This is Daniel Parker with the Division of Environmental Health in the Florida Department of Health. Public health and urban planning are gaining more and more importance in Florida due to large population increases, post-9/11 fears, and more active hurricane seasons. On the national front, research continues to show that these fields need to be closer together to create more healthier built environments and to respond to public needs.
Florida has been at the forefront of this movement with the use of the Protocol for Assessing Community Excellence in Environmental Health, or PACE EH. This community assessment model has been instrumental in recognizing built environment problems as public health problems.
The results of Florida’s PACE EH project have been thought provoking. When county health department, environmental health officials worked with communities on PACE EH, they began by asking the community this question: What are your Environmental Health issues? What we found is that if you let a community identify their issues, they will identify what is usually in the realm of urban planning, the built environment, as a public health issue. For example, no sidewalks, no bike paths, no street lights, cut off from other neighborhoods, dilapidated housing, no fire hydrants, heavy traffic, sewage, flooding, and noise. These are critical findings. Private health care primarily focuses on the individual. Public health focuses on the community and thereby the social aspects of health. We spend a lot of time as public health officials discussing obesity, getting fit, and using alternative transportation such as a bike or your feet. We don’t spend a lot of time discussing whether one’s community has sidewalks to walk to school, or whether residents are too fearful of sending their children out into their neighborhood. It is as if we offer a prescription and only fill half the bottle.
Here in Florida, these built environment issues are critical. Last year alone, Florida had 400,000 new residents. The balance between creating healthy, well-connected new communities, while addressing older, established, and perhaps forgotten communities is going to be tremendous. But it can be done.
It is important for both public health advocates and urban planners to remember how public health and planning are interrelated. In the planning field, modern zoning dates back to 1926, to the Village of Euclid vs. Ambler Realty Co. decision in Ohio. That decision established that zoning was a proper use of local government to restrict unhealthy activities. Here was planning and public health together. Eighty years later, as public health and urban planning work primarily apart from each other, some writers have asked whether public health outcomes of planning have been completely forgotten; whether zoning hasn’t exacerbated the current challenges with urban sprawl, isolated communities, and many social, mental, and public health measures pointing in the wrong direction.
The feedback from the PACE EH communities, when they are allowed to define their environmental health issues themselves, is actually very in line with the definition of Environmental Health given by the Centers for Disease Control and Prevention in their Healthy People 2010 initiative. A definition that recognizes the interaction between planning and public health. A structural problem is that most government programs are created to be limited and very program based. The results from the communities, and this CDC definition, urges both planning and public health fields to be wary of a programmatic mind frame. A mind frame that says, If we don’t have a program for it, or a legislative mandate, or a monetary provider, it is not our business. As public servants, we need to consider that this broad cross-cutting thinking is exactly what government should be doing more of. Public health and urban planning are supposed to see the bigger picture.
When we talk about the built environment, what are we talking about? Health Canada defines the built environment as all of the buildings, spaces, and products created, or at least significantly modified by people. This would include the existence or lack thereof of urban green space, sidewalks, connected communities, mixed use communities, and so on. Ask yourself what is the built environment around where you live or work, how much of it do you use, and for the parts that you don’t use, why not?
There are several ways in which the built environment is influencing public health, including access to healthy food, support for social capital, or what some would define as civic involvement in one’s community, and opportunities for walking or biking without fear.
It is clear by now that not everyone is going to be reached with the importance of making good healthy decisions.
And we have to remember that free will and personal responsibility are still an important determinant, if not the most important determinant of healthy living. But the public health data calls for action. In March, 2006, the International Journal of Pediatric Obesity reported the number of overweight children will increase significantly by 2010 with great repercussion to health and to economies. Relying on personal behavioral decisions alone is no longer an option.
The obesity trend is being influenced in several ways, including by urban planning decisions. Public health and planning has to find and continually review the interaction between a resident and one’s environment. In February of 2006, researchers with the RAND corporation say that several factors influence children’s weight, including their age, hours of television viewing per week and their mother’s weight. Researchers considered additional influencing factors to be access to parks and playgrounds and whether they live in safe neighborhoods. These factors echo the response from communities undertaking the Florida PACE EH process.
A relevant question to ask is how many urban planners know the public health statistics of their communities. If one looks at the overweight and obesity statistics across the United States, the prevalence is alarming. It is predicted that by 2008, 73% of US adults will be classified as overweight or obese. In order to assess all contributing factors, there must first be a willingness amongst planners to accept that land use decisions can be influencing these health results.
