Healthy Cities: How the Design of Our Built Environment Can Support Human Health and Sustainability

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1 Healthy Cities: How the Design of Our Built Environment Can Support Human Health and Sustainability Andrew L. Dannenberg, MD, MPH Affiliate Professor, University of Washington, Seattle Dept. of Environmental and Occupational Health Sciences Dept. of Urban Design and Planning NZ Centre for Sustainable Cities, Department of Public Health University of Otago, Wellington 15 November 2013

2 Some Choices

3 What is Health? a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity World Health Organization Physical health Mental health Well-being Livability

4 Factors that Affect Health Smallest Impact Education Clinical Interventions Largest Impact Long-lasting Protective Interventions Changing the Context to make individuals default decisions healthy: BUILT ENVIRONMENT Socio-Economic Factors Frieden, AJPH, 100:590, 2010

5 Community Design and Health Related to land use Related to automobile dependency Related to social processes Obesity, physical activity, CVD Water quantity and quality Access to healthy food Air pollution and asthma Climate change contribution Car crashes Pedestrian injuries Mental health impact Social capital Environmental justice

Physical Activity A sedentary lifestyle increases the risk of overall mortality (2 to 3-fold) cardiovascular disease (3 to 5-fold) some types of cancer, including colon and

6 Physical Activity A sedentary lifestyle increases the risk of overall mortality (2 to 3-fold) cardiovascular disease (3 to 5-fold) some types of cancer, including colon and breast cancer The effect of low physical fitness is comparable to that of hypertension, high cholesterol, diabetes, and even smoking. Wei et al., JAMA 1999; Blair et al., JAMA 1996

Determinants of Physical Activity More likely to exercise if: Walking trails, parks and gyms accessible Sidewalks present and scenery enjoyable Many people exercising Friends available with whom to

7 Determinants of Physical Activity More likely to exercise if: Walking trails, parks and gyms accessible Sidewalks present and scenery enjoyable Many people exercising Friends available with whom to exercise Less likely to exercise if: Too little time Too tired Unmotivated Perceived traffic, crime or danger Long distance to exercise location Source: Brownson RC et al, AJPH 91:1995, 2001 HealthStyles Survey, 1999

8 Obesity Increasing weight is associated with: risk of overall mortality risk of cardiovascular mortality risk of gall bladder disease risk of diabetes risk of hypertension Willett et al, NEJM, 1999; JAMA, 282: 1523.

Unintended Costs of Epidemic of Obesity Mean weight gain of Americans in 1990s: 10 pounds Airline distance flown in 2000 in US: 515 billion passenger-miles Weight transported 1 mile by 1 gallon of

9 Unintended Costs of Epidemic of Obesity Mean weight gain of Americans in 1990s: 10 pounds Airline distance flown in 2000 in US: 515 billion passenger-miles Weight transported 1 mile by 1 gallon of fuel: 7.3 tons (passengers or cargo) Jet fuel to transport added weight in 2000: 350 million gallons Cost of extra fuel: $275 million CO 2 emissions from extra fuel: 3.8 million tons Data sources: NCHS; US Dept. of Transportation

10 Obesity Trends Among U.S. Adults Behavioral Risk Factor Surveillance System (BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

11 Obesity Trends among Australian Adults 1995 National Nutrition Survey and National Health Survey Australia Bureau of Statistics

12 Walkable Community Designs: Connectivity and Physical Activity Suburban Development Traditional Neighborhood Drawing by Duany Plater Zyberk, in ITE Journal 1989;59:17-18

14 Durham, NC

15 Transportation Design to Discourage Physical Activity

16 Transportation Design to Encourage Physical Activity Cooper River Bridge, Charleston, SC

17 Access to Parks

19 Transportation Planning and Land Use Choices Source: Atlanta Journal-Constitution, March 10, 2006

20 Percent Fatalities Walking and Bicycling: International Comparisons Percent of trips by walking and biking, USA 7 Germany 34 Netherlands 46 Pedestrian fatalities per 100 million trips, USA 17 Germany 5.2 Netherlands 1.1 Pucher, AJPH 93:1509,2003

21 12,500 Increasing Bicycle Use, Portland, OR Cyclists Per Day Bikeway Miles ,000 Bridge Bicycle Traffic Bikeway Miles ,500 5,000 2, : 78 miles of bikeways 2,850 daily trips 2006: 263 miles of bikeways 11,956 daily trips Year: Bridge Bicycle Traffic 2,850 3,555 3,885 3,830 3,207 4,520 5,225 5,690 5,910 6,015 7,686 8,250 8,562 8,875 10,192 11,956 Bikeway Miles

