Creating A Healthy

CREATING A HEALTHY
ENVIRONMENT
THE IMPACT OF THE
BUILT ENVIRONMENT ON PUBLIC HEALTHY

“In its broadest sense, environmental health comprises those aspects of human health, disease, and injury that are determined or influenced by factors in the environment. This includes not only the study of the direct pathological effects of various chemical, physical, and biological agents, but also the effects on health of the broad physical and social environment, which includes housing, urban development, land-use and transportation, industry, and agriculture.”
—Healthy People

PUBLIC HEALTH/LAND-USE MONOGRAPH

Introduction
When people consider factors adversely affecting their health, they generally focus on influences, such as poor diet or the need for more exercise. Rarely do they consider less traditional factors, such as housing characteristics, land-use patterns, transportation choices, or architectural or urban-design decisions, as potential health hazards. However, when these factors are ignored or poorly executed, the ecosystems in our communities collapse, people suffer the consequences. We have always known that a 2-hour commute to work each day on America’s freeways is not a pleasant experience; it is also becoming clear that it is an unhealthy experience. We see evidence every day that Americans exercise less often and suffer higher levels of stress than they did in the past. Yet we often fail to make the connection between these all-too-common facets of everyday life and how unhealthy we are. As America increasingly becomes a nation that permits and even encourages thoughtless development and unmanaged growth, the impact of these factors grows clearer, and we ignore them at our peril.

Land-use planning and zoning have their roots in a desire to protect the public’s health. As far back as 1926, the U.S. Supreme Court, in Village of Euclid vs. Ambler Realty Co., cited public health protection as one of the basic responsibilities of local governments, thus giving them a legal mandate to restrict or control landuse decisions in a community.2 In this monograph, we address some of these land-use decisions, discuss how they affect our health, and offer some suggestions on how public health professionals can collaborate with their colleagues in land-use planning and urban design to help ensure the health and quality of life of the people in their communities. In recent years, public health organizations have emphasized that public health agencies and programs must not only control disease, but also work to prevent it. The World Health Organization (WHO) has defined health as “a state of complete physical, mental, and social well-being, not just the absence of disease or infirmity.”3 The National Academy of Science’s Institute of Medicine has asserted that the public health system should “fulfill society’s interest in assuring conditions in which people can be healthy.”4 Environmental public health initiatives have historically been among the most effective approaches for assuring healthy living conditions. In 1854, Dr. John Snow was credited with taking bold action when he suspected that contaminated water from a public pump on Broad Street was causing a deadly cholera outbreak in London. As a result of this discovery and Dr. Snow’s actions to remove the handle on the pump, the cholera outbreak ended. Much of the improvement in disease death rates in the last century can be attributed to basic environmental public health actions such as Dr. Snow’s that resulted in improved sanitation, cleaner air and water, injury prevention, and protection of citizens from dangers posed by industrial pollution in their communities. We believe that applying public health criteria to land-use and urban design decisions could substantially improve the health and quality of life of the American people. Therefore, in this monograph, we focus mainly on the following:
The relation of land-use decisions to air quality and respiratory health;

• The built environment (including all manmade physical components of human settlements such as buildings, streets, open spaces, and infrastructure) in terms of whether it promotes or discourages physical activity;

• The impact of urban design on the number of pedestrian injuries and deaths, particularly among children;

• The choices communities make about the built environment that improve mobility and the quality of life for their elderly and disabled residents; and

• The ways that various land-use decisions affect community water quality, sanitation, and the incidence of disease outbreaks. A brief summary of other health impacts of urban sprawl is also included, with a final section that describes some steps that both the planning community and the public health community can take to ensure that public health concerns figure prominently in decisions made about the built environment.