When one considers changing routine or process, it is helpful to consider what the outcomes or the goals are supposed to be. In reflecting on these quotes here, there are several questions to consider. What is the goal of public health? What is the goal of urban planning? One may consider that public health and urban planning are trying to accomplish the same thing. A place where one knows one’s neighbors, where kids can roam free, where active commerce is healthy, and where the exchange of ideas and pleasantries are made in public, on common ground. A healthy place.
Consider the built environment from a child’s perspective. What is necessary to instill a sense of community and a sense of awareness for those who will be the next generation of leaders?
Think back to when you yourself were a child. What places did you explore? Are those places still there? Do your own children have places to explore in your neighborhood? In today’s America, we cannot imagine our children doing as Einstein did at the age of four, but what is it that we can imagine, and then put into action?
Children need space to explore. Planners and public health officials should consider it a challenge to preserve rich outdoor environments from which the young will learn. This will require seeing the big picture and following the smart growth principles of preserving open space, fostering a strong sense of place, and creating walkable neighborhoods. Also, combating perceived fears of allowing our children to explore.
If we don’t think about the overall goal, we will not recognize the linkage between the built environment and healthy living. And that is to our own peril. Public service is constantly under attack for what this speaker believes is the times that we miss understanding this bigger picture.
Missing the linkages means that neighborhoods start falling through the cracks.
The Wabasso neighborhood in Indian River is a prime example. Because there had been no investment and a history of neglect, there was no social capital. Until Environmental Health began a community assessment process, this community was forgotten. Even while new development was going on right next door. A public health message of getting fit and eating right will fall on deaf ears in a community where the built environment of housing, water, sewer, sidewalks, and streetlights are missing.
If you are a public health professional, become familiar with the smart growth principles. A good question to consider is how do each one of these relate to public health? A walkable neighborhood relates to public health through the ability to exercise everyday in one’s own neighborhood. A strong sense of place equates to social capital, the ability to get issues addressed such as drinking water, and streetlights. If you are a planner, you know these principles. Consider how these principles impact health. How would mixed land uses promote a more healthy community?
Within the urban planning realm, there is always much attention paid to preserving open space and urban green space, perhaps as a buffer between the urban and the rural. The State of Florida has been remarkable in its foresight to support a Preservation 2000 Program that has preserved millions of acres for public use. There is still a lot of research to be completed to evaluate how the preservation of open space and farmland relate to public health. This speaker is reminded of a drive to work that was for many years lined with pines and cow pastures. This has since been replaced with new commercial and residential development. This speaker feels that this change in the built environment, the loss of the tree-lined road and the open pastures, have a psychological impact. In Richard Louv’s new book, Last Child in the Woods, Gordon Orians, a professor emeritus at the University of Washington, believes the current research on human health and structured and unstructured environments suggests “that our visual environment profoundly affects our physical and mental well-being.” In looking at other smart growth principles, providing a variety of transportation choices has a direct impact on public health. If a safe route to walk or ride a bike exists, the quicker we can be serious about the nationwide obesity epidemic. This also reminds the speaker of a friend who lived in New York. He never felt fearful walking or using commuter transportation because there was always a crowd. How can we get a crowd on the streets, or a crowd of kids outside in their own neighborhoods, or a gaggle of children walking to school? The issue of fear and safety so permeates our communities right now, this speaker believes it is not being adequately address by either public health or urban planning.
Consider the smart growth principle of creating walkable neighborhoods. The American Journal of Preventive Medicine previewed a study in February 2005 that related how the built environment, in this case, how walkable a neighborhood was, to public health recommendations of physical fitness. The three walkability factors in the study were mix of shops, homes, and schools, the residential density, and the number of connecting streets. These are common features of interest to the urban planning trade, and the results of this study should be closely considered by land use planners.
Schools are part of the built environment. In Florida and across the nation, there has been a loss of neighborhood schools. Because of sizing requirements, most new schools are located on the urban periphery, adding to urban sprawl and making it difficult to bike or walk because of the distance. This study related how, as neighborhood schools declined, so did the number of students walking. But the research also brought up the fear factor. The difficulty in traversing today’s roads and traffic make many parents, and even school officials, prefer to have students driven. Consider how the built environment here has affected transportation choices.
The research by Allen Dearry with the National Institute of Environmental Health found that the US average time for driving is 73 minutes a day. This correlates with other research that looks at urban sprawl, which shows Americans are living and working further and further apart. The most interesting statistic here is the one that shows that Americans make only 6% of their trips by walking or biking, while countries like Italy and Sweden make almost half their trips by walking or biking.
The American Journal of Public Health in 2003 and 2004, and the Institute of Medicine in 2005, looked closer at the connection between health and the built environment. These articles addressed issues related to safety, crime, and areas being far from each other. The Institute of Medicine research is especially interesting as they advocated the need for professionals who can understand the links between public health and urban planning.
