Urban Vision And Public Health: Designing And Building Wholesome Places

GCPH Seminar Series 2 Paper 5

Illustrated transcript of Dr Howard Frumkin’s lecture: Thursday 20 April 2006

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URBAN VISION AND PUBLIC HEALTH:

DESIGNING AND BUILDING WHOLESOME PLACES

Dr Howard Frumkin:

Thank you all for coming. I apologise for the delay in getting started. We are starting about 15 or 20 minutes later than you expected and that was intentional, that was to put us on the same emotional wavelength because I’ve been waiting for my luggage to arrive from the airport. [Laughter] It arrived about 20 minutes ago. So the feeling of apprehension and expectation is something we all share. I also want to thank Kevin [Kane] especially for the scheduling of today, the reception and drinks are after the talk and not before and given that I’ve just flew all night it’s my great good luck that the drinks come after the talk and it’s your great good luck too. [Laughter]

Having moved from academia to government I have to show you this disclaimer, you don’t have to read it, but I’ve shown it to you now. [Laughter] I want to pose the question as Kevin foreshadowed about the link between urban planning and public health and I want to suggest that one way to think about that, initially, is to ask ‘what are the major health challenges that we face’? A century ago or a century and a half ago the answer may have been infectious diseases and so the piped water that Kevin referred to would have been a planning and infrastructure response to that public health challenge. But now the challenges we face are very different and I think we probably share these on both sides of the ocean. So let me very briefly review a few of the major public health challenges that those of us in the health world worry about.

Sedentary lifestyles; overweight; obesity – this complex of inactivity and the diseases that follow from it. Injuries are a major cause of morbidity and mortality; cardiovascular disