Creating a Healthy Environment 2

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cIn 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. d 4Healthy People 2010, U.S. Department of Health and Human Services 1 Creating A Healthy Environment: The Impact of the Built Environment on Public Health Richard J.

Jackson, MD, MPH Chris Kochtitzky, MSP Centers for Disease Control and Prevention S P R A W L W A T C H C L E A R I N G H O U S E M O N O G R A P H S E R I E S Acknowledgements Sprawl Watch Clearinghouse would like to thank Jonathan Dushoff, of Princeton University; Peter Engelke, of the City and Regional Planning Program, College of Architecture, Georgia Institute of Technology; Karen Roof, of the National Association of County and City Health Officials; Marla Hollander, of the Robert Wood Johnson Foundation; Rich Killingsworth, of the CDC 9s National ... more. less.

Center for Chronic Disease Prevention and Health Promotion; Pat Meehan, of the CDC 9s National Center for Environmental Health; Lee Epstein, of the Chesapeake Bay Foundation; Chuck Connerly, of the Florida State University Department of Urban and Regional Planning; Bob Deyle, of the Florida State University Department of Urban and Regional Planning; Rebecca Miles, of the Florida State University Department of Urban and Regional Planning; Rich Shieber, of the CDC 9s National Center for Injury Prevention and Control; Bruce Stiftel, of the Florida State University Department of Urban and Regional Planning; Dorothy Sussman, of the CDC 9s National Center for Environmental Health; Patti Seikus, of the CDC 9s National Center for Environmental Health; Don Lollar, of the CDC 9s National Center for Birth Defects and Developmental Disabilities; Maisha Kambon, CDC 9s National Center for Environmental Health; Robert Weissman, of Essential Information and Betsy Garside, of the American Farmland Trust for their help in editing this report and the Educational Foundation of America whose support made this report possible. About the Authors Dr. Richard Joseph Jackson, MD, MPH Dr. Richard Jackson is the Director of the National Center for Environmental Health of the Centers for Disease Control and Prevention. During his tenure at NCEH, he has worked to increase support for stronger environmental health protection efforts throughout federal agencies, to engage CDC and local and state health departments in the genetics crevolution, d and to increase efforts to improve the nutritional status of people in developing countries. In addition, Dr. Jackson is collaborating with groups and individuals from many disciplines; planners, architects, engineers, academicians, and policy makers 9 to explore the implications of urban sprawl on the nation 9s environmental health. Jackson received his baccalaureate degree from St. Peter 9s College in Jersey City; a Master of Medical Sciences degree from Rutgers Medical School in New Brunswick; his M.D. from the University of California, San Francisco; and his M.P.H. in epidemiology from the University of California at Berkeley. Chris Kochtitzky, MSP Chris Kochtitzky is the Associate Director for Policy and Planning in the Centers for Disease Control and Preventions National Center for Environmental Health, Division of Emergency and Environmental Health Services. Mr. Kochtitzky was hired as senior legislative analyst at the Centers for Disease Control and Prevention 9s (CDC 9s) National Center for Environmental Health (NCEH). NCEH is one of CDC 9s key centers with responsibilities involving the impact that the environment (both natural and manmade) has on human health. In his years at NCEH, Mr. Kochtitzky has also served as Acting Deputy Associate Director of the Office of Planning, Evaluation, and Legislation, which is responsible for strategic planning and policy analysis within the center. Kochtitzky received a BA in political science in 1989 from Millsaps College and an MS in planning, with a concentration in environmental and natural resources planning, from Florida State University in 1992. About Sprawl Watch Clearinghouse The Sprawl Watch Clearinghouse mission is to make the tools, techniques, and strategies developed to manage growth, accessible to citizens, grassroots organizations, environmentalists, public officials, planners, architects, the media and business leaders. At the Clearinghouse we identify, collect, compile, and disseminate information on the best land use practices, for those listed above. Sprawl Watch Clearinghouse is a nonprofit organization based in Washington, DC Allison Smiley, Executive Director This report and many other sources of information on sprawl and smart growth are available on the World Wide Web at www.sprawlwatch.org Sprawl Watch Clearinghouse " 1400 16th St., NW " Suite 225 " Washington, DC 20036 " 202-332-7000 " www.sprawlwatch.org Preface Here at the start of the 21st century our understanding of which factors promote health and which damage health has grown considerably. The diseases of the 21st century will be cchronic d diseases, those that steal vitality and productivity, and consume time and money. These diseases-heart disease, diabetes, obesity, asthma, and depression- are diseases that can be moderated by how we design and build our human environment. It is now accepted that, in addition to direct hazards from infectious diseases and environmental toxins, human behaviors play a critical role in determining human health. As we begin to include consideration of