By Rachel Beck
We don’t always pay attention to the streets, offices, homes, parks, and schools we spend time in every day, but they impact our health in a myriad of ways. Safe streets and access to nature affect a person’s level of physical activity and sense of social inclusion, which can decrease risk for chronic disease and boost mental wellbeing. Today, rapidly growing populations and increased mobility mean that more and more people are living in urban areas. This puts urban communities at a greater risk for health problems related to climate change, such as infectious disease, cardiovascular disease, malnutrition, and asthma induced by air pollution. At the same time, the obesity rate is expected to reach or exceed 44 percent in every state by 2030, due in no small part to the fact that our communities are designed to discourage physical activity.
As Heleen Dewey of the Spokane Regional Health District points out, a renewed focus on these issues is simply “going back to our roots, because public health started with the built environment.” Public health departments in the United States were initially created to handle built environment issues like sanitation to prevent the spread of diseases. Although they may speak a different language, planners are public health professionals too. Concepts like multimodal levels of service and social capital are different terms from public health concepts like active living and mental health. The built environment is still as critical to public health today as it has always been, but more awareness is needed about the connection between the two
Designing Active Communities
In the United States, transportation and opportunity are intimately linked. Historically, highways in major cities have been built through low-income, minority neighborhoods—cutting them off from the rest of the city to move other residents more quickly. This has also resulted in the underdevelopment of certain communities. Today, only 49 percent of low-income neighborhoods have sidewalks, compared to 75 percent in high-income areas. Cities with more compact urban districts – meaning better street networks – have lower rates of obesity, asthma, diabetes, and other chronic conditions.
A recent Lancet study of almost 7,000 adults from five continents found a significant increase in physical activity in communities with more public parks, better public transportation, higher residential density, and more streets with pedestrian accessible intersections. Walkability benefits aging populations too. In Detroit, older adults living in more accessible neighborhoods were 18 percent more likely to be mobile than their neighbors in less accessible areas. Well-designed communities feature safe sidewalks, frequent transit service, and nearby grocery stores and healthcare facilities, which improve quality of life for everyone.
Good design makes it easy for people to make healthy choices. In a study in the Journal of Applied Physiology, researchers found that communities designed to promote exercise “can prevent 90 percent of type 2 diabetes, as well as 50 percent of heart disease, stroke, and site-specific cancers.” The benefits of walkable communities also extend beyond physical health; a study in Portland, Oregon found that residents in pedestrian-oriented neighborhoods felt a greater sense of community than those in automobile-oriented places. Innovation in this space is also key – Pokémon Go, a popular smartphone game, got young people walking in their communities at the height of its popularity the summer of 2016. Despite some fears of risk via injury by public health professionals, these sorts of creative strategies can be harnessed to encourage healthy behaviors.
Legislation is also a useful tool for achieving these outcomes. The Complete Streets Bill went into effect in July 2011 “to encourage street designs that safely meet the needs of all users and also protect and preserve a community’s environment and character.” Complete Streets provides grants to cities and towns to make improvements that increase safe access for all users, such as a new sidewalk or improved bike lanes. These projects improve safety for all residents, encourage active living by making alternatives to driving more attractive, and create community vibrancy. In Seattle, voters approved the Levy to Move Seattle, a nine-year funding plan to maintain and improve the city’s transportation infrastructure. This includes building 50 blocks of new sidewalks in 2017 to provide access to public transit and safer routes to local schools.
More Green, More Good
Green residential spaces are described by the American Planning Association as “gathering places where neighbors form social ties that produce strong, safer neighborhoods.” While they are important for encouraging physical activity, they can do more than that – they can even lead to a decrease in crime. In Philadelphia, roadside “gray spaces” that were converted into vegetated plots experienced an 18 to 27 percent decrease in narcotics possession. Another study in Youngstown, Ohio saw a decrease in both property and violent crime when green spaces were installed. Modest investments into green space improvements can produce a substantial return on investment in terms of quality of life and the health of a community.
Public green spaces can take many forms, from plant installations and urban gardens to parks, bioswales, and multiuse trails. Even being able to see green space affects mental and physical health—in multiple studies, hospital patients who had nature views experienced less anxiety and required fewer doses of pain medication. The positive impact of outdoor exposure on physical and mental health is so great that healthcare providers have begun participating in park prescription programs. The National ParkRx Initiative helps organizations establish programs promoting activities that improve individual and community health, such as walking on trails with a doctor and prescribed exercise plans.
