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Hk icth2016 13th_june2016_website version

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The health impacts of transport planning and policy

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Hk icth2016 13th_june2016_website version

  1. 1. The Health Impacts of Traffic-related Exposures in Urban Areas: Understanding Real Effects, Underlying Driving Forces and Co-producing Future Directions Haneen Khreis, 2nd International Conference on Transport and Health, San Jose, 13-15 June, 2016 Session: Collaboration for a Healthy Change in Transport Planning, Advocacy, and Policy
  2. 2. Acknowledgements Karyn Warsow, Health Policy Management and Leadership Ersilia Verlinghieri, public participation in transport planning Alvaro Guzman, power in transport planning Luc Pellecuer, Incorporation of Environmental Impacts into engineering Antonio Ferreira, Governance and Transport Policies Ian Jones, Urban and Transport planning Eva Heinen, Active travel behavior David Rojas-Rueda, Epidemiology and public health Natalie Mueller, Public health Paul Schepers, Traffic safety Karen Lucas, Transport and social analysis Mark Nieuwenhuijsen, Epidemiology and public health
  3. 3. Background ■ The world is witnessing its largest surge of urban growth in history ■ e.g. 75% of the European population live in urban areas ■ Urbanization being shaped by step changes in transport connectivity and related land-use practices ■ Transport often envisioned as a driver for urban development and a contributor to economic returns ■ But has negative impacts on the health of a population exacerbated in urban areas Rydin et al. 2012
  4. 4. Background ■ Each year, > 1.3 million deaths and 78 million injuries warranting medical care result from motor vehicle crashes ■ Air pollution and decreases in physical activity associated with annual estimates of 7 million and 2.1 million global deaths, respectively ■ Current land-use planning and policy patterns are reinforcing excessive use of motorized transport modes ■ Health impacts are disproportionately distributed, contributing further to gross inequalities in health
  5. 5. Background ■ Sustainable transport infrastructure/modes effective in promoting active travel; increasing physical activity and reducing exposures ■ Can reduce health inequalities through modifying some of the pathways by which low socioeconomic position can lead to diseases ■ This evidence reinforces the need to develop and implement effective policies that define and address health consequences
  6. 6. Rationale – A clear scoping of traffic-related health impacts (in urban areas)… – Understanding and discussing the underlying driving forces behind where we are now… – Is there a need for a new health- aware perspective in the transport/development agenda? – Examples of good practice and lessons learned from case studies – Consider stakeholders involved and make recommendations Where are we now? How did we get here? Where do we want to go? What will guide us? How will we get there?
  7. 7. ■ Initial meeting at the 1st International Conference of Transport and Health 2015 – London ■ Bring together expertise in transport engineering, transport and urban planning, research and strategic management, epidemiology and health impact assessment ■ Built on/led to recent reviews on this topic by some authors ■ Arrange meetings amongst the authors. Full collaboration has been made possible through the use of online tools such as Google Docs and emails ■ Organize (4) workshops around the key synergies between transport and health ■ Concepts presented were developed further and discussed amongst the authors, and others attending ■  this paper emerged from a collective rather than a solitary exercise Methods
  8. 8. Where are we now? Adverse health impacts associated with traffic Motor vehicle crashes Physical inactivity Air pollution exposure Noise exposure Temperature (rises) exposure Green space reduction exposure
  9. 9. Motor vehicle crashes ■ One of the earliest recognized traffic-related health issues (obvious effects…) ■ Vulnerable populations and road users including the elderly, children, the economically disadvantaged and pedestrians and cyclists are the most impacted ■ Half of the world’s road traffic deaths occur amongst motorcyclists, pedestrians and cyclists, with 31% of deaths amongst car occupants (rest is unspecified) ■ Low-income and middle-income countries account for over 90% of the world’s roads fatalities despite having 48% of the world’s registered vehicles ■ Have received more policy attention partly due to the attention to crash severity and loss of life ■ Incidence rates for active travel depend on the number of active travellers resulting in a rapid decline in MVC when the number of these users increase
  10. 10. Motor vehicle crashes “I'm listening to a live streaming of the US Department of Transportation 50th Anniversary ceremony. The overwhelming theme is automotive safety. t is ingrained in the culture not specific to people. This perspective requires a cultural shift at the policy level, which is happening slowly in the US ” “Perhaps mention safety concerns were raised soon after ww2. At least in NL in the ’60 and ’70. As a consequence there cars were banned and it was one of the reasons to stimulate bicycling”
