Health, Equity, and the Built Environment Advancing Health Equity: From Theory to Practice Richmond, VA September 10, 2009 Howard Frumkin, M.D., Dr.P.H., Director National Center for Environmental Health / Agency for Toxic Substances and Disease Registry Centers for Disease Control and Prevention

The sense of place

What is the “Built Environment”? Where people live, work, play, and study From the small scale… Homes, schools, workplaces To the intermediate scale… Neighborhoods, parks To the large scale Metro areas, transportation systems

Where people live, work, play, and study

From the small scale…

Homes, schools, workplaces

To the intermediate scale…

Neighborhoods, parks

To the large scale

Metro areas, transportation systems

Ten Leading Causes of Deaths, US (2004) Affected by the Built Environment

Agenda Housing Schools Parks Neighborhoods Transportation Equity Evidence-based decisions The broader context The need for long-term thinking The opportunity of co-benefits

Housing

Schools

Parks

Neighborhoods

Transportation

Equity

Evidence-based decisions

The broader context

The need for long-term thinking

The opportunity of co-benefits

Healthy housing

Housing hazards Rodents Insects Mold Poor infrastructure Proximity to waste sites Indoor air pollution Crowding Lead Injuries

Rodents

Insects

Mold

Poor infrastructure

Proximity to waste sites

Indoor air pollution

Crowding

Lead

Injuries

Housing disparities Shortage of affordable housing Substandard housing

Shortage of affordable housing

Substandard housing

Selected substandard housing conditions 2005 American Housing Survey Tables 2-2 (Height and Condition of Buildings) and 2-7 (Additional Indicators of Housing Quality) http://www.census.gov/hhes/www/housing/ahs/ahs05/tab2-2.xls and http://www.census.gov/hhes/www/housing/ahs/ahs05/tab2-7.xls PER CENT

Trailers Long-term housing: 8.7 million units 17.2 million people Post-disaster housing Classrooms and workplaces

Long-term housing:

8.7 million units

17.2 million people

Post-disaster housing

Classrooms and workplaces

Opportunities for housing

Solutions: Healthy housing Sufficient affordable housing Control hazards Removal of lead paint Mitigation of rodents, insects, mold “Green” housing Research

Sufficient affordable housing

Control hazards

Removal of lead paint

Mitigation of rodents, insects, mold

“Green” housing

Research

Indoor air quality Chemical hazards Cleaning materials Lighting Animals Safe playgrounds School travel “ Food environment” Healthy schools

Indoor air quality

Chemical hazards

Cleaning materials

Lighting

Animals

Safe playgrounds

School travel

“ Food environment”

Active transport to school, 1969 and 2001 Source: CDC. Kids Walk-to-School: Then and Now—Barriers and Solutions. www.cdc.gov/nccdphp/dnpa/kidswalk/then_and_now.htm

Two approaches to school siting Hubbard Lake Elementary School Hubbard Lake, Michigan "Outstanding in Its Field"

Safe Routes to School

The “food environment” at school

Fast food near schools Median distance from any Chicago school to nearest fast-food restaurant: 0.52 km 78% of schools had at least 1 fast-food restaurant within 800 m Fast-food restaurants clustered near schools (3-4X as many as expected) Austin SB et al. Clustering of fast-food restaurants around schools: A novel application of spatial statistics to the study of food environments. Am J Public Health 2005;95:1575–81.

Median distance from any Chicago school to nearest fast-food restaurant: 0.52 km

78% of schools had at least 1 fast-food restaurant within 800 m

Fast-food restaurants clustered near schools (3-4X as many as expected)

Solutions: Healthy schools Healthy school facilities: lighting, indoor air quality, cleaning procedures, chemicals, etc. Crime Prevention Through Environmental Design (CPTED) Safe playgrounds and sports fields Healthy cafeteria food Safe Routes to School Collaboration Health, environment, park & rec agencies, education agencies (including Boards of Education), parent groups, teacher groups

Healthy school facilities: lighting, indoor air quality, cleaning procedures, chemicals, etc.

Crime Prevention Through Environmental Design (CPTED)

Safe playgrounds and sports fields

Healthy cafeteria food

Safe Routes to School

Collaboration

Health, environment, park & rec agencies, education agencies (including Boards of Education), parent groups, teacher groups

Parks and greenspace

Community gardens

Park proximity and health Large urban parks, Copenhagen, summer Access to greenspace associated with: Lower level of self-reported stress Lower risk of obesity This relationship not fully explained by the number of visits to greenspace Nielsen and Hansen, Health & Place 2007

Access to greenspace associated with:

Lower level of self-reported stress

Lower risk of obesity

This relationship not fully explained by the number of visits to greenspace

Neighborhood greenness and childhood weight gain 3800 inner-city children (3-18) followed over 2 years Neighborhood greenness assessed using satellite photos Controlled for age, race, sex, residential density. Findings: Greener neighborhoods associated with slower increases in body mass Bell JF, Wilson JS, Liu GC. Neighborhood greenness and 2-year changes in body mass index of children and youth. Am J Prev Med 2008;35:547-53.

3800 inner-city children (3-18) followed over 2 years

Neighborhood greenness assessed using satellite photos

Controlled for age, race, sex, residential density.