Land-use and Its Effects on
Air Quality and Respiratory
Health

Sprawl — uncontrolled, poorly planned, low-density, and single-use community growth — depends on individual motor vehicles to flourish. As people move farther and farther from cities, they inevitably will travel longer distances to work, shop, and play. From 1960 through 1990, the percentage of workers with jobs outside their counties of residence increased by 200 percent, while the proportion of workers commuting within their counties of residence declined.5 This trend contributed to an increase in the number of vehicle miles traveled in passenger cars `— an increase of more than 250 percent (915 billion miles) from 1960 through 1997.6 This dependence on the automobile has only accelerated in recent years. For instance, according to the Sierra Club, the average American driver spends 443 hours each year behind the wheel — the equivalent of 55 nine-hour days or 11 work weeks.7 Residents of cities that have grown more over the last decade ave also experienced a greater increase in the average time spent traveling in a car than residents of cities where growth has remained stable. From 1992 through 1996, the increase in the number of annual person-hours of delay spent in an automobile in Los Angeles was 9 percent; in Atlanta 44 percent; in Orlando 62 percent; and in Kansas City 81 percent.8 This increase in driving time results in an increase in air pollution and in the incidence of respiratory diseases. Despite tremendous progress in reducing U.S. air pollution since the passage of the Clean Air Act almost 30 years ago, cars and trucks are still a major source of pollution, because even though individual cars pollute less, the number of cars and trucks and the number of miles people drive increases.9 According to a recent report completed by the Congressional Research Service, in 1997, on-road vehicles accounted for about 58 percent of carbon monoxide (CO) emissions in the United States, nearly 30 percent of nitrogen oxides (NOx), roughly 27 percent of volatile organic compounds (VOCs), and about 9 percent of particulate matter (PM). NOx and VOCs contribute to ground-level ozone pollution, which is known as smog.10, 11 Research presented on the impact of automobiles and the transportation sector on human health at the Third Ministerial Conference on Environment and Health held in London in 1999 indicated the following:
Z Motor vehicle traffic is the main source of ground-level urban concentrations of air pollutants with recognized hazardous properties. In Northern Europe, this traffic contributes practically all CO, 75 percent of NOx, and about 40 percent of the particulate
matter (PM10) concentrations.
Z Approximately 36,000 to 129,000 adult deaths a year can be attributed to long-term exposure to air pollution generated by traffic in European cities.12
Also presented at the conference were results from a recent study of the health effects of air pollutants from traffic in Austria, France and Switzerland and their related costs. This study, using comparable methods, found that air pollution caused 6 percent of total mortality in the three countries, more than 40,000 deaths per year. About half of all mortality caused by air pollution was attributed to motorized traffic. This corresponds to about twice the number of deaths due to traffic accidents in these countries. When researchers analyzed the data from the study they found that automobile-related pollution was responsible for more deaths than traffic accidents. The economic burden of the health impact of automobile pollution was estimated at more than EUR 27 billion
(approximately $23.8 billion in U.S. dollars).12 Data from studies conducted in the United
States strongly suggest significant links between air pollution and negative health outcomes such as asthma. The President’s Task Force on Environmental Health Risks and Safety Risks to
Children reports that:
“Many common air pollutants, such as ozone, sulfur dioxide, and particulate matter are
respiratory irritants and can exacerbate asthma. Air pollution may also act synergistically with other environmental factors to worsen asthma. For example, some evidence suggests that exposure to ozone can enhance a person’s responsiveness to other inhaled allergens. Whether long term exposure to these pollutants can actually
contribute to the development of asthma is not yet known.”13

Planners, Architects,
Engineers, and Public Health
Professionals Can Make a
Difference

The challenge facing those with responsibility for assuring the health and quality of life of Americans is clear. We must integrate our concepts of “public health issues” with “urban planning issues.” Urban planners, engineers, and architects must begin to see that they have a critical role in public health. Similarly, public health professionals need to appreciate that the built environment influences public health as much as vaccines or water quality. In a recently published list of the 10 most important public health challenges for the new century, CDC Director Jeffrey Koplan, MD, included at least four that are significantly linked to some of the land-use and urban design issues.
They are:
(1) integrating physical activity into our daily lives;
(2) cleaning up and protecting the environment;
(3) recog-nizing the contributions of mental health to overall health and well-being; and
(4) reducing the toll of violence in society.