  11. 11. Physical inactivity ■ The biggest public health problem of the 21st century ■ 2.1 million global deaths/year attributable ■ Physically inactive people have a 20% to 30% increased risk of all-cause premature mortality ■ Increased physical activity associated with a reduction in risk of chronic diseases e.g. cardiovascular disease, dementia, Alzheimer's and Parkinson's disease, type-2 diabetes, breast cancer, colon cancer depression and anxiety symptomatology ■ Emerging evidence for a role in delaying cognitive decline/improving brain health ■ Positive effect on pulmonary function, which can have a role in reducing the negative health effects of traffic- related air pollution
  12. 12. Active travel and physical activity ■ 20% to 50% of population do not meet physical activity guidelines ■ Active travel could provide means to build physical activity into daily routines ■ Active travel associated with higher levels of objective and self-reported physical activity ■ Countries with higher levels of active travel have lower obesity levels suggesting ■ Providing for active travel will boost its levels, although the effects of new infrastructure may not be immediate ■ Available resources for physical activity participation including parks and walking and biking trails vary by neighbourhood socioeconomic status with the pattern of fewer options for the more deprived
  13. 13. Traffic-related air pollution ■ In urban areas, ambient air pollution is dominated by motor vehicles traffic ■ Associated with all-cause mortality, childhood asthma incidence, cardiovascular disease incidence, cardiovascular mortality and morbidity, cerebrovascular mortality and morbidity, decreased lung function in children, infant mortality, lung cancer, low birth weight, pregnancy-induced hypertensive disorders, preterm birth, respiratory infections, and respiratory mortality and morbidity ■ Contributing to an estimated 370,000 premature deaths and on average a 9 month reduction in life expectancy in Europe ■ Source models not widely available ■ TRAP disproportionately distributed amongst socio-economic and vulnerable groups e.g. low-income groups and minorities, as their schools and residences are often located in high traffic exposure areas
  14. 14. Traffic-related noise ■ Ambient noise are associated with the road network, junctions, traffic flow, speed and load ■ Health effects of traffic-related noise are increasingly being recognized as attributable to a large burden of disease that may be comparable to that of air pollution ■ One million healthy life years are lost every year from traffic-related noise in the western part of Europe alone ■ Ambient noise has been associated with all- cause mortality, cardiovascular mortality and morbidity, annoyance and sleep disturbance, adverse reproductive outcomes, cognitive problems in children, diabetes type-2, high blood pressure in children, mental health and well- being problems and stroke ■ Cardiovascular effects by ambient noise have been shown independent of air pollution exposures ■ Low-income individuals and visible minorities tend to be located in the areas most polluted by road traffic noise
  15. 15. Urban Heat Islands and Greenhouse Gases ■ High density urban settlements and roads heat absorbing concrete and asphalt structures dominate the landscape = heat island effect ■ Traffic also release anthropogenic heat by way of tailpipe emissions (black carbon, carbon dioxide, methane, nitrous oxide) and can amplify urban temperatures ■ High ambient temperatures have been associated with all-cause mortality, cardiorespiratory morbidity, children’s mortality and hospitalization, heat stress, hospital admissions, increased health service use for chronic diseases, including respiratory diseases, hypertension and diabetes, preterm birth, reduced lung function in children and MVC
  16. 16. Green infrastructure ■ Associated with a number of beneficial health effects, including decreased premature mortality, reduced cardiovascular disease, higher birth weight, improved mental health, improved sleep patterns, recovery from illness, reduced children's behavioural problems, reduced incidence of childhood asthma, increased social contacts ■ Other beneficial effects on cognitive development, physical activity and obesity ■ Possible mechanisms for health benefits are due to increased physical activity, more space to enable social interaction, psychological restoration and stress reduction, and mitigation of environmental exposures including air pollution, noise and heat ■ Distribution of (access to) green spaces can be differential by socioeconomic status in favour with those with resources to move to greener areas ■ Amount of green space is often limited in cities ■ Varies considerably between and within cities, European cities average around 18.6% green space ■ Transport and utilities use significant amounts of land which could arguably be or be used for green infrastructure
  17. 17. Results – A clear scoping of traffic-related health impacts (in urban areas)… – Understanding and discussing the underlying driving forces behind where we are now… – Is there a need for a new health- aware perspective in the transport/development agenda? – Examples of good practice and lessons learned from case studies – Consider stakeholders involved and make recommendations Where are we now? How did we get here? Where do we want to go? What will guide us? How will we get there?
