed care environment -- and it was already beginning to put resources into Healthy Orlando. The Disney team began talking with them not only about making Celebration a healthy place, but making Disney Development and its subsidiary The Celebration Company into "healthy companies."

From those meetings grew the concept of Celebration Health, not only a facility that brings wellness and medicine together in the same physical plant, but a concept that extends health, medicine, and wellness training throughout the community.


Rising From the Swamps


Today, the town is rising from the swamps and pastures of Florida. The bulldozers have pushed the palmetto, bald cypress, and pine into piles, and burned the piles under the gusts of enormous tubular fans. The downtown area has risen around its lake, the streets are laid out and paved, the utilities are installed, the bare plots on which the residents will build the first 350 homes are marked out with tiny plastic flags on wooden sticks, and the first homes are a-building.

The first group of homes will accommodate some 1,000 people. Eventually, at "build-out," as developers say, Celebration will grow to some 8,000 homes and a population of 20,000. Disney has given over 5,000 acres to the project, snaking through an additional 4,600 acres of wilderness dedicated, permanently and legally, as a "greenbelt," or "wilderness area," left to its original state as swamp and forest.

Designing a healthy habitat
turns out to be the same
as designing one that is
comfortable, beautiful, safe,
sustaining, clean,
one that works
for the humans who live there.

The huge town model in the Preview Center looks like a direct translation of Dr. Hancock's vision into paint and art board -- though most of the physical aspects of the town were already designed when Corr met the health futurists. Here as elsewhere, things come together. Designing a healthy habitat turns out to be the same as designing one that is comfortable, beautiful, safe, sustaining, clean, one that works for the humans who live there.

Despite its evolution from Walt Disney's 1960's dream of an "Experimental Prototype Community of Tomorrow" (which eventually became EPCOT Center), Celebration does not look futuristic at all -- there is no climate-control dome, no soaring buildings, no monorails, people-movers or swooping elevated roadways. Instead, the look of the overall planning is determinedly pre-World War II, from the $500 per month apartments over the downtown stores to the large homes around the golf course. The homes will take their designs from a style book featuring a variety of common, popular pre-war styles, such as Greek Revival, Victorian, and Country French.

Compared to many modern American subdivisions, the differences are striking: the plots of land set aside for homes are small, some free-standing home plots only 40 feet across, and townhouse plots only 25 feet. The streets are intentionally narrow -- the major arterials into the town are 35 feet across, and many of the residential streets measure no more than 20 feet. Narrow streets and lots lead to slower traffic, a greater sense of intimacy in neighborhoods, and a shift in focus away from the car and toward walking.

Most of the houses have porches broad enough to actually sit on in the warm Florida evenings. All have alleys behind them, to keep the cars and trash cans hidden away. The town plan is strewn with walkways, bike paths, and small pocket parks just big enough to toss around a ball, or sit on a bench with the morning paper. "We think of them more as shared front yards," says Corr, now Celebration's manager of community business development. "Our assumption is that people crave community."

The downtown is small, clustered around a lakefront, with a main street only 25 feet across. Though they are designed by a team of the world's great architects, the buildings are not all the same. Like the buildings of an ordinary town, the bank, designed by Robert Venturi, is a sober-looking, blocky thing, while Cesar Pelli's cinema has a touch of `50s futurism. In fact, it's the only part of Celebration that looks anything like Walt Disney's Jetsons-style City of the Future.

Some 20,000 people trooped through the Preview Center in the first month it was open, and interest was so strong that the Celebration Company (a Disney subsidiary) had to hold a drawing for the rights to determine who got first pick of the lots, townhouses, and apartments. Nearly 4,500 people put in applications. The interest is not surprising. As veteran town planner James Rouse put it approvingly, "What they are doing is much more intensive, much more sensitive, and much more searching than what is occurring generally in the planning and development of urban life." As Disney executives put it, they "sweated the details."


A sense of control


On the surface, the town looks little like Walt's version of the future, but even here the biggest differences are hidden, and they revolve around a central concept: control. Walt wanted it. When he was planning his "City of Tomorrow," his associate Donn Tatum commented that what Walt really wanted was "an experimental absolute monarchy," Walt playfully replied, "Can I have one?" It was a joke, but it was real all the same. He wanted to have a dress code for his community, and a behavior code: residents could be evicted for public drunkenness or cohabiting before marriage. He would outlaw, among other things, pets, unemployment and voting. "It will be a planned, controlled community," he said two months before he died. "There will be no landowners, and therefore no voting control. People will rent houses instead of buying them . . . There will be no retirees. Everyone must be employed."