Once one starts to review the research and literature on the interaction between heath and the built environment, several themes become apparent. For a variety of reasons, pedestrian traffic is often an issue of last consideration. The research also shows that crime and safety are critical factors in whether people get out and walk or bike somewhere, yet crime and safety are rarely specified as an urban planning and public health issue.
Howard Frumkin, the current director of the National Center for Environmental Health, has been a pioneer in recreating the link between public health and urban planning. He was one of three authors in 2004 who wrote a book on the subject, suggesting that the rise in asthma, obesity, antidepressant prescriptions, and medical expenditures can be connected to land use and community design.
The 2005 Trust for America’s Health report stated that 1 out of 5 Floridians are obese. Consider what this means in health care costs. Also consider Benjamin Franklin’s famous saying, “An ounce of prevention is worth a pound of cure.” What would a percent difference in the obesity rate mean in cost savings for health care and insurance? One can conclude that it might be much more effective, and much cheaper, to ensure smart growth principles such as promoting mixed uses, and strengthening existing communities.
Consider what we have seen with the aftermath of Hurricane Katrina. How many officials would now make the decision to reinforce those walls and improve that built environment? A 1999 report estimated the cost of obesity to be $100 billion. How much would this be offset by an adherence to a smart growth principle such as encouraging community and stakeholder collaboration?
The issue of fear came up in three studies completed between 1995 and 2000. All of these studies came from health journals and reports. Relevant to planners will be the findings related to neighborhood safety, the presence of enjoyable scenery, and lack of structure or facilities. A concerted effort between public health and planning to combat both real and perceived fear should see public health benefits. The listener might ask which smart growth principle would be applicable to these studies?
When we talk about crime and safety, we have to ask ourselves is it of public health significance that people fear for their safety? Is fear the primary factor that drives sprawl or development in areas outside of city limits? The post World War II suburbanization has been characterized by some as “white flight”. Regardless of whether racism was a primary factor in the movement outward, the relevant issue today is whether fear still plays a part in community formation. The New York Times reported in 2005 on research completed in Tampa Florida by KB Homes, one of the nation’s largest home builders. The results should be of interest to both planners and public health professionals. When asked what they valued most in their community, safety is always a primary factor, even in communities where there is virtually no crime. How will people respond to an event if they feel the only safe place is in their home? Is our current urban planning process inadvertently supporting studies that show us becoming less civic-minded, less social, and less able to live with each other?
Continuing with this issue of fear, the New York Academy of Medicine, in an effort to judge the readiness of residents for a terrorism event, conducted their own survey. Their results showed both a fear and a disconnect between the public, public health, and planners. This study was done in 2004, and one can make the conclusion that the events in New Orleans in 2005 after Hurricane Katrina were synonymous with this survey. Many communities in New Orleans did not have the means to evacuate, nor the trust. A community assessment model such as Florida’s PACE EH would have better addressed some of these communities built environment issues, built more trust between communities and their public officials, and have responded better to calls for evacuation. And remember, it meets the Smart Growth principles of strengthening existing communities, and encouraging community and stakeholder collaboration.
The USA Today in December, 2004 touched on the fear epidemic, finding parents as well as some schools not wanting their children walking to school. We can have free range chickens but we are making less and less room in our urban planning process for free range kids.
In a 1980’s study of Livable Streets by Donald Appleyard, a Professor of Urban Design at the University of California, Berkeley, he found that traffic has a great impact on how social we are. The lower the traffic along the streets we live on, the higher our number of friends and acquaintances. The heavier the traffic, the fewer our friends and acquaintances in the neighborhood.
Before traffic impacts to a community, the places people associate are free and open.
After traffic impacts, people begin to adapt to their new environment by moving indoors and socializing less outside. The breakdown of the “community” begins.
Will McDonough, a world renowned architect and designer and winner of three Presidential awards, spoke in 2003 at the Sixth National Environmental Public Health Conference. He talked about nature and urban design and challenged public health professionals to think and act boldly. He reminded those present of what was in the Declaration of Independence; life, liberty, and the pursuit of happiness. This editorial that appeared in the New York times in 2005 was a reminder of McDonough’s message. Planners ask yourselves what kind of communities are you trying to attain? Public health officials, what is the goal of public health?
Dr. Catherine O’Brien, with York University in Toronto, has written extensively on urban planning, public health, and happiness. In this graph, Dr. O’Brien demonstrates how the rise in the U.S. gross national product has not equated to perceived happiness. She states in a 2005 paper on Planning for Sustainable Happiness , that links between health and happiness have yet to influence transportation and urban planning policy and practice.