  18. 18. How did we get here? ■ A significant burden of disease associated with transport practices ■ Suggest that transport design, planning and policy are operating separate from health at some level – Trends of development, – (lack of) Public policies – Public’s perceptions and awareness, – The state of the transport investment appraisal – and the influence of powerful actors in leading to the current state and maintaining it
  19. 19. Rapid and car-centred urbanization ■ Advanced a car-centred planning approach dominated urban and transport planning since post-Second World War ■ The car has become socially, culturally, economically, politically, ethically and environmentally ingrained in westernised countries ■ The very nature of urbanization enhances exposure to heat, air pollution, and radiation via street canyons, heat island effects, depleting green space ■ Given the global trends towards a more urbanised world population, impacts are forecasted to continue and intensify ■ The car has become socially, culturally, economically, politically, ethically and environmentally ingrained in westernised meaningful public transport system and a gradual abandonment of these urbanised areas ■ Reinforces policy focus on ‘economic centres of agglomeration’ ■ Fosters a self-reinforcing cycle of car dependence by creating a system of ‘auto- mobility’ ■ Auto -mobility systems – increased the fraction of the exposed population living and working in close proximity to highways and roads – decreased physical activity – and reduced the feasibility and convenience of active travel and of public transport provision ■ The very nature of urbanization enhances
  20. 20. Rapid and car-centred urbanization ■ Car-centred urbanisation increases the physical separation of activities and the need for motorized transport ■ Increased spatial separation of activities lowers urbanised population densities, and results in lower commuter numbers needed to support a meaningful public transport system and a gradual abandonment of these urbanised areas ■ Reinforces policy focus on ‘economic centres of agglomeration’ ■ Fosters a self-reinforcing cycle of car dependence by creating a system of ‘auto- mobility’
  21. 21. Rapid and car-centred urbanization ■ Auto -mobility systems – Increased the fraction of the exposed population living and working in close proximity to highways and roads – Decreased physical activity – Increased the need and convenience for motorized transport – and reduced the feasibility and convenience of active travel and of public transport provision
  22. 22. “The transport sector is susceptible to long term effect on design decisions. Urban form does not change as rapidly (or even at all) as building or roads are built or demolished, for example many roman road still exist in the landscape or still serve as roads” In regard to transport policy measures : “Why land use policy measures seem to receive the least attention whilst they could be most effective?” – “I agree with you! Is true, there are the most effective because there are the cause of the cause. But at the same time is the harder to be changed from a politician perspective, is a change of model. But is the most important and effective intervention”
  23. 23. Mass Motorization and Ethical Positions Towards Human Life ■ Increasing the number of vehicles and infrastructure priorities ■ Manifested most clearly in the substantial deaths due to MVC, and less clearly in the rise of chronic diseases related to traffic exposure and practices over the same periods that car traffic undergone large changes ■ Systems approach; such as the Vision Zero initiated by Sweden and Sustainable Safety in the Netherlands  based on an ethical position in which it is unacceptable to have people seriously injured or killed on the network ■ Transport infrastructure design is inherently conceived to drastically reduce crash risk ■ This clarity in policy and guidance may have led to a substantive influence for human life in the transport design agenda
  24. 24. The Car Lobby ■ Acknowledge car industry as a powerful and diffuse force in advocating for mass motorization through marketing strategies to increase uptake and maintenance of driving ■ Opposing measures that may reduce car use, e.g. fuel duty increases, reduction in parking supply, proposals for car-free zones, improvements in traffic safety and delayed EU emissions regulations ■ Little public support for measures to rectify the impact ■ The car industry with its economic reach to provide jobs including manufacturing, dealerships, hire companies, parking garages, motoring organizations, oil and gas companies, construction and engineering firms, insurance industry and others, make it difficult to regulate ■ It is moving into new markets in low and middle- income countries
  25. 25. Public Policy Favouring Car Mobility “For national and local policy makers, I suggest the following ranking of priorities in transport policy: (1) stimulate the economy by facilitating the smooth flow of goods and people, (2) ensure social equity by facilitating access to mobility for disadvantaged groups (especially via public transport), and (3) addressing negative externalities in the following order of importance: (a) congestion, because it has negative social and economic implications, (b) local ‘quality of life’ problems such as air pollution, parking and spatial problems, (c) safety (traffic deaths and injuries), and (d) environmental sustainability such as climate change. This externality ranking explains why most transport policy programs address congestion (via congestion charging, dynamic traffic management, and demand management)” (Geels 2012)
