Health, Equity and the Built Environment: What do Healthy Communities Look Like?


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Presentation by Howard Frumkin, MD, MPH, DrPH at the 2009 Virginia Health Equity Conference.

Focusing on how inequities in the built environment – places where we work, live and play; transportation; food; and parks and green spaces - impact health, Dr. Frumkin described the dimensions of healthy communities and community design principles and the opportunities for effective interventions. He described the work of the Centers for Disease Control and Prevention in promoting health equity through healthy places. He also gave examples of communities that are advancing health equity through healthy places.

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  • Changes in land use from farm, field, and forest to residential.
  • Individual lots can be very large.
  • Same here—monotony and isolation. Wherever you want to go, you have to go by car.
  • Low connectivity.
  • Friedman MS, Powell KE, Hutwagner L, Graham LM, Teague WG. Impact of changes in transportation and commuting behaviors during the 1996 summer Olympic games in Atlanta on air quality and childhood asthma. JAMA 2001;285:897-905
  • Ewing R, Schieber R, Zegeer C. Urban sprawl as a risk factor in motor vehicle occupant and pedestrian facilities  Am J Public Health 2003;93:1541-45. Sivak M. Is the U.S. on the Path to the Lowest Motor Vehicle Fatalities in Decades? University of Michigan Transportation Research Institute Report # UMTRI-2008-39, July 2008. Available:
  • Public Street Improvements and Infill Development COLFAX AVENUE, DENVER, COLORADO: Done in association with Space Analytics, LLC for Colfax on the Hill, Inc., funded in part by the Denver Foundation 1 - Existing conditions 2 - Mixed-use buildings on one corner 3 - Public street improvements: street trees, street lamps, decorative traffic signals, sidewalk bulbouts 4 - Additional mixed-use development, remodeling of existing buildings
  • Infill Development on declining shopping center EL CERRITO, CALIFORNIA: Done to demonstrate infill development potential on shopping center site. 1 - existing conditions 2 - Additional Stores built up to the street , Mixed-use architecture (office space above retail), zebra-striped crosswalks, street trees, street lamps added 3 - Mixed-use architecture (residential added above office space) 4 - Additional infill accommodates pedestrians and improves visibility for merchants
  • Traffic Calming on Neighborhood Street NAPLES PARK, FLORIDA: Done with Dover, Kohl & Partners and Glatting Jackson, Inc. to demonstrate traffic calming techniques for Collier County, Florida 1 - existing conditions 2 - Neighborhood traffic circle added, sidewalks and zebra-stripped crosswalks added, landscaped with palm trees OR 3 - landscaped with shade trees
  • Health, Equity and the Built Environment: What do Healthy Communities Look Like?

    1. 1. 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
    2. 2. The sense of place
    3. 3. What is the “Built Environment”? <ul><li>Where people live, work, play, and study </li></ul><ul><li>From the small scale… </li></ul><ul><ul><li>Homes, schools, workplaces </li></ul></ul><ul><li>To the intermediate scale… </li></ul><ul><ul><li>Neighborhoods, parks </li></ul></ul><ul><li>To the large scale </li></ul><ul><ul><li>Metro areas, transportation systems </li></ul></ul>
    4. 4. Ten Leading Causes of Deaths, US (2004) Affected by the Built Environment
    5. 5. Agenda <ul><li>Housing </li></ul><ul><li>Schools </li></ul><ul><li>Parks </li></ul><ul><li>Neighborhoods </li></ul><ul><li>Transportation </li></ul><ul><li>Equity </li></ul><ul><li>Evidence-based decisions </li></ul><ul><li>The broader context </li></ul><ul><li>The need for long-term thinking </li></ul><ul><li>The opportunity of co-benefits </li></ul>
    6. 6. Healthy housing
    7. 7. Housing hazards <ul><li>Rodents </li></ul><ul><li>Insects </li></ul><ul><li>Mold </li></ul><ul><li>Poor infrastructure </li></ul><ul><li>Proximity to waste sites </li></ul><ul><li>Indoor air pollution </li></ul><ul><li>Crowding </li></ul><ul><li>Lead </li></ul><ul><li>Injuries </li></ul>
    8. 9. Housing disparities <ul><li>Shortage of affordable housing </li></ul><ul><li>Substandard housing </li></ul>
    9. 10. Selected substandard housing conditions 2005 American Housing Survey Tables 2-2 (Height and Condition of Buildings) and 2-7 (Additional Indicators of Housing Quality) and PER CENT
    10. 11. Trailers <ul><li>Long-term housing: </li></ul><ul><ul><li>8.7 million units </li></ul></ul><ul><ul><li>17.2 million people </li></ul></ul><ul><li>Post-disaster housing </li></ul><ul><li>Classrooms and workplaces </li></ul>
    11. 12. Opportunities for housing
    12. 13. Solutions: Healthy housing <ul><li>Sufficient affordable housing </li></ul><ul><li>Control hazards </li></ul><ul><ul><li>Removal of lead paint </li></ul></ul><ul><ul><li>Mitigation of rodents, insects, mold </li></ul></ul><ul><li>“Green” housing </li></ul><ul><li>Research </li></ul>
    13. 14. <ul><li>Indoor air quality </li></ul><ul><li>Chemical hazards </li></ul><ul><li>Cleaning materials </li></ul><ul><li>Lighting </li></ul><ul><li>Animals </li></ul><ul><li>Safe playgrounds </li></ul><ul><li>School travel </li></ul><ul><li>“ Food environment” </li></ul>Healthy schools
    14. 15. Active transport to school, 1969 and 2001 Source: CDC.  Kids Walk-to-School: Then and Now—Barriers and Solutions.
    15. 16. Two approaches to school siting Hubbard Lake Elementary School Hubbard Lake, Michigan &quot;Outstanding in Its Field&quot;
    16. 17. Safe Routes to School
    17. 18. The “food environment” at school
    18. 19. Fast food near schools <ul><li>Median distance from any Chicago school to nearest fast-food restaurant: 0.52 km </li></ul><ul><li>78% of schools had at least 1 fast-food restaurant within 800 m </li></ul><ul><li>Fast-food restaurants clustered near schools (3-4X as many as expected) </li></ul>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.
    19. 20. Solutions: Healthy schools <ul><li>Healthy school facilities: lighting, indoor air quality, cleaning procedures, chemicals, etc. </li></ul><ul><li>Crime Prevention Through Environmental Design (CPTED) </li></ul><ul><li>Safe playgrounds and sports fields </li></ul><ul><li>Healthy cafeteria food </li></ul><ul><li>Safe Routes to School </li></ul><ul><li>Collaboration </li></ul><ul><ul><li>Health, environment, park & rec agencies, education agencies (including Boards of Education), parent groups, teacher groups </li></ul></ul>
    20. 21. Parks and greenspace
    21. 24. Community gardens
    22. 25. Park proximity and health Large urban parks, Copenhagen, summer <ul><li>Access to greenspace associated with: </li></ul><ul><ul><li>Lower level of self-reported stress </li></ul></ul><ul><ul><li>Lower risk of obesity </li></ul></ul><ul><li>This relationship not fully explained by the number of visits to greenspace </li></ul>Nielsen and Hansen, Health & Place 2007
    23. 26. Neighborhood greenness and childhood weight gain <ul><li>3800 inner-city children (3-18) followed over 2 years </li></ul><ul><li>Neighborhood greenness assessed using satellite photos </li></ul><ul><li>Controlled for age, race, sex, residential density. </li></ul><ul><li>Findings: Greener neighborhoods associated with slower increases in body mass </li></ul>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.
    24. 27. Trees and urban Life
    25. 30. Robert Taylor Homes interview study <ul><li>Interview study compared people in buildings with and without nearby trees </li></ul><ul><li>Nearby trees strongly predicted: </li></ul><ul><ul><li>Knowing and greeting neighbors </li></ul></ul><ul><ul><li>Acknowledging and helping neighbors </li></ul></ul><ul><ul><li>Less psychological aggression </li></ul></ul><ul><ul><li>Less violent behavior </li></ul></ul>University of Illinois William Sullivan, Frances Kuo Images courtesy of W. Sullivan
    26. 31. Places to explore and play
    27. 32. Play in natural settings
    28. 33. Getting kids outdoors
    29. 34. Arabia Mountain Trail, Georgia
    30. 35. Solutions: Parks and greenspace <ul><li>More parks / greenspace in all communities </li></ul><ul><li>Adequate maintenance and law enforcement </li></ul><ul><li>Culturally appropriate, safe, fun recreational activities for residents of all ages </li></ul><ul><li>Collaboration </li></ul><ul><ul><li>Public health, environment, natural resource, park & rec agencies, community groups, private sector </li></ul></ul>
    31. 36. Neighborhood design
    32. 41. Squalor and blight
    33. 43. Squalor and Blight in the American Housing Survey (2005) <ul><li>Homes that had, within 300 feet… </li></ul><ul><li>Other buildings vandalized or with interior exposed ( ~ 5%) </li></ul><ul><li>Bars on windows of buildings ( ~7%) </li></ul><ul><li>Major street repairs needed (~6%) </li></ul><ul><li>Trash, litter, or junk on streets or properties </li></ul><ul><ul><li>major accumulation ( ~ 2.5% ) </li></ul></ul><ul><ul><li>major accumulation ( ~ 6% ) </li></ul></ul>
    34. 44. The Broken Windows Theory <ul><li>Theory that broken windows beget broken windows (Wilson & Kelling 1982) </li></ul><ul><li>Empirical links to health: “Broken windows index” predicts gonorrhea incidence (Cohen et al. 2000) </li></ul>
    35. 45. Gentrification
    36. 46. American Journal of Psychiatry 1996;153:1516-23/
    37. 47. Solutions: Healthy community design <ul><li>Healthy community design </li></ul><ul><ul><li>Density </li></ul></ul><ul><ul><li>Mixed land use </li></ul></ul><ul><ul><li>Activity centers </li></ul></ul><ul><ul><li>Housing diversity </li></ul></ul><ul><li>Placement of food stores, medical clinics, other essential services </li></ul><ul><li>Social policy to address gentrification </li></ul><ul><li>Collaboration </li></ul><ul><ul><li>Public health, housing, community groups </li></ul></ul>
    38. 48. Transportation
    39. 50. Pedestrian infrastructure
    40. 58. Pharmacies
    41. 59. Dry Cleaners
    42. 60. Fine Food
    43. 61. Coffee
    44. 62. Tunnel of Vows Drive-Thru Wedding Chapel Las Vegas, NV
    45. 63. Funerals Gardner Memorial Chapel Davidson, TN Junior Funeral Home Pensacola, FL Adams Funeral Parlor Compton, CA
    46. 64. The next frontier of drive-thru: Health care?