We have discussed the loss of social capital, or civic involvement, and its relation to getting built environment issues addressed. Here is another way of understanding this important issue. In 1996, Robert Putnam, author of the critically acclaimed, Bowling Alone , wrote an article to assess why Americans were dropping out, and becoming more and more civically disengaged. He reviewed data on all the factors common thought has portrayed as being the problem: Being too busy, economic hard times, suburbanization, the movement of women into the paid labor force, the stresses of two-career families, divorce, changes in the economy such as the rise of chain stores, branch firms, and the service sector, disillusion with public life, cultural revolt against authority, civil rights, television, the electronic revolution, and other technological changes. Only one of these factors was consistent with the evidence, and that is the amount of time spent watching television. The average American in 1995 watched television roughly four hours per day, absorbing 40 percent of their free time. The author relates television’s arrival with reduction in participation in social, recreational, and community activities among people of all ages. Controlling for education, income, age, race, place of residence, work status, and gender, TV viewing is strongly and negatively related to social trust and group membership. A study from the Kaiser Family Foundation in 2005 indicates that the amount of TV watching has remained steady. Among young people, TV watching is steady, but now being “multi-tasked” with other media. So, why is this important to public health and urban planning? The data we have reviewed suggests that obesity, physical fitness, fear, crime, and the loss of social capital can all be related to an inadequate built environment. Public health and urban planning should therefore focus on each of these issues together to get residents outside and re-involved. Their greatest competitor to doing this is television.
If we can be successful in considering the things discussed in this presentation, the result is going to be a paradigm shift for how we view public health. That is, that community design, transportation, and social capital all impact public health and should therefore be addressed by public health with urban planners.
There are several specific activities underway in Florida that will help bring planning and public health together. There is increased interest in health impact assessments as a part of development procedures. There has been a Memorandum of Agreement drafted between the state’s leading public health, planning, and environmental agencies. Divisions of Health focused on environmental health and family health have begun working closer together to address safety and physical fitness. And health officials have spoken at and written for planning venues.
Bringing public health and urban planning together will require several things. A community assessment model such as the PACE EH, which has been proven to address built environment issues and smart growth principles, needs to become common place. Public health officials and planners need to not view themselves not as regulators, but educators. If we don’t see the bigger picture, who will? The fear factor needs to be studied as it relates to human health, urban planning, and social outcomes. In order to assist planners, we need more public health data.
We have several counties in Florida where public health officials sit on planning commissions, development review committees, and other public entities. This also needs to become a regular part of public health responsibilities. Planners need to find ways to inject public health into the process. A good start would be to review available public health data for existing communities, and to support community assessments where the community speaks. The mental health connection to the built environment needs more rigorous review, including changes in the built environment and the coinciding effect on public health.
We as planners and public health officials need to take ownership in this issue. The research shows that the built environment impacts health. The challenge is to create built environments that are smart, safe, user-friendly, and attractive, that will compete head-on with the drive in-doors, and will show public health and civic involvement results. In Richard Louv’s new book, Last Child in the Woods, Howard Frumkin, the Director of the National Center for Environmental Health at CDC, recommends that “environmental-health research be done in collaboration with architects, urban planners, park designers, landscape architects, pediatricians, and veterinarians.” A great place to do this is through a community assessment process such as the PACE EH.
-For more information on our Florida PACE EH Pilot Project, please visit our website. This is Daniel Parker with the Florida Department of Health, Division of Environmental Health.
Bridging the Gap Between Public Health and Urban Planning Florida Department of Health Division of Environmental Health Daniel Parker, MSP Division Operations and Management Consultant
Protocol for Assessing Community Excellence In Environmental Health (PACE EH) http://www.myfloridaeh.com/programs/PACE-EH/PACE-EH.htm
“ 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.”
The built environment encompasses all of the buildings, spaces, and products created, or at least significantly modified, by people.
Health Canada, Health and Environment, 1997.
Land Use (industrial or residential)
Buildings (housing, schools, workplaces)
Public Resources (parks, museums)
How might the built environment influence human health?