these factors into our health-related decision-making, we must additionally guard against using too narrow a definition of the environment. Every person has a stake in environmental public health, and as environments deteriorate, so does the physical and mental health of the people who live in them. There is a connection, for example, between the fact that the urban sprawl we live with daily makes no room for sidewalks or bike paths and the fact that we are an overweight, heart disease-ridden society. Obesity can increase the risk of (adult-onset) type 2 diabetes by as much as 34 fold, and diabetes is a major risk factor for amputations, blindness, kidney failure, and heart disease. The most effective weight loss strategies are those that include an increase in overall physical activity. In a recent type 2 diabetes trial, weight loss and physical activity were more effective in controlling the disease than medication. In addition, for treatment of relatively mild cases of anxiety and depression, physical activity is as effective as the most commonly prescribed medications. It is dishonest to tell our citizens to walk, jog, or bicycle when there is no safe or welcoming place to pursue these clife-saving d activities. Respiratory disease, especially asthma, is increasing yearly in the U.S. population. Bad air makes lung diseases, especially asthma, worse. The more hours in automobiles, driving over impervious highways that generate massive tree-removal, clearly degrade air quality. When the Atlanta Olympic Games in 1996 brought about a reduction in auto use by 22.5%, asthma admissions to ERs and hospitals also decreased by 41.6%. Less driving, better public transport, well designed landscape and residential density will improve air quality more than will additional roadways. In order to address these critical health problems we must seize opportunities to form coalitions between doctors, nurses, and public health professionals and others such as architects, builders, planners and transportation officials, so that we are all cat the table d when environmental decisions are made. Such decisions include whether to install sidewalks in the next subdivision. It means thinking about what constitutes safe and affordable housing, safe neighborhoods, providing green space for people to enjoy where they live and work, and rethinking how we travel from one place to another. Land-use decisions are just as much public health decisions as are decisions about food preparation. What, for example, are the implications for children with asthma of building yet another expressway? We must also question whether a fatality involving a pedestrian isn 9t actually the result of poor urban planning, thoughtless land use, or inferior urban design rather than csimply d a motor vehicle crash. We must be alert to the health benefits, including less stress, lower blood pressure, and overall improved physical and mental health, that can result when people live and work in accessible, safe, well-designed, thoughtful structures and landscapes. We must measure the impact of environmental decisions on real people, and we must begin, in earnest, to frame those decisions in light of the well being of children, not only in this country but across the globe. Richard J. Jackson, MD, MPH Director, CDC 9s National Center for Environmental Health Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë 4 S P UBLIC H EALTH /L AND - USE M ONOGRAPH Introduction W hen 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 9s 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. Photo: USDA Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë P UBLIC H EALTH /L AND - USE M ONOGRAPH S 5 Land-use planning and zoning have their roots in a desire to protect the public 9s 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 land- use decisions in a community. 2 In this mono- graph, 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 ca state of complete physical, mental, and social well-being, not just the absence of disease or infirmity. d 3 The National Academy of Science 9s Institute of Medicine has asserted that the public health system should cfulfill society 9s interest in assuring conditions in which people can be healthy. d 4 Environmental public health initiatives have historically been among the most effective approaches for assuring healthy living condi- tions. 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.TAs a result of this discovery and Dr. Snow 9s 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 environ- mental public health actions such as Dr. Snow 9s 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: S The relation of land-use decisions to air quality and respiratory health; S The built environment (including all man- made physical components of human settlements such as buildings, streets, open spaces, and infrastructure) in terms of whether it promotes or discourages physical activity; S The impact of urban design on the number of pedestrian injuries and deaths, particularly among children; S The choices communities make about the built environment that improve mobility and the quality of life for their elderly and disabled residents; and S 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. Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë 6 S P UBLIC H EALTH /L AND - USE M ONOGRAPH Land-use and Its Effects on Air Quality and Respiratory Health S prawl 4 uncontrolled, poorly planned, low-density, and single-use community growth 4 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 4 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 4 the equivalent of 55 nine-hour days or 11 work weeks. 