$388-$594 million Fuel savings of $143-$218 million Benefit-cost ratios are

22 Costs and Benefits of Bicycling Investments in Portland, Oregon By 2040, investments of $138-$605 million will result in: Health care cost savings of $388-$594 million Fuel savings of $143-$218 million Benefit-cost ratios are between 3.8 and 1.2 to 1 Gotschi T. J Phys Activ Health 2011, 8(Suppl 1), S49-S58

23 Total and Per-Capita Vehicle-Miles Traveled, United States,

25 Children Walking to School Parental reported barriers to walking/biking to school: 55% distance, 40% traffic danger Source: MMWR 2002;51(32):

26 Hubbard Lake Elementary School Hubbard Lake, Michigan "Outstanding in Its Field"

27 Safe Routes to Schools Benefits for the Larger Community Watson M, Dannenberg AL. Preventing Chronic Disease. July 2008; 5(3):A90

Asthma and Air Pollution Natural experiment during 1996 Summer Olympic games in Atlanta Peak morning traffic decreased 23% and peak ozone levels decreased 28%

28 Asthma and Air Pollution Natural experiment during 1996 Summer Olympic games in Atlanta Peak morning traffic decreased 23% and peak ozone levels decreased 28% Asthma-related emergency room visits by children decreased 42% Children s emergency visits for non-asthma causes did not change during same period Friedman et al. JAMA 2001;285:897

29 Water Quality Water run-off from roads and parking lots can pollute water supplies with possible impact on human health Increased erosion and stream siltation causes environmental damage and may affect water treatment plants

30 Deaths and Injuries to Motor Vehicle Occupants and Pedestrians Leading cause of deaths among persons 1-34 years old Annual toll from motor vehicle crashes in United States: 34,000 deaths 2.4 million nonfatal injuries $100 billion in costs Sources: NHTSA 2010; USDOT 2008; Naumann 2010

31 Mental Health Issues that may Relate to Community Design Depression Relieved by physical activity and social interaction Stress Aggravated by long commutes Attention Deficit-Hyperactivity Disorder Greenspace may improve function in ADHD Violent Behavior Impulse Control Example: road rage

32 Social Capital Defined as social networking, civic engagement, trust and reciprocity Decreased by long commutes

33 Building Social Capital Sunflower drawn in Portland OR intersection Sidewalk conversations, photos, pause to admire, and reading signs increased to 32% of users vs. 7% in similar unimproved intersection Semenza J, AJPH 93:1439, 2003

34 Community Design and Income Inequality

35 Community Design and Income Inequality

LIFE EXPECTANCY by community area: Baltimore City, Maryland, 2002

36 LIFE EXPECTANCY by community area: Baltimore City, Maryland, average Roland Park: 83 years Hollins Market: 63 years

37 Design Principles to Address Climate Change Transportation alternatives Density Mixed land use Parks and green spaces Energy efficient buildings

38 Smart Growth is Likely to Feature: Higher density, more contiguous development Preserved green spaces Mixed land uses with walkable neighborhoods Limited road construction, balanced by transportation alternatives Architectural heterogeneity Economic and racial heterogeneity Development and capital investment balanced between central city and periphery Effective, coordinated regional planning

39 SMART GROWTH good for Obesity! Heart disease! Cancer! Depression! Diabetes! Gall bladder! Social life!

40 What Smart Growth Is And Is Not More transportation choices and less traffic Not against cars and roads Vibrant cities, suburbs, and towns Not anti-suburban Wider variety of housing choices Well-planned growth that improves quality-of-life Not about telling people where or how to live Not against growth Slide credit:

41 Envisioning Change

Oregon state law: Footpaths and bicycle trails shall be provided

42 Complete Streets Definition: a safe, comfortable and convenient route designed for travel via automobile, foot, bicycle, and transit. Oregon state law: Footpaths and bicycle trails shall be provided wherever a highway, road or street is being constructed, reconstructed, or relocated.

43 LEED for Neighborhood Development LEED-ND Rating System Integrates the principles of smart growth, urbanism, public health, and green building into the first national standard for neighborhood design

44 Some Health Benefits of LEED-ND Reduce risk of obesity, heart disease, and diabetes by community design where it is safe and enjoyable to walk and bike to destinations Reduce risk of asthma and motor vehicle-related injuries by community design that is less dependent on automobiles. Increase social capital and sense of community cohesion by community design with comfortable street environments, parks, and active open spaces

45 Some Health Benefits of LEED-ND (cont.) Improve mental health by mixed-use community design that facilitates shorter commuting time and more family and recreational time Encourage healthier diets by design that promotes community-based and local food production, such as farmers markets and community gardens Dockside Green, Victoria, Canada Platinum-level LEED-ND certified

47 Walkscore can be Added to Real Estate Listings to Assist Homebuyer Decisions Walkscore 0-10 Few destinations Walkscore Many destinations

$20,000/cubicle Sources: Industry data (www.vtpi.