  26. 26. Public Policy Favouring Car Mobility ■ Historic strong association between economic development and an increase in the demand for transportation and number of road vehicles ■ Infrastructure banks and governmental agencies have funded road construction for several decades ■ Motorized mobility remains a criterion for measuring country-level economic success ■ Economic investment in roads is seen as an important determinant of economic growth ■ Traffic optimization and travel time savings remain the lead principles in transport planning ■ Technical-orientation in practice (mainly an engineering and economic focus) underestimate the negative externalities of transport infrastructure decisions ■ Even solutions supposedly aimed at alleviating car use such as transit and bus rapid transit are directly measured by travel time savings ■ Road investment strategies continue to support motor vehicle travel, thereby attracting more cars whereas considerably less is allocated to active and public transport modes or mobility management strategies
  27. 27. 100 major schemes funded by £15.2 billion of public money
  28. 28. The State of the Practice of Transport Appraisal ■ Cost Benefit Analysis (CBA) is the most commonly used instrument to determine whether a certain transport project is to be preferred over another ■ A project that has the highest positive monetary value, or the highest benefit to cost ratio is the preferred project by decision-makers ■ Monetized items include (changes in) travel times, consumer surplus, (changes in) employment, business activity and earnings, MVC, casualties, carbon and air quality emissions and noise impacts
  29. 29. The State of the Practice of Transport Appraisal ■ But many inherent limitations: – CBA accept transport users’ willingness-to-pay as an appropriate indicator factored in the calculations – CBA are embedded in an econometric ontology that associates lower economic benefits and costs to events taking place in the future due to economic depreciation rates. As a result, short-term economic benefits (e.g. higher accessibility to jobs, lower travel costs) are likely to be overvalued when measured against more complex and distant costs such as long-term environmental and health impacts – CBA assumes the outputs of transport planning models in the calculations – It is acceptable to consider the time savings for existing travellers that use the services of a new transport project as benefits. It also establishes that it is valid to sum time savings to the time spent by travellers that were induced to travel by the new project (induced demand) – CBA logic assumes that time savings are a benefit when time spent travelling can be positively valued by transport users, especially those using transit and active travel modes – Impacts on morbidity are not addressed
  30. 30. The State of the Practice of Transport Appraisal “Would it be the solution to conduct an overall appraisal/evaluation of a plan/intervention. Not just health or economic benefits, but as wide as possible? I guess that is the main problem at the moment that evaluations/appraisals are mostly done by domain”
  31. 31. Results from transport practitioners Economic Growth Travel Time Savings Cost Effectiveness Land-use Accessibility Noise Reductions Equality Providing for Cars Efficiency SafetySustainability Policy Integration Connectivity Economic Growth Travel Time Savings Cost Effectiveness Accessibility Carbon ReductionsNoise Reductions Equality Providing for Cars Efficiency Safety Policy Integration Connectivity Sustainability AirQuality
  32. 32. Public Perceptions and Awareness ■ Historically, societal acceptance and preference toward private car ownership was celebrated as a process of democratization fulfilling individual desires of flexibility and self-determination ■ It also symbolized the idea of freedom and independence as well as, power, superiority, and social status ■ Behind public perceptions are driving forces of this development such as “the leading industrial sectors and the iconic firms within 20th-century capitalism (Ford, GM, Rolls- Royce, Mercedes, Toyota, VW and so on), and the industry from which the definitive social science concepts of Fordism and Post-Fordism have emerged.” (Urry 2004) ■ These forces are behind a persistent car-mobility paradigm making car dependence a phenomenon that operates societally ■ Cultural norms reinforced by public policy and institutions that, although should represent the public interest and are oriented around sustainability tend to exercise power to protect special interests
  33. 33. ■ Health impacts of transport were not widely recognized until the 1990s ■ Lack of public awareness of these impacts, even those which have been receiving increasing media coverage such as air pollution; reinforce the lack of political commitment and initiative to address these problems
  34. 34. Results – A clear scoping of traffic-related health impacts (in urban areas)… – Understanding and discussing the underlying driving forces behind where we are now… – Is there a need for a new health- aware perspective in the transport/development agenda? – Examples of good practice and lessons learned from case studies – Consider stakeholders involved and make recommendations Where are we now? How did we get here? Where do we want to go? What will guide us? How will we get there?
  35. 35. Where do we want to go? ■ Mitigating or preventing adverse health impacts will have a long run benefit to society in terms of overall well-being, productivity, economic prosperity, reduction in healthcare costs  societal investments rather than societal costs ■ An integrated cross-disciplinary planning effort to move away from a car-based society to high quality and equitable public and active travel systems ■ More importance to health in the development and transport agenda ■ Knowledge transfer and collaboration in research, policy, and practice will play a fundamental role in promoting healthy transport practices
  36. 36. Results – A clear scoping of traffic-related health impacts (in urban areas)… – Understanding and discussing the underlying driving forces behind where we are now… – Is there a need for a new health- aware perspective in the transport/development agenda? – Examples of good practice and lessons learned from case studies – Consider stakeholders involved and make recommendations Where are we now? How did we get here? Where do we want to go? What will guide us? How will we get there?
  37. 37. What will guide us? ■ Example of good practice emerging from a collaborative and open-ended project bringing together expertise in health, environmental sciences, air pollution, transport planning, economics, practice and advocacy and policy making ■ HEAT aims at making the health benefits of regular cycling and walking visible to transport and urban planners ■ Whilst addressing the importance of CBA in transport design and planning decisions ■ The tool offers economic estimates of health benefits of walking and cycling by estimating the economic value of reduced mortality that results from specified amounts of walking or cycling in a defined population ■ Been used in research, policy making recommendations, advocacy and in practice ■ Was recommended in the official toolbox for transport investment appraisal (WebTAG) in England and in the Action Plan for Improving the health of Londoners by Transport for London
  38. 38. What will guide us? ■ iConnect study aimed at measuring and evaluating the changes in travel, physical activity and carbon emissions related to Sustrans' Connect2 programme ■ Connect2 an ambitious UK-wide project that transformed local travel in more than 80 communities creating new crossings and bridges to overcome barriers increasing physical activity ■ Initial funding for this programme came from a non- transport source, the UK Big Lottery Fund (£50 million), in which public vote demonstrating the huge amount of public support for this programme was essential ■ This funding was used to unlock other sources of funding necessary to complete the programme at an overall value of £175 million
  39. 39. What will guide us? ■ Bradford Metropolitan District Council recently undertaken a low emission zone feasibility study ■ Involved stakeholders, researchers and practitioners from different disciplines including transport planning, environmental sciences, public health and health economics alongside collaboration with other city councils in the West Yorkshire ■ The relative impact of several transport interventions scenarios beyond the ‘business as usual’ case were modelled ■ The impact that these scenarios may have on projected air quality concentrations, health of the local population and the costs and benefits associated with each intervention measure were calculated and presented ■ Was used to provide strong evidence in support of two funding bids at an approximate value of £1 million that aim at improving air quality in the region
  40. 40. Results – A clear scoping of traffic-related health impacts (in urban areas)… – Understanding and discussing the underlying driving forces behind where we are now… – Is there a need for a new health- aware perspective in the transport/development agenda? – Examples of good practice and lessons learned from case studies – Consider stakeholders involved and make recommendations Where are we now? How did we get here? Where do we want to go? What will guide us? How will we get there?