7 Residents of cities that have grown more over the last decade have 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 (NO x ), roughly 27 percent of volatile organic compounds (VOCs), and about 9 percent of particulate matter (PM). NO x and VOCs contribute to ground-level ozone pollution, which is known as smog. 10, 11 Research presented on the impact of auto- mobiles and the transportation sector on human health at the Third Ministerial Conference on Environment and Health held in London in 1999 indicated the following: S 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 NO x , and about 40 percent of the particulate matter (PM10) concentrations. S 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 Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë P UBLIC H EALTH /L AND - USE M ONOGRAPH S 7 air pollution and negative health outcomes such as asthma. The President 9s Task Force on Environmental Health Risks and Safety Risks to Children reports that: cMany 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 9s responsiveness to other inhaled allergens. Whether long term exposure to these pollutants can actually contribute to the development of asthma is not yet known. d 13 For instance, in the summer of 1997, smog pollution was responsible for more than 6 million asthma attacks, 159,000 visits to emergency rooms for treatment of asthma attacks, and 53,000 asthma-related hospitaliza- tions. 14 Results of a study conducted by the Centers for Disease Control and Prevention (CDC) during the 1996 Olympic Games in Atlanta, at which time vehicular traffic was kept at artificially low levels by city authorities, showed that the peak daily ozone concentrations decreased 27.9 percent and peak weekday morning traffic counts dropped 22.5 percent; at the same time the number of asthma emergency medical events dropped by 41.6 percent. Non- asthma medical events did not drop during the same time period. 15 Results that support the Atlanta findings were found in a 1999 study of adverse health effects associated with ozone in the eastern United States. This study, conducted by ABT Associates, found that during a single ozone season, asthma attacks that were directly attributed to excessive ozone pollution numbered approximately 86,000 in Baltimore, 27,000 in Richmond, and 130,000 in Washington, D.C. 16 T Children with asthma are believed to be particularly sensitive to air pollution. 13 As many as 25 percent of children in America live in areas that regularly exceed the U.S. Environmental Protection Agency 9s (EPA) limits for ozone, more than 25 percent of which comes from auto emissions. 13 Asthma rates among children in the United States more than doubled from 1980 through 1995, from 2.3 million 17 to 5.5 million. 18 Reducing children 9s exposure to environmental pollutants such as ozone will reduce the frequency and severity of their asthma attacks, will reduce their depen- dence on medication for asthma management, and will improve their overall lung function. 13 The significant contribution of automobile use to the overall air pollution problem seems clear. As the American population drives longer distances, these problems will most likely only worsen. Therefore, it seems imperative that new transportation options be developed and implemented in order to help alleviate the public health problems related to worsening air quality in the United States. Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë 8 S P UBLIC H EALTH /L AND - USE M ONOGRAPH The Built Environment and Physical Activity P eople who participate in regular physical activity reap substantial health benefits. According to the Surgeon General the most significant are as follows: S Lower mortality rates for both older and younger adults. Even moderate increases in activity are helpful; S Lower risk for heart disease and stroke; S Prevention or delay of the onset of high blood pressure and actual lowering of blood pressure among people with hypertension; S Decreased risk for colon cancer; S Lowered risk for noninsulin-dependent diabetes; S Weight loss and redistribution of body fat; increase in muscle mass; S Relief of the symptoms of depression and anxiety and improvement of mood; and S Apparent improvement in health-related quality of life by enhancing psychological well-being and by improving physical functioning among people with poor health. 19 The built environment presents both opportuni- ties for and barriers to participation in physical activity, thereby influencing whether or not we exercise. According to a recent survey about research studies, 20 one of the more important determinants of physical activity is a person 9s immediate environment (one 9s neighborhood). One study examined environmental variables, such as the presence or absence of sidewalks, heavy traffic, hills, street lights, unattended dogs, enjoyable scenery, frequent observations of others exercising, and high levels of crime. Positive environmental determinants of physical activity included enjoyable scenery (presence associated with more activity), whereas the greatest perceived barrier was the lack of a safe place to exercise. 