Green space, like other elements of the built environment, can also foster social inclusion. One study found a strong relationship between the presence of trees and the amount of time urban residents spent in outdoor common spaces around public housing. Research shows that social capital, which is built upon and generates norms of trust, reciprocity, and cooperation, is associated with mental and physical wellbeing. The built environment is key in this respect because thoughtfully designed spaces encourage people to spend time in their community and develop social ties.
However, access to green space is not always equitable. Abundant urban green space tends to concentrate in high-income neighborhoods, and low-income communities of color are more likely to suffer from lack of access to green space. “Play deserts” can be identified with mapping tools like GIS, highlighting communities that lack public spaces for children to play and be active. Parks and open spaces receive limited amounts of public funding, so cities often have to look for creative solutions. “Creating linkages between health services and parks and building green opportunities into every state and local health prevention strategy is a win-win strategy to promote environmental sustainability and community health,” say public health researchers in an article published by the CDC. Even small green spaces such as micro-gardens and bioswales build upon each other to create benefits greater than the sum of their many parts.
Housing for Health
The health of indoor spaces matters too – Americans spend 90 percent of their time indoors, where pollutants can be concentrated at two to five times greater amounts than the outdoors. The American Public Health Association and the National Center for Healthy Housing (NCHH) have created standards to ensure that housing is safe and promotes wellbeing. Enforcing healthy building codes, designing spaces that encourage healthy behaviors, and providing everyone with access to nature are key to healing and thriving.
Poor housing conditions disproportionately affect low-income communities. In 2013, the NCHH reported that compared to the national average, Seattle-area homes were more likely to have problems related to rats, incomplete plumbing, and faulty roofing. These problems were more common in homes within the city center. At the state level, approximately 11 percent of Washington homes were constructed before 1940 and are likely to contain lead-based paint. Lead exposure can lead to poisoning, asthma, and other respiratory problems, particularly for children. Data from 2013 shows that asthma afflicts more than 600,000 Washington residents, nearly 5,000 of which are hospitalized each year.
The Washington State Healthy Housing Initiative was launched in 2013 “to help residents improve the environmental health conditions in their home through education and collaboration with existing community based resources and home health care providers.” The Office of Superintendent of Instruction also approved $5 million dollars in the 2015-17 capital budget for the Healthy Kids-Healthy Schools grant program. Under this initiative, schools can apply for grants to fund renovations and improvements to existing buildings as well as the installation of new equipment to reduce the risks of injury as well as lead and asbestos poisoning.
Thriving at Every Age
Investment into the built environment benefits everyone, but especially vulnerable populations such as children and the elderly. Amenities for aging populations make life enjoyable for all: benches in parks and at public transit stations, well-maintained sidewalks, easy access to bathrooms, and public spaces that foster social inclusion. A 2012 AARP study found that approximately 90 percent of seniors intend to live in their current homes for the next five to ten years. However, only half reported that their communities offer adequate public transportation to get around. Aging at home requires careful land use and transportation planning that considers the unique needs of older individuals.
Policy tools that benefit this population include “tax incentives and rebates that support homeowners in creating physical improvements to address safety concerns for older adults.” The CDC recommends “intentional community planning” that supports aging in place by making local resources more accessible and promoting social interaction. Movements like universal design and Lifelong Communities provide guidance for how to create spaces that are accessible to people of all abilities. The U.S. Department of Health and Human Services’ Healthy People 2020 Initiative urges states to invest in the prevention of injuries, particularly falls, which are the leading cause of injuries among older adults. In public spaces, these includes simple changes like wheelchair ramps, streetlights, and improved street crossings.
These improvements also benefit child health. Obesity, asthma, and lead poisoning are just some of the problems related to the built environment that affect Washington’s children, particularly those in marginalized communities. In 2012, approximately one in four young children on WIC were overweight or obese. Of the 120,000 children with asthma in Washington, the rate among children in low-income households is almost 65 percent greater than those in high-income households. Additionally, extremely elevated levels of lead toxicity in young children in the state increased significantly between 2008 and 2014. These problems are associated with a variety of built environment risks, such as limited access to healthy food and green space, air pollution, and lead pollution in homes and schools.