But an important element of a healthy life is a sense of control. A healthy community is one that can take part in creating its own future. So the planners of Celebration are actually attempting something more difficult than even Walt contemplated (though they blink in surprise when this is suggested). Unlike Walt, they are willing to do their best to design the perfect town, and then relinquish control, bit by bit, to its citizens. Public spaces, streets, lighting and the rest of the infrastructure will be owned and controlled not by Disney (as reported in Time), but by a pair of special services districts whose boards will be elected by residents. The school will be part of the local public school district. Emergency services will be provided by the Osceola County, and future developments will submit (as this one did) to the regular county planning process, as well as state environmental requirements.

The Celebration Foundation (which will also be eventually controlled by residents) will attempt to build civic life. It will begin by taking the first wave of residents through the same kind of "principles and values" exercises that The Celebration Company used to design the town in the first place, taking people back to the deep values that they hold in common. Later the foundation will run yearly "brainwriting" sessions to help the community continually and consciously re-invent itself. It will experiment with everything from crafts fairs and public forums to baseball tournaments to discover what will forge Celebration into a true community.

"The town will be what people make of it," says Chris Corr. He and his colleagues have seen that if they want to build not just a development but a community, they must let chaotic humanity in, and they must get out of the way. "Disney can't possibly do it all," says Charles Adams, director of community development for Celebration. "But if we build strong links between the different parts it will work."


Underground, it's the millennium


The skin of Celebration is old-fashioned, warm, and huggable. Under the skin, the nerves are new, and they are powerful. Underground, it's the millennium. The futuristic technology in Celebration is hidden away -- and it is put to the service of building community.

If you look carefully at each house plot, you'll find some hints in the pipes that emerge from the ground. Here's the sewer connection, the gas pipe, the electrical cable, and the fresh water pipe. The purple pipe is recycled water, for the landscaping. The last pipe is the information cable. The entire village is wired. Glass fiber runs straight to every curb. This is for far more than cable service: in a small building downtown, AT&T is installing a broadband server and a series of switches that will allow every citizen not just to call a friend, watch cable television, download movies and order pizza, but to provide information as well, to arrange garden clubs, town meetings, and baseball games, to discuss homework, trade recipes and gossip, to look at the specials at the cafe, browse the shelves at the library, or plot assignations in the night.

The first wave of residents will be provided with computers, cellular phones, or personal communicators if they don't already have them. The town planners intend the system to help bring the community together -- they sometimes describe it as the "glue" of the town's culture -- not drive it apart into electronic cubicles. There is evidence that this approach works. Many users of the Well computer conferencing system, which originally grew mainly within California's Bay Area, report that their social lives, the regular face-to-face kind, have grown enormously since they began using the system. In the wall-to-wall wired town of Blackwood, Virginia, residents send each other an average of 8 email messages each per day, and big users include the Girl Scouts, the League of Women Voters, and the local arts council.

If the television has become our "electronic hearth," in Celebration the TV, the PC, or the screenphone will become the electronic "back fence." Amy Westwood, manager of this "Celebration Network," says that its goal will be to "reinvent the small-town porch and the general store." So the company has decided that it will not own and run the local conferencing system itself, but will give it to the town's foundation. "We have to turn this over to the community," says Adams.


No standard classrooms


Even the town's school is built around ideas that promote community. Six specific values form the core of the curriculum: ethics, diversity, cooperation, critical thinking, wellness, and community service. Four-teacher teams will handle "neighborhood" groupings of 100 students. The buildings will not be divided into standard classrooms with desks set in rows, but into home-like "hearth" areas, with big comfy reading chairs and window seats overlooking the wetlands, and "wet" areas, where students will do such messy things as cook, paint, and dissect frogs. Every student will have access to computers, linked into the town's information system, and through it to the Internet. No use telling mom you don't have any homework -- she can find out on the server.

Backed against a part of the dedicated wilderness area, the school will be linked directly with a teaching academy next door that will involve some of the nation's top schools of education, including Harvard, Auburn, Johns Hopkins, and the University of Minnesota. Eventually the academy will train some 3,000 educators a year in the latest techniques. It that will serve not just Celebration, but the entire school district of the surrounding Osceola County. So will the school: some 220 slots a year will be reserved for students who live elsewhere in the county.

The possibility of building something truly new has excited teachers from as far away as California, Canada, and the United Kingdom to apply for jobs at the school.


A radical experiment


Celebration Health itself is a radical experiment in the role a healthcare institution plays in a healthy community. The planners, focused on the roots of health in the community, considered having no health center at all, spreading the health functions through the town -- but focus groups let them know that people associate state-of-the-art healthcare with imposing buildings.

A rendering of the Celebration Health facility
Robert Stern's renderings show a large, elegant Mediterranean-style building with palms lining the drive, nearly surrounded by small lakes.