20 Research by CDC and others 21, 22 has also indicated that two of the main reasons given as reasons for not exercising are lack of structures or facilities (such as sidewalks and parks) and fears about safety. Overall, CDC reports that higher levels of perceived neighbor- hood safety are associated with higher levels of physical activity, with the differences being greatest among racial or ethnic minorities and people older than 65 years of age. 21 Thus, people are more likely to use parks, paths, and bikeways when they are easy to get to and are safe and well maintained. Conversely, people tend to get less exercise as outlying suburbs are further developed and the distances between malls, schools, and places of employment and residence increases. Many theories have attempted to explain the radical changes in the health status of American society, but one of the strongest theories is the significant decline in activity levels among Americans today compared with levels from 50 or 100 years ago. 23 According to the U.S. Surgeon General 9s Report on Physical Activity in America, 19 changes in our lifestyles and communities have played the greatest role in the decline of activity levels among Americans. Millions of Americans drive to and from work and use a car to run almost every errand. In 1977, children aged 5 to 15 years walked or biked for 15.8 percent of all their trips; by 1995, children made only 9.9 percent of their trips by foot or bicycle 4 a 37 percent decline. 24 Results of a study in South Carolina showed that students are four times more likely to walk to schools built before 1983 than to those built Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë P UBLIC H EALTH /L AND - USE M ONOGRAPH S 9 more recently. 25 This would seem to point to some basic change in the cwalkability d of newer schools, possibly because these schools aren 9t as geographically close to the students they serve or because the school 9s property and its environs were designed to meet the needs of automobiles rather than the needs of pedestrians and bicyclists. In addition, many different types of urban design encourage sedentary living habits. For example, parking lots are built as close as possible to final destinations in order to increase convenience and safety for motorists. While older cities and towns were planned and built based on the practical idea that stores and services should be within walking distance of residences, the design of most new residential areas reflects the supposition that people will drive to most destinations. Work, home, school, and shopping are often separated by distances that not only discourage walking but may even necessitate the use of a car in order to reach any destination safely. Sedentary living habits also contribute to poor health outcomes because they are a significant factor in the incidence of overweight and obesity. From 1976 through 1994, the prevalence of U.S. adults who were overweight or obese rose from 47 percent to 56 percent, and by 1999 had risen to 61 percent. 26 More disturbing, however, was the fact that the prevalence of overweight children and adolescents almost doubled during this same period. 27 Some researchers have estimated that as many as 300,000 premature chronic disease deaths each year are due to obesity. 28 Figures 1-3 show the alarming increase in obesity prevalence among adults in the United States during a single decade. Major health care costs are also associated with the lack of physical activity and concomitant rises in obesity rates. In 1995, the direct health care costs of obesity were estimated at $70 billion. 29 Adding to that figure the estimated direct health care costs of physical inactivity ($37 billion), 29 we can conservatively attribute an overall health care burden of more than $100 billion to obesity and low levels of physical activity in the United States each year. Figure 1 Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë 10 S P UBLIC H EALTH /L AND - USE M ONOGRAPH Figure 2 Figure 3 Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë P UBLIC H EALTH /L AND - USE M ONOGRAPH S 11 Urban Design and Pedestrian and Bicyclist Safety A nother important issue is the impact of urban design on a number of injuries involving pedestrians and bicyclists. According to a recent report by the Surface Transportation Policy Project, in 1997 and 1998, 13 percent of all traffic fatalities 4 10,696 people 4 were pedestrians. Approximately 1,500 of these victims were children, while 22 percent were older than 65 years of age, even though only 13 percent of the population is elderly 30 . Although Americans make fewer than 6 percent of their trips on foot, 13 percent of all traffic fatalities occur among pedestrians; of the pedestrian deaths for which information is recorded, almost 60 percent occurred in places where no crosswalk was available. 30 The report concluded that the most dangerous metropolitan areas for walkers were newer, sprawling, southern and western communities where transportation systems are more focused on the automobile at the expense of other transportation options. A study conducted in New Zealand asserted that there are several potentially modifiable environ- mental risk factors for injury to child pedestrians. Particularly strong associations were found between the risk for pedestrian injuries and high traffic volume. The risk for injury to children living in neighborhoods with the highest traffic volumes was 13 times that of children living in the least-busy areas. Restricting curb parking at specific crossing points may be an effective approach to reducing children 9s injuries in this arena. 