Findings: Greener neighborhoods associated with slower increases in body mass

Trees and urban Life

Robert Taylor Homes interview study Interview study compared people in buildings with and without nearby trees Nearby trees strongly predicted: Knowing and greeting neighbors Acknowledging and helping neighbors Less psychological aggression Less violent behavior University of Illinois William Sullivan, Frances Kuo www.lhhl.uiuc.edu Images courtesy of W. Sullivan

Interview study compared people in buildings with and without nearby trees

Nearby trees strongly predicted:

Knowing and greeting neighbors

Acknowledging and helping neighbors

Less psychological aggression

Less violent behavior

Places to explore and play

Play in natural settings

Getting kids outdoors

Arabia Mountain Trail, Georgia

Solutions: Parks and greenspace More parks / greenspace in all communities Adequate maintenance and law enforcement Culturally appropriate, safe, fun recreational activities for residents of all ages Collaboration Public health, environment, natural resource, park & rec agencies, community groups, private sector

More parks / greenspace in all communities

Adequate maintenance and law enforcement

Culturally appropriate, safe, fun recreational activities for residents of all ages

Collaboration

Public health, environment, natural resource, park & rec agencies, community groups, private sector

Neighborhood design

Squalor and blight

Squalor and Blight in the American Housing Survey (2005) Homes that had, within 300 feet… Other buildings vandalized or with interior exposed ( ~ 5%) Bars on windows of buildings ( ~7%) Major street repairs needed (~6%) Trash, litter, or junk on streets or properties major accumulation ( ~ 2.5% ) major accumulation ( ~ 6% )

Homes that had, within 300 feet…

Other buildings vandalized or with interior exposed ( ~ 5%)

Bars on windows of buildings ( ~7%)

Major street repairs needed (~6%)

Trash, litter, or junk on streets or properties

major accumulation ( ~ 2.5% )

major accumulation ( ~ 6% )

The Broken Windows Theory Theory that broken windows beget broken windows (Wilson & Kelling 1982) Empirical links to health: “Broken windows index” predicts gonorrhea incidence (Cohen et al. 2000)

Theory that broken windows beget broken windows (Wilson & Kelling 1982)

Empirical links to health: “Broken windows index” predicts gonorrhea incidence (Cohen et al. 2000)

Gentrification

American Journal of Psychiatry 1996;153:1516-23/

Solutions: Healthy community design Healthy community design Density Mixed land use Activity centers Housing diversity Placement of food stores, medical clinics, other essential services Social policy to address gentrification Collaboration Public health, housing, community groups

Healthy community design

Density

Mixed land use

Activity centers

Housing diversity

Placement of food stores, medical clinics, other essential services

Social policy to address gentrification

Collaboration

Public health, housing, community groups

Transportation

Pedestrian infrastructure

Pharmacies

Dry Cleaners

Fine Food

Coffee

Tunnel of Vows Drive-Thru Wedding Chapel Las Vegas, NV

Funerals Gardner Memorial Chapel Davidson, TN Junior Funeral Home Pensacola, FL Adams Funeral Parlor Compton, CA

The next frontier of drive-thru: Health care?

Parking

?

April 22, 2003 The result

Factors that predict walking Good trails and sidewalks Nearby destinations Greenery Other people walking Safety

Good trails and sidewalks

Nearby destinations

Greenery

Other people walking

Safety

Transportation and air quality: The Atlanta Olympics Friedman et al. JAMA 2001;285:897-905 Peak traffic  23% Peak ozone  28% Acute asthma among children  11-44%

Less driving, fewer fatalities Ewing et al. Am J Public Health 2003;93:1541-45 Sivak. UMTRI-2008-39, July 2008

Transit and physical activity Transit users walk a median of 19 minutes daily to and from transit 29% exceed 30 minutes of physical activity daily Besser and Dannenberg, Am J Prev Med 2005

Transit users walk a median of 19 minutes daily to and from transit

29% exceed 30 minutes of physical activity daily

Besser and Dannenberg, Am J Prev Med 2005

Transportation equity

Solutions: Healthy transportation Healthy transportation policy Transit Pedestrian / bicycle infrastructure Transportation equity Collaboration Public health and transportation agencies, community groups, bike/ped advocates, elderly advocates, elected officials

Healthy transportation policy

Transit

Pedestrian / bicycle infrastructure

Transportation equity

Collaboration

Public health and transportation agencies, community groups, bike/ped advocates, elderly advocates, elected officials

Summary Housing Schools Parks Neighborhoods Transportation Evidence-based decisions Equity The broader context The need for long-term thinking The opportunity of co-benefits

Housing

Schools

Parks

Neighborhoods

Transportation

Evidence-based decisions

Equity

The broader context

The need for long-term thinking

The opportunity of co-benefits

Complexity Reality (simplified)

Climate change

Peak petroleum Source: Hubbert, 1956

Resource depletion

The courage to paddle upstream

Health Impact Assessment

Beyond the short term Hau de no sau nee (the Six Nations Iroquois Confederacy): planning for the seventh generation

Care for the individual patient Care for the community Care for future generations THE CLINICAL APPROACH THE PUBLIC HEALTH APPROACH THE LEGACY APPROACH

Promoting co-benefits

Co-benefits: Trees Carbon sequestration Cooler temperatures Reduced energy demand Clean water Clean air Protection from sunlight Venues for physical activity Noise reduction Mental health Spiritual fulfillment

Carbon sequestration

Cooler temperatures

Reduced energy demand

Clean water

Clean air

Protection from sunlight

Venues for physical activity

Noise reduction

Mental health

Spiritual fulfillment

Co-benefits: Food and nutrition

Co-benefits: Transportation  Physical activity  Air pollution And by the way…  Infrastructure costs  Social capital  CO 2 emissions  Depression  Injuries  Osteoporosis

Envisioning Change

Conclusions In a nation with pressing health problems, in a nation with persistent health disparities, in a nation with emerging environmental and resource challenges… we can and must build safe, healthy, sustainable, and attractive communities for all people, today and in future generations.

In a nation with pressing health problems,

in a nation with persistent health disparities,

in a nation with emerging environmental and resource challenges…

we can and must build safe, healthy, sustainable, and attractive communities for all people,

today and in future generations.

Thank you!