    47. 66. Parking
    48. 67. ?
    49. 68. April 22, 2003 The result
    50. 70. Factors that predict walking <ul><li>Good trails and sidewalks </li></ul><ul><li>Nearby destinations </li></ul><ul><li>Greenery </li></ul><ul><li>Other people walking </li></ul><ul><li>Safety </li></ul>
    51. 71. 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%
    52. 72. Less driving, fewer fatalities Ewing et al. Am J Public Health 2003;93:1541-45 Sivak. UMTRI-2008-39, July 2008
    53. 73. Transit and physical activity <ul><li>Transit users walk a median of 19 minutes daily to and from transit </li></ul><ul><li>29% exceed 30 minutes of physical activity daily </li></ul><ul><li>Besser and Dannenberg, Am J Prev Med 2005 </li></ul>
    54. 74. Transportation equity
    55. 75. Solutions: Healthy transportation <ul><li>Healthy transportation policy </li></ul><ul><ul><li>Transit </li></ul></ul><ul><ul><li>Pedestrian / bicycle infrastructure </li></ul></ul><ul><li>Transportation equity </li></ul><ul><li>Collaboration </li></ul><ul><ul><li>Public health and transportation agencies, community groups, bike/ped advocates, elderly advocates, elected officials </li></ul></ul>
    56. 76. Summary <ul><li>Housing </li></ul><ul><li>Schools </li></ul><ul><li>Parks </li></ul><ul><li>Neighborhoods </li></ul><ul><li>Transportation </li></ul><ul><li>Evidence-based decisions </li></ul><ul><li>Equity </li></ul><ul><li>The broader context </li></ul><ul><li>The need for long-term thinking </li></ul><ul><li>The opportunity of co-benefits </li></ul>
    57. 77. Complexity Reality (simplified)
    58. 78. Climate change
    59. 79. Peak petroleum Source: Hubbert, 1956
    60. 80. Resource depletion
    61. 81. The courage to paddle upstream
    62. 84. Health Impact Assessment
    63. 85. Beyond the short term Hau de no sau nee (the Six Nations Iroquois Confederacy): planning for the seventh generation
    64. 86. Care for the individual patient Care for the community Care for future generations THE CLINICAL APPROACH THE PUBLIC HEALTH APPROACH THE LEGACY APPROACH
    65. 87. Promoting co-benefits
    66. 88. Co-benefits: Trees <ul><li>Carbon sequestration </li></ul><ul><li>Cooler temperatures </li></ul><ul><li>Reduced energy demand </li></ul><ul><li>Clean water </li></ul><ul><li>Clean air </li></ul><ul><li>Protection from sunlight </li></ul><ul><li>Venues for physical activity </li></ul><ul><li>Noise reduction </li></ul><ul><li>Mental health </li></ul><ul><li>Spiritual fulfillment </li></ul>
    67. 89. Co-benefits: Food and nutrition
    68. 90. Co-benefits: Transportation  Physical activity  Air pollution And by the way…  Infrastructure costs  Social capital  CO 2 emissions  Depression  Injuries  Osteoporosis
    69. 91. Envisioning Change
    70. 95. Conclusions <ul><li>In a nation with pressing health problems, </li></ul><ul><li>in a nation with persistent health disparities, </li></ul><ul><li>in a nation with emerging environmental and resource challenges… </li></ul><ul><li>we can and must build safe, healthy, sustainable, and attractive communities for all people, </li></ul><ul><li>today and in future generations. </li></ul>
    71. 96. Thank you!