31 Several regulatory and design strategies can be applied to make communities safer for both child and adult pedestrians and bicyclists. These strategies include (1) setting and enforcing lower speed limits in residential areas; (2) protecting pedestrians in crosswalks by using traffic signals; (3) instituting and enforcing ctraffic- calming d measures, such as traffic circles or speed bumps; (4) providing sidewalks and pedestrian walkways; (5) providing crossing guards and bike paths in areas where most pedestrians are children, (e.g., near schools, parks, and playgrounds) and (6) providing overpasses, underpasses or tunnels for pedestrians and bicyclists to bypass particularly dangerous roads and intersections. Inherent in each strategy is a refocusing of design goals toward pedestrians and, to a degree, away from motorists. Photo: Hugh Morris Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë 12 S P UBLIC H EALTH /L AND - USE M ONOGRAPH Environmental Barriers for the Elderly and People with a Disability F ree and easy movement through public areas in the communities where we live is some- thing most people take for granted and, if asked, would probably claim as a right. However, people with disabilities often find that they cannot move easily from place to place and that they have trouble gaining access to medical and other basic health care and social services. People with disabilities are even more vulnerable to cenviron- mental barriers d than children or the elderly. Environmental barriers are defined as the cphysical attributes of buildings, facilities, and communities which by their presence, absence, or design present unsafe conditions and/or deter access and free mobility for the physically handicapped. d 32 These attributes can include the absence of ramps for wheelchairs, lack of depressed curbs (periodic breaks in curbs that act as ramps), narrow doorways that cannot accommodate various assistive devices (such as wheelchairs, motorized scooters, walkers, etc.), and lack access to mass transit routes or other public services. Often, something as simple as the lack of a sidewalk or curb cut keeps people with disabilities from getting any physical activity at all. A study in Houston, Texas, for example, found that three out of five disabled and elderly people do not have sidewalks between their residences and the nearest bus stop. 33 An even greater percentage of these households lack depressed curbs in their neighborhoods (71 percent) and bus shelters by the nearest bus stops (76 percent). Although close to 50 percent of the elderly and disabled live within two blocks of a bus stop, the lack of sidewalks, curb cuts, and bus shelters actually makes use of the transportation system by these people impossible. Fewer than 10 percent of the disabled and elderly use public transportation in Houston. In addition, fear of crime prevents close to two-thirds of the elderly and disabled from walking to the bus stop at night. 33 For elderly citizens and people with disabilities, these issues are not simply about convenience or even quality of life; rather, they are critical health issues. Without access in the community, these groups cannot adequately participate in physical activity, establish a community of support, or get to or use health care facilities. Thus, lack of physical access in a community becomes a factor leading to illness and even death. 33 Efforts to address these barriers through cuniversal design d have begun to show significant success. The concept of universal design maintains that 4 c&all products, environments and communications should be designed to consider the needs of the widest possible array of users. Universal design is a way of thinking about design that is based on the following premises: varying ability is not a special condition of the few but a common characteristic of being human, and we change physically and intellectu- ally throughout our life. Usability and aesthetics are mutually compatible. 34 As land-use and urban-design decisions are made, planners, architects, and engineers must keep in mind the needs of all community members. It is easy to see that if citizens in an urban setting such as Houston have encountered environmen- tal barriers to mobility and accessibility, people living in suburban or rural settings may face even greater challenges. Residents of the urban areas of most major cities in the United States such as Houston have access to some type of mass transit and can also find residential housing that permits some amount of pedestrian access to needed shopping and service facilities. In suburban parts of these cities and certainly in more rural areas of the country, mass transit is nonexistent, and distances to commercial facilities make pedestrian access impossible. Such circumstances can therefore make life very difficult for anyone who cannot drive or does not have easy access to an automobile, with the pronounced hardships experienced by the elderly and disabled. Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë P UBLIC H EALTH /L AND - USE M ONOGRAPH S 13 The Impact of Uncontrolled Growth on Water Quality U ncontrolled growth and the loss of greenspace that often accompanies it can drastically affect both surface and groundwater quality. Between 1970 and 1990, central Puget Sound experienced a 38 percent increase in population, while the amount of land developed in that same period rose by 87 percent. This large-scale alteration of the natural landscape had profound effects on water resources and quality. Under natural conditions, rainfall is either intercepted by vegetation or percolates slowly through the soil to receiving waters. In urbanized areas, rainfall that once filtered slowly downhill becomes surface runoff. It flows across compacted earth and impervious man-made surfaces (e.g., asphalt, concrete, rooftops often covered with oil and other pollutants) and is channeled into storm drains. This disruption of the natural hydrologic cycle causes stormwater runoff to reach streams and rivers more quickly than these water bodies can absorb it and also before it has had an adequate chance for filtration of pollutants through the ground (the flush of auto contaminants from malls and other large parking areas that runs into surface water bodies during the initial period of a heavy rainfall contributes significantly to the non-point source loading of pollutants entering streams). 35 Undisturbed forested lands generally have the highest capacity to absorb water and subsequently the lowest rates of stormwater runoff. In contrast, impervious surfaces have the highest runoff rates. The volume of stormwater that washes off one- acre parking lots is about 16 times greater than that of a comparable size meadow. 36 According to research published in 2001 by Johns Hopkins University, more than 50 percent of waterborne disease outbreaks between 1948 and 1994 were preceded by extreme rainfall events. Outbreaks due to surface water contamination were most strongly and most immediately related, while outbreaks due to groundwater contamination were most often delayed by a month or two. These findings can, in some part, be attributed to the increase in impervious surfaces in areas of population concentration, thereby rendering the land incapable of absorbing and filtering the amount of water that falls during these extreme weather events. 37 An additional threat to water quality posed by sprawling uncontrolled growth is the overuse of septic systems in low-density suburban and rural residential development that results in groundwa- ter contamination. For instance, according to the 1990 United States Census, approximately 26 percent of Florida 9s population was served by onsite sewage treatment and disposal systems (OSTDS). More than 1.8 million systems were estimated to be in use statewide. Since 1990, approximately 40,000 new systems have been installed each year. By comparison, in 1998, the Department of Health only issued 3,651 OSTDS abandonment permits where establishments were being connected to a central sewer system. It is estimated that OSTDS discharge 450 million gallons per day of partially treated, nondisinfected wastewater. 38 Photo: USDA Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë 14 S P UBLIC H EALTH /L AND - USE M ONOGRAPH Other Potential Health Effects of Land-use Decisions L and-use decisions and the built environment affect the way humans act and interact, with myriad impacts on public health. Sprawl and overdevelopment is closely correlated with a range of harmful public impacts: S In a study of conflict and violence in and around public housing in Chicago, researchers found that the residents of buildings with surrounding greenspace had a stronger sense of community, had better relationships with their neighbors, and reported using less violent ways of dealing with domestic conflicts, particularly with their partners. 39 S Urban heat islands increase the demand for cooling energy, increase the health risks associated with heat-related illnesses and deaths, and accelerate the formation of smog. Heat islands are created when natural vegetation is replaced by heat-absorbing surfaces such as building roofs and walls, parking lots, and streets. This phenomenon can raise air temperature in a city by between 2-8°F. 40, 41 S Sprawl increases the risk of flooding. Development pressures lead to the destruc- tion of wetlands, which are natural flood- absorbing sponges. In the last 8 years, floods in the United States killed more than 850 people and caused at least $89 billion in property damage. Much of this flooding occurred in places where weak zoning laws allowed developers to drain wetlands and build on floodplains. 42 S Residential development next to farmland can pose unique health and quality-of-life concerns as well. In this czone of conflict, d which might extend one-third of a mile from residential development, the spillover effects of agriculture, such as excess noise, blowing dust, and pesticide overspray potentially can have negative health effects on the occupants of the residential development. 43 S As sprawl-type development pulls people and resources away from central cities, those left behind can experience many negative consequences. School districts pressed to save money are often enticed by donations of unknowingly contaminated property or seek out the cheapest land they can find. Some of these properties, called cbrownfields, d are touted as the answer to all of the problems facing financially strapped school districts. Brownfields, defined by EPA as abandoned, idled, or underused industrial and commercial facilities where expansion or redevelopment is complicated by real or perceived environ- mental contamination, 44 can, in some instances, be the only type of property a school district feels it can afford. The land is cheap, and in some cases EPA may enter into agreements with prospective purchasers of property, providing a covenant not to sue for existing contamination. 