48 Which do we value more: Employees or their cars? 180 sq ft/space Size 100 sq ft/cubicle $15,000/space Cost $20,000/cubicle Sources: Industry data ( and Buildings and Facilities Office, CDC; costs exclude land

49 Health Impact Assessment A tool to increase partnerships and communication between public health professionals and planners and other decision-makers

50 Health Impact Assessment Definition HIA is a systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. HIA provides recommendations on monitoring and managing those effects. National Academies Committee on HIA, 2011

51 A Vision of Health Impact Assessment Planners and others will request information on potential health consequences of projects and policies as part of their decision-making process Health officials will have a tool to facilitate their involvement in planning and land use decisions HIAs will lead to a better informed decisions

52 Steps in Conducting an HIA Screening Identify projects/policies for which HIA useful Scoping Identify which health impacts to include Assessment Identify how many and which people may be affected Assess how they may be affected Recommendations Identify changes to promote health or mitigate harm Reporting of results to decision-makers Evaluation of impact of HIA on decision process

53 Voluntary vs. Regulatory Approach to Using an HIA Voluntary (a tool used by a health officer to inform a planning agency) Simpler, less expensive, less litigious Less likely to be used if not required More politically acceptable Regulatory (modeled on a required environmental impact statement) More complex, more expensive, more litigious More likely to be used if required May be less politically acceptable

54 HIA Level of Complexity Qualitative describe direction but not magnitude of predicted results Easy to predict; hard to use in cost/benefit models Example: Build a sidewalk and people will walk more Quantitative describe direction and magnitude of predicted results Difficult to obtain data; useful for cost/benefit models Hypothetical example: Build a sidewalk and 300 people who live within 200 yards of location will walk an average of 15 extra minutes per day

Public Transit and Physical Activity Transit users walk a median of 19 minutes daily to and from transit 29% of transit users exceed 30 minutes of

55 Public Transit and Physical Activity Transit users walk a median of 19 minutes daily to and from transit 29% of transit users exceed 30 minutes of walking daily to and from transit USDOT 2001 National Household Travel Survey; 3312 transit users Besser LM, Dannenberg AL Amer J Prev Med 29:273, 2005

56 Community Involvement in Conducting an HIA Increases community buy-in to project Helps identify social issues as well as health issues Routinely used in EIA process Commonly used in HIAs in Europe May add to time and resources needed to conduct HIA

57 Impact of HIA on Subsequent Decisions in HIAs in U.S. Documentable impacts were evident for some HIAs Plan improvements to increase pedestrian safety Change in redevelopment plans to provide 1:1 housing replacement for affected families Noise mitigation measures required Living wage ordinance adopted Urban road corridor plans improved Most HIAs raised awareness of health issues for some audiences

OR 21 CA 63 WA 9 AZ 2 AK 18 Completed and In Progress HIAs United States, 1999-2013 (N = 241) MT 2 CO 6 NM 3 NE 3 KS 2 TX 5 MN 12 MO 4 WI 8 IL 4 IN 3 MI 8

58 OR 21 CA 63 WA 9 AZ 2 AK 18 Completed and In Progress HIAs United States, (N = 241) MT 2 CO 6 NM 3 NE 3 KS 2 TX 5 MN 12 MO 4 WI 8 IL 4 IN 3 MI 8 TN 3 OH 8 KY 3 GA 7 SC 2 FL 2 PA 2 VA 1 NC 7 ME 2 NY 1 NJ 1 MD 5 NH 3 MA 11 CT 3 DC 1 DE 1 Federal HIAs: 5 Puerto Rico: 1 HI 1 Source: Health Impact Project

59 HIAs of Projects and Policies Housing redevelopment Highway corridor redevelopment Pedestrian/bicycle trail development Highway bridge replacement Transit line Community transportation plan Local area and comprehensive plans After-school programs Living wage ordinance Paid sick leave policy Coal-fired power plant Low income home energy subsidies Oil and gas leasing policies

60 HIA of Los Angeles Football Stadium 60 Context Farmers Field, 72,000-seat football stadium in downtown LA. Local community organizations (LA CAN, LAFLA, PSR-LA) work with HIP to conduct an HIA on stadium proposal. Analysis Issues being ignored by existing analyses: gentrification, displacement; employment; housing; public safety; access to open space. Rapid HIA conducted within 45 day comment period; responding to 10,000 page environmental document Outcomes HIA used in campaign that secured: $15 million for affordable housing; $5 million for parks/open space, neighborhood improvement plans, funding for a community team to promote health and protect tenant rights in the area; and local hiring commitments Media campaign brought attention to issues addressed in the HIA Residents from surrounding neighborhoods highly engaged