Access to medical and other health care
Quality of and access to schools
Healthy food outlets
Ease of social interaction and resulting social capital
Air and water quality
Opportunities for physical activity
The Burden of Physical Inactivity Rich Bell, Project Officer, Active Living by Design*, UNC School of Public Health *A National Program of The Robert Wood Johnson Foundation Email: [email_address] Web: www.activelivingbydesign.org
Emergence of a Sedentary Society Rich Bell, Project Officer, Active Living by Design*, UNC School of Public Health *A National Program of The Robert Wood Johnson Foundation Email: [email_address] Web: www.activelivingbydesign.org
According to the Center for Disease Controls' Healthy People 2010 Report, the definition of Environmental Health may include housing, urban development, land-use, and transportation. Submit Clear A) True B) False
Prevalence of Overweight and Obesity Among US Adults, Age 20-74 Years* Obese BMI ≥30.0 Percent BMI = body mass index. *Age-adjusted by the direct method to the year 2000 U.S. Bureau of the Census estimates using the age groups 20-34, 35-44, 45-54, 55-64, and 65-74 years. NHANES II 1976-80 (n=11207) NHANES III 1988-94 (n=14468) NHANES 1999 (n=1446) NHANES III 1999-2000 (n=4115) Projected 2008 Overweight or obese BMI > 25.0 Overweight BMI 25.0-29.9
Quotes “ It is the occupation of a child to immerse herself in her environment". “ Lowly, unpurposeful and mundane as they appear, sidewalk contacts are the small change from which a city’s wealth of public life may grow.” Jane Jacobs, The Death & Life of Great American Cities “ There is much more to walking than walking.” Jan Gehl, New City Spaces
Unkempt properties, pollution cited in west Ocala survey By SUSAN LATHAM CARR, STAFF WRITER, Star Banner Residents of west Ocala complain that unkempt lots lower the value of their property. ERICA BROUGH/STAR-BANNER
Indian River County PACE EH Project http://www.myfloridaeh.com/programs/PACE-EH/PACE-EH.htm
What is PACE EH? Submit Clear A) The Packers and Cubs Exchange B) Principles of Community Eating C) Protocols for Assessing Community Excellence in Environmental Health
Studies show association between deteriorated physical environment and higher rates of crime. Safety influences activity.
Transportation Research Board/Institute of Medicine, January 2005
Does the Built Environment Influence Physical Activity?
“ Universities should develop interdisciplinary education programs to train professionals in conducting the recommended research and prepare practitioners with appropriate skills at the intersection of physical activity, public health, transportation, and urban planning.” http://trb.org/publications/sr/sr282.pdf
Florida ranked 38 th in the U.S. in highest rate of adult obesity at 20.7%.
64.5% of adult Americans overweight or obese.
“… .Decisions about where we build new houses and highways or schools and sidewalks can mean the difference between giving people more or less opportunity to participate in physical activity.” – Parris Glendening, former Governor of Maryland, president of Smart Growth Leadership Institute.
Need smarter design, including evaluation of health impacts of new building efforts, updating existing development, and encouraging design that promotes and integrates space, sidewalks, public transportation…in new development.
An Ounce of Prevention… http://healthyamericans.org/
Cost to reinforce the walls vs. Cost to rebuild New Orleans
Cost to promote smart growth vs. cost of obesity (Obesity cost estimate is $100 billion) 29 Colditz, GA. Economic costs of obesity and inactivity. Medicine and Science in Sports and Exercise, 1999; S664-5.
Pick the Smart Growth Principles in this List Submit Clear A) Mix Land Use B) Put assets in New Communities C) Create New Roads for Faster Access to Destinations D) Provide a Variety of Transportation Choices E) Encourage Community & Stakeholder Collaboration
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.
Research indicates that two of the main reasons given for not exercising are lack of structures or facilities (such as sidewalks and parks) and fears about safety.
Overall, higher levels of perceived neighborhood safety are associated with higher levels of physical activity.
King AC, et al. Personal and environmental factors associated with physical inactivity among different racial-ethnic groups of U.S. middle-aged and older-aged women; Health Psych 2000:19(4):354-64. CDC.
Neighborhood safety and the prevalence of physical inactivity-selected sates, 1996. Mor Mortal Wkly Rep 1999:48(7):143-6.
Pate RR, et al. Physical Activity and Public Health: A recommendation from the CDC and the American College of Sports Medicine. JAMA 1995;273(5):402-7.
“ The freedom and adventure of walking to school has been replaced with overscheduled and oversupervised kids. As Royce Yeater of the National Trust for Historic Preservation puts it, consumers demand free-range chickens for their table but won’t let their kids out of the house.” – USA Today, 1/25/2005, Trek to school not like it used to be, by Martha Moore
“ Our sense of happiness is created by many things that are not easily measured in purely economic terms, including a sense of community and purpose, the amount and content of our leisure and even our sense of the environmental and ecological stability of the world around us …A clearer understanding of what makes humans happy-not merely more eager consumers or more productive workers-might help begin to reshape those assumptions in a way that has a measurable and meliorating outcome on the lives we lead and the world we live in.”