28 Specific actions from the public health sector to address these issues might include the following:

• Supporting research to determine the impact that changes in the built environment can have on public health, such as the addition of greenspace, sidewalks, and bike paths, and the reduction in impervious surfaces. Just as traffic studies are completed to ensure that road capacity can support new growth, so too should the public health community conduct research to determine the air quality impacts that increasing numbers of automobiles in use in a community have on its air quality. Just as engineers use data that have been collected over time in other places to determine the diameter of sewer pipe needed to serve a section of a community, so too should public health officials use data on pedestrian injury patterns to create new urban design techniques.

• Participating in local planning processes, such as comprehensive planning meetings, zoning hearings, and urban planning workshops known as charrettes (intense, community-based, local planning and problem-solving workshops where local leaders and decision-makers develop consensus vision of the desired future of their community). Just as the developers, the neighbors, the school board, and the planners have their say in land-use decisions, so too should physicians and public health officials have the opportunity to provide input. It is their role to ask the questions such as “Why aren’t there any sidewalks in a new subdivision?” or “What is the air quality impact that is expected from a widening of the local highway?” and to press for evidence to substantiate any claims upon which any new growth and development are based.

• Working with planners and other land-use professionals to provide them with the strong public health arguments they need to support “smart-growth” designs and initiatives. The public health and medical community must play an active role in the land-use and development decisions made in their community. It is their role to make policy makers and planners aware of the health impacts of the decisions they make. It is also critical that when they find that no data or analyses exist to answer the questions that they raise, they push researchers and policy makers to collect the information they need and conduct the research to ensure that all of the impacts of various land-use decisions are known before irrevocable actions are taken. Just as there is an expanded role for health care workers and public health professionals inmaking land-use planning decisions, so too is there an expanded role for urban designers and planners to begin to view themselves as a previously untapped force for public health. It is time for the planning community to remember its roots in public health protection — to remember that in the beginning many, if not most, land-use decisions were made to separate people from land-uses and industrial processes that posed a threat to their health or safety. To reclaim their role as public health protectors, the planners and urban designers might take the following actions:

• Balancing the potential public health consequences of their choices with other considerations. “Smart growth” doesn’t mean “no growth,” but it does mean planned, controlled growth. The health impacts of land-use decisions need to receive at least as much consideration in development decision-making processes as economic impacts.

1. Designing communities around people rather than around automobiles. Reviving the concept that the end result of urban design should be improved quality-of-life and that where people live as it relates to where they work, shop or go to school can have a dramatic impact on their health and quality of life.
2. Changing existing zoning codes to encourage multiuse land-development patterns that make it possible to work, shop, and go to school within walking distance of people’s homes. The influence of last century’s community designers on our communities and on the behavior choices that we make everyday was seriously underestimated. The obesity epidemic in the United States was never imagined by those who made it difficult, if not impossible, to walk to the grocery store and to school and who also made it far easier to drive to the shopping mall or the movie theater across town then to walk to such neighborhood establishments.
3. Changing existing building codes to encourage building and site design that is accessible to people who have various degrees of mobility. It is a clear, if largely unrealized, fact that the more each member of society is able to participate and contribute, the better off society is. [Not only would those who were previously hampered by the inaccessibility feel better, but they also need less help to participate in society and be more able to contribute to their communities.] And all of this could be possible if appropriate design choices are made which, in most cases, would not cost appreciably more or negatively affect others.
4. Encouraging greenspace development that promotes community, reduces violence, and improves mental health. The mental and physical health benefits of community parksand other green spaces have been demonstrated. The question that remains is whether communities want to spend money up front to create an environment that prevents violence and increases psychological well-being or whether they want to spend money after the fact to address the violence and stress which results from communities without parks and communal areas. Public health professionals and those in architecture, urban design, and planning have much in common. The challenge now is for each profession to learn from each other how best to address the needs of the communities they serve, to determine what answers each has that the other needs, to create a common language, and to initiate the opportunities to use it. To meet these challenges, we need a broader view of those factors influencing public health and a much better understanding of the interdisciplinary nature of the problem. We need a collaborative and concerted effort to influence both public health policy and other public policy on these issues in order for positive changes to take place that will improve the health and quality of life for all Americans.