45 Some groups feel that the supposed community benefit of cleaning up and reusing an abandoned site is outweighed by the risks posed if, when these sites are redeveloped, they are only cleaned up to standards set for commercial or industrial property, rather than residential property standards which are more stringent. 46 Washington Post Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë P UBLIC H EALTH /L AND - USE M ONOGRAPH S 15 School Case Study Marion, OH Military Dump River Valley High School and Middle School stand on the former site of the US Army 9s Marion Engineering Depot, part of which served as a dumping ground in the 1950s. In 1990, commu- nity members formed a group in response to alarming rates of leukemia and rare cancers among former students. Their efforts led to an investigation that revealed widespread campus contamina- tion. Today, no one may exit back doors of the middle school or access several playing fields. Recently a bond issue passed to fund a new school, but students remain on the contaminated site until completion. 46 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 cpublic health issues d with curban planning issues. d 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)Tcleaning 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: S 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 Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë 16 S P UBLIC H EALTH /L AND - USE M ONOGRAPH community, so too should public health officials use data on pedestrian injury patterns to create new urban design techniques. S 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 cWhy aren 9t there any sidewalks in a new subdivision? d or cWhat is the air quality impact that is expected from a widening of the local highway? d and to press for evidence to substantiate any claims upon which any new growth and development are based. S Working with planners and other land-use professionals to provide them with the strong public health arguments they need to support csmart-growth d designs and initiatives. The public health and medical community must play an active role in the land-use and develop- ment 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 in making 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 4 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: S Balancing the potential public health consequences of their choices with other considerations. cSmart growth d doesn 9t mean cno growth, d 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. S 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. S 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 9s homes. The influence of last century 9s 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 Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë Ë P UBLIC H EALTH /L AND - USE M ONOGRAPH S 17 such neighborhood establishments. S 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. S Encouraging greenspace development that promotes community, reduces violence, and improves mental health. The mental and physical health benefits of community parks and 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 psychologi- cal 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. Photo: Hugh Morris 18 S P UBLIC H EALTH /L AND - USE M ONOGRAPH References 1. Department of Health and Human Services (US). Healthy people 2010. Volume 1. Washington: DHHS; November 2000. p.8-3. 2. Village of Euclid v. Ambler Realty Co ., 272 U.S. 365 (1926) (USSC+). 3. World Health Organization. (No date). 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Do trees strengthen urban communities, reduce domestic violence? In U.S. Department of Agriculture, Forest Service, Southern Region. Forestry Report RB-FR 56, January 1996 [Online]. Available: http:// www.urbanforestrysouth.org/pubs/Tech_bulletin/tb4.htm [2001 August 6]. 40 Gorsevski V, Taha H., Quattrochi D, Luvall J (No date) Air pollution prevention through urban heat island mitigation: An update on the urban heat island pilot project [Online]. Available: http://www.ghcc.msfc.nasa.gov/uhipp/epa_doc.pdf [2001, August 6]. 41. Blum LN, et al. Heat-related illness during extreme weather emergencies. JAMA 1998;279(19).1514. 42. The Sierra Club (No date). Sprawl fact sheet [Online]. Available: http://www.sierraclub.org/sprawl/factsheet.asp [2001, August 6]. 43. American Farmland Trust (No date). Alternatives for future urban growth in California 9s Central Valley: The bottom line for agriculture and taxpayers [Online]. Available: http://www.farmlandinfo.org/fic/ft/cv/cv-intro.html [2001, August 6]. 44. USEPA Office of Solid Waste and Emergency Response Glossary of Terms. [Online] Available: http://www.epa.gov/ swerosps/bf/glossary.htm#brow [1997, September 30]. 45. United States Environmental Protection Agency, Office Solid Waste and Emergency Response. Brownfields Economic Redevelopment Initiative Quick Reference Fact Sheet. EPA 500-F-00-241 [Online] Available: http://www.epa.gov/swerosps/bf/ html-doc/econinit.htm [2000, October]. 46. Child Proofing Our Communities: Poisoned School Campaign. Poisoned schools: invisible threats, visible actions (2001) [Online]. [2001, August 6]. Sprawl Watch Clearinghouse 1400 16th St., NW " Suite 225 Washington, DC 20036 202-332-7000 www.sprawlwatch.org

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