  41. 41. What action and from who? ■ No “one size fits all” approach and policy transfer is a highly politicised process justifying preferred solutions ■ Technological improvements are not it! Counter-productive in instances such as the failure of the massive technology change from petrol towards to mitigate climate change ■ Public transport and active travel provision and behavioural and societal transformations are needed ■ Active involvement and collaboration of engineers, planners, economists, epidemiologists, and medical providers to ensure health is at the top of the list of competing priorities
  42. 42. How will we get there? ■ Transport Engineers and Planners ■ Try and bridge the gap between design, planning, economics and health – Bring the health agenda to the table – Consider the health impacts of engineering and planning decisions as more explicit outcomes of the transport design and appraisal process – Expand transport planning curriculums beyond the functional quality of infrastructure – Engage more with the public – Consider health through transport design as an additional objective – Adopt tools and methods that would enable assessing health impacts of transport design and planning (e.g. Health Impact Assessment tools
  43. 43. How will we get there? ■ Health practioners – Improve understanding of the urban and transport planning agenda – Play a proactive role to include health as a transport project objective – Advocate for effective policies that encourage active travel and reduce car use – Partner with urban and transport planners from the start of design and planning process to ensure that health is a recognized objective – Support transport engineers and planners in conducting health impact assessments for possible transport scenarios – Develop innovative and usable health economic assessment tools to be added to existing or novel transport design and planning tools
  44. 44. How will we get there? ■ Researchers – Start appraising tools that are being used in transport planning to provide a holistic point of view in regards to impacts on health – Advocate for co-production and cross-disciplinary work – Increasing the outreach and communication between the research community and transport practitioners, local governmental entities and the public constituency – Epidemiologists and health researchers can contribute to resolving open scientific issues and improving the evidence base for health impact assessment – Follow-up to how policy guidance/recommendations will be interpreted or altered – Increase public outreach and awareness of health impacts of transport choices and practices
  45. 45. How will we get there? ■ Policy makers – Include long-term health impacts that are difficult to grasp or measure on the short term – Reallocate funding streams at the policy level to include health impact assessment – Expand CBA and similar appraisal methods – Set operational goals and indicators in a transparent and non-sectorial manner – Have strict legislation for integrated transport planning with land-use – Clear policy and guidance to transport professionals to include health in the development and transport agenda “This is difficult to ask to people who are already under pressure to do their job as fast as possible and whose boss does not recognise the importance of integrating health impact”
  46. 46. Changing perspectives? ■ “Economic investment in roads is seen as an important determinant of economic growth. It is important to break this cycle and think about economic development rather than growth” ■ “It might be worth a quick thought experiment around what a health oriented approach to transport planning might look like. Stated differently, from an engineer’s perspective, accounting for black spots and reducing fatalities is health. From an urban designer perspective, designing places for human interaction is health. From an urban planning perspective (at least land use), separating land uses like residential from commercial or industry (like pig slaughter houses) is health. As such, contemporary urban planning reflects a variety of different perspectives and aims, which are often tied to specific pots of monies and constrained and constituted via specific professional remit and duties” ■ “As my focus is more on design, I don’t think I’m the best person to contribute to the sections about policy. In my role as policy advisor for the ministry I am of course involved in policy, but this papers helps me realize how lucky road safety experts are” ■ “Neoliberalism and CBAs as wrong instruments at two levels: technical and fundamental” ■ “Yes CBAs are based on reducing travel time see article you sent me. While increasing travel time may be beneficial in case of active transportation”
  47. 47. Conclusions “Citing Frank and Engelke's 2001 literature review, the very first sentence in Northridge et al. (2003) article is "While it has been stated before, it nonetheless bears repeating that the connections between urban planning and public health are not new. Clearly, though such connections are not new, they have been inadequate to generate consensus towards a more sustainable, healthy and ethical urban and transport systems. There is probably several articles you can point to which have sought to make similar points and cross disciplinary boundaries. That being said, whereas such examples evidence Karen's point, I remain unconvinced they evidence practice. There remains a gap between the academic and professional circles. Again, this is not to pick on professionals or civil servants, who for the most part do or at least strive to do a good job, but if things were different, you wouldn't have a paper. They're aren't different, and thus, you still have valid points and a paper”
  48. 48. A few learning experiences ■ “The big questions will only be answered by cooperation of multiple disciplines” ■ “Transport and Health seem to have quite different histories, experiences and (vested) interests and we need to develop a common narrative and close collaboration to tackle the transport and health problems” ■ “Collaboratively writing this paper helps me to put my own discipline (road safety in my case) in the broader context of health. For instance, some safety measures are helpful for road safety only while other measures contribute to other health benefits as well. This stimulates thinking” ■ “The one major lesson learnt is that although health has made significant advances in demonstrating effects from car-oriented planning (which I was not aware of), such work has yet to contribute to a more evidence-based approach to urban policy and practice” ■ “Collaborative efforts of both sectors are needed to provide healthy and sustainable transport policies” ■ “…How to combine both interest in a sustainable manner will be the challenge of the near future”
  49. 49. A few learning experiences? ■ “It will take a lot of time and effort to develop principles for designing the road system that are helpful for all important health aspects. And even more difficult (or impossible), principles that work in different contexts. Having such principles (e.g. the Sustainable Safety principles in the Netherlands) were extremely helpful for road safety policy. It would be great to have such principles for transport and health in general. It seems we have a long way to go to develop such principles” ■ “What a pleasant surprise to realise we were so many, with so different backgrounds, thinking that health should be taken into account while planning transport systems. Joining our forces is definitely a promising avenue towards a more integrated way of thinking transport issues”

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