Only part of the space in the new facility, scheduled to open in early 1997, is dedicated to taking care of illness. Much of it is given to fostering a healthy lifestyle, to being what futurist Kaiser calls "a design center for the health of the community." "This is not just for acute care in a crisis," says Des Cummings, CEO of Celebration Health. "A big part of the physical plant is dedicated to prevention and wellness, and that is integrated with the medical side. This is a community center, a rallying point for health, for healthy people and healthy pleasures." It will incorporate a health club and workout facility (in the "Health Activities Center"), educational areas and a bookstore, meeting rooms, and mental health counseling rooms. Children can play in the "kids gym," a restaurant will serve good, healthy food, and adults can take classes in how to cook and eat better. It will be a place to go when you are not sick.

At the same time, the facility's Center for Health Innovations will be a proving ground and demonstration laboratory for new technology, from electronic patient records and images available to doctors over the town's server system to the advanced operating rooms designed by Ethicon Endosurgery and Olympus Endoscopy. General Electric will demonstrate and research advanced imaging methods, and other companies will demonstrate new medical information systems. Eventually, it should be possible to perform many home-health services, including remote monitoring and even some diagnostics, over the town's information server.

The clinical side of the health center will boast an outpatient surgery centre, diagnostic imaging, rehabilitation and sports medicine, a pharmacy and a dental clinic, as well as both primary care doctors and specialists.

The details of working with patients will be different. For instance, there will be no waiting rooms. You will make the appointment from home, through the server. When you show up, you'll get a beeper, so that if you have to wait at all, you can wait while strolling the grounds or looking through the bookstore.

"Typically," says Stanford's Dr. Pelletier, "a physician might tell a patient to stop smoking or lose weight, but leave the patient thinking `Now what do I do?' It's that `Now what?' part that is different here." At Celebration Health, the patient could go straight from the doctor to the work out center to set up an exercise program, to the information center to check out videos or sign up for a cooking class, and to the bookstore to buy a guidebook to his condition. Once home, he can log into the network to do continuing self-evaluation, ask the doctor a question, join a support group, or just compare notes with friends.

"It should be as seamless as possible," says Rich Morrison, a vice president of Florida Hospital. "We want to be part of the tapestry of life in Celebration." For instance, Celebration Health is working with the Osceola School District and the Florida Department of Education to develop ways of integrating wellness in to the life of the school.

Wellness training for chronic patients, adults and children alike, will be one area Celebration Health will emphasize, "because that's where you get the most immediate return," says Cummings. "For instance, if you give asthma sufferers some wellness training, you can cut ER visits by 25 percent." Such returns will be important for Florida Hospital to demonstrate -- though the exact financial structures are still in flux, the hospital has committed itself to being "rewarded financially based on improving the health of the community" -- that is, it intends to be at risk.


A doctor who knows all the words to "Itsy Bitsy Spider"


That's one reason that Celebration Health managers intend to fight hard to change the intimidating clinical atmosphere so common in healthcare. The primary care physicians and psychiatrists will all be direct employees of Celebration Health, giving the center a greater ability to make certain that they serve the patients' needs. Florida Hospital will contract for specialists' services from groups they already know and work with. Physicians will have to commit to sharing systems, staff, support services, and even space.

Physicians will have to
commit to sharing systems,
staff, support services,
even space.

In the world of hotel and resort management, Disney is considered a leading expert on "guest relations," the art of making customers feel welcome and cared for. The entire staff of Celebration Health, from the ophthalmologists to the receptionists, will go through Disney University training, to give the facility a uniquely warm "people feel." "It's definitely `high tech, high touch," says Dr. Ted Hamilton, medical director of Florida Hospital. A sign in the Preview Center describes the goal as: "A 60,000-square-foot Health Activities Center, 100 healthcare professionals, and a doctor who knows all the words to `Itsy Bitsy Spider.'"

Florida Hospital thinks of Celebration Health as a laboratory. Hamilton says, "We have made a major commitment: Celebration Health will be allowed, encouraged, and expected to explore opportunities in healthcare that may be outside our traditional business lines. We don't know exactly what that will mean yet."

The facility is far larger than necessary to serve Celebration, even when the town reaches its full size. "The market has to be bigger than that," says Hamilton. Not only its marketing, but its innovation, will effect an area much larger than Celebration. "We have an obligation to the broader community," says Morrison. "We hope to be able to transport much of what we learn about how to make health digestible and even entertaining."

"The long-term test," says Bezold, "is not just whether Celebration will be a healthy place to live -- because I think it will -- but whether Celebration will help make Orlando healthier."

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