Health: HEALTH AND SUSTAINABILITY a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity CO-BENEFITS

Health Sustainability: harvesting or using a resource so that the resource is not depleted or permanently damaged -Merriam Webster Sustainable development:

61 Health: HEALTH AND SUSTAINABILITY a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity CO-BENEFITS -WHO Constitution Public health: what we, as a society, do collectively to assure the conditions in which people can be healthy - IOM, The Future of Public Health Sustainability: harvesting or using a resource so that the resource is not depleted or permanently damaged -Merriam Webster Sustainable development: development that meets the needs of the present without compromising the ability of future generations to meet their own needs - WCED "Our Common Future"

62 Green, Sustainable and Healthy Actions Unplug unused electronics Recycle newspapers Install solar panels Build and use walking and biking infrastructure Use non-toxic cleaners Take the stairs Plant trees Buy locally grown organic food Get regular exercise Get adequate sleep Eat a low-salt diet Green and Sustainable Healthy

Buildings Green design; energy efficiency; on-site energy generation; nontoxic materials; daylighting Climate benefits carbon footprint Other environmental benefits Raw

63 Buildings Green design; energy efficiency; on-site energy generation; nontoxic materials; daylighting Climate benefits carbon footprint Other environmental benefits Raw material conservation air pollution Urban stormwater management Health benefits toxic exposures Improved indoor air quality comfort Routine physical activity Natural lighting

64 Transportation Increased active transport and transit; safer, more efficient vehicles Climate benefits CO 2 emissions Other environmental benefits air pollution resource use Health benefits physical activity air pollution motor vehicle related injuries social capital

Urban design Compact, mixed use, walkable, vibrant neighborhoods; adequate affordable housing; access to fresh food Climate benefits CO 2 emissions Other

65 Urban design Compact, mixed use, walkable, vibrant neighborhoods; adequate affordable housing; access to fresh food Climate benefits CO 2 emissions Other environmental benefits resource use land use water use regional air pollution Health benefits physical activity social capital motor vehicle related injuries

Climate benefits Carbon sequestration Habitat resiliency Other environmental benefits Biodiversity Energy and material flows Nature Conservation and restoration of ecosystems;

66 Climate benefits Carbon sequestration Habitat resiliency Other environmental benefits Biodiversity Energy and material flows Nature Conservation and restoration of ecosystems; accessible parks and greenspace Health benefits Protection from disasters Recreation Venues for physical activity Psychological benefits Increased appeal of urban living Other ecosystem services

benefits air pollution waste streams landscape destruction Health benefits

67 Energy Shift from fossil fuels to renewables; efficiency; conservation; distributed generation Climate benefits CO 2 emissions Other environmental benefits air pollution waste streams landscape destruction Health benefits respiratory and cardiovascular disease occupational injury/illness toxic exposure (e.g. mercury)

deforestation Reduced fuel use in transportation Other environmental benefits Soil

68 Food and agriculture Local production; organic farming; sustainable intensification; climate-tolerant crops; eating lower on food chain Climate benefits Reduced deforestation Reduced fuel use in transportation Other environmental benefits Soil conservation Water conservation pesticide use Health benefits cardiovascular disease cancer pesticide exposure

awareness Other environmental benefits More efficient recovery Health

69 Preparedness Resiliency; surveillance and other public health infrastructure; coordinated response; resources for recovery Climate benefits public awareness Other environmental benefits More efficient recovery Health benefits morbidity & mortality in disasters social capital Strengthened public health capacity

70 Selected Policies and Tools to Promote Healthy Community Design Complete streets Transport funding Urban growth boundary Joint use policies School siting Rail to trail conversion Unbundling parking Bike share programs LEED-ND Walk/bike friendly cities Active Design Guidelines NYC WalkScore and realty listings Health impact assessment, checklists Multi-modal level of service Safe Routes to Schools Safe routes to transit, parks, etc Health element in comprehensive plans Retrofit failed suburban shopping mall Health in All Policies approach Joint Planning/Public Health degrees

71 Making Healthy Places: Designing and Building for Health, Well-Being, and Sustainability Andrew Dannenberg, MD, MPH Howard Frumkin, MD, DrPH Richard Jackson, MD, MPH Island Press, 2011

72 Community design and transportation choices can promote or harm human health

Incorporating Health Impact Assessment into Community Design & Transportation Decisions

Incorporating Health Impact Assessment into Community Design & Transportation Decisions Andrew L. Dannenberg, MD, MPH National Center for Environmental Health Centers for Disease Control and Prevention