Programs like Safe Routes to School promote child health by allocating funding to infrastructure improvements and teaching kids bicycling and walking safety skills. Other national programs targeted specifically at improving the health of children include EPA’s Office of Children’s Health Protection and the U.S. Department of Energy’s “Energy Smart Schools” program.
Accessing Healthy Food
Many people often overlook the fact that the built environment is also linked to healthy eating. Although most King County residents live within a 10-minute drive to a grocery store, a lack of convenient public transportation to get there presents a barrier to purchasing fresh and healthy foods. A University of Washington study found that “on foot, at most only 34 percent of the vulnerable populations could reach a supermarket at all, and only 3 percent could reach a low-cost store.” Inequitable food access is not just a problem for urban communities; in the Pacific Northwest region, almost 40 percent of those living in food deserts live in rural areas.
There are several ways that investing in the built environment can lead to more equitable food access. For example, opening grocery stores in urban areas that are pedestrian-friendly, close to transit, and near or on mixed-use affordable housing sites means more people can use them. Urban agriculture is another solution, and can range in size from sidewalk plots to large parks. There are approximately 18,000 community gardens in the United States that allow community members to grow their own produce. WSDA’s Farm to School initiative makes connections between schools and local agricultural producers to support both the use of fresh produce in school cafeterias and promote health education opportunities. In Washington, more than 100 registered farmers markets offer an EBT-matching program to enable low-income families to purchase fresh fruits and vegetables. When these resources are easily accessible to pedestrians and transit users, they can be a valuable tool for improving health equity.
Policymakers have the power to make decisions about the built environment that impact health, safety, environmental justice, and climate change resilience. For example, improving access to public transportation for all communities makes it easier to get to school, grocery stores, employment, and medical care. Other strategies include investing in parks and green spaces, supporting Safe Routes to School, building affordable and safe housing, and conducting health impact assessments (HIAs) of proposed policies or programs. These actions can make a difference in creating enduring health equity.
In Washington, voters recently approved Sound Transit 3, a transit proposal set to extend public transportation access north into Everett and south into Lakewood with rapid bus, light-rail and commuter train lines. With one million additional people expected to live in the region by 2040, this plan will address the strain on transportation capacity. Local communities can also improve the quality of their built environment by adopting a Complete Streets plan that maximizes accessibility for all people. These policies, developed by Smart Growth America, help cities design streets so that they are friendly to pedestrians, cyclists, and transit users. Vision Zero is another example of multiple partners – including the Seattle Department of Transportation and Cascade Bicycle Club – coming together to increase pedestrian safety and in turn encourage active transportation.
Recent changes to the Complete Streets grant program are driving planning innovation around the state. Jurisdictions that have a Complete Streets ordinance in place recently competed for Complete Streets awards, in amounts up to$500,000. This model incentivizes jurisdictions and city leaders to take risks and create innovative multimodal solutions. So far, almost 50 cities across Washington have a Complete Streets ordinance in place, and this number is growing. This overview provides a resource guide and case studies of early adopters of Complete Streets improvements.
One of the most important policy tools for improving the built environment, however, is partnerships. Public health agencies can partner with planners, law enforcement, schools, trail systems, parks departments, clean air agencies, and sanitation departments to find common ground for change. For example, health districts can work with schools to develop safer drop-off areas to reduce the risk of injury, even while encouraging kids to bike and walk to school. Building these relationships requires working across sectors and learning the language of planners, engineers, and other public service professionals who can be champions for public health.
Finally, to share the importance of the built environment, public health professionals, planners, and policymakers must do a better job to engage the public. Heleen Dewey shared that one Spokane resident felt that “planning was happening to them, not with them.” Public engagement requires more than hosting occasional open house events, where the most interested and informed residents self-select to attend. Creative outreach across multiple media platforms, hosting frequent public engagement opportunities, and meeting people where they are – be it schools, farmers markets, or places of employment – are crucial to building communities that are healthy and inclusive.
Rachel Beck was a Policy Fellow at Foundation for Healthy Generations from 2015-2016. She holds a Master of Public Administration degree from the University of Washington, where she focused on the intersection of health, environmental, and urban policy. She currently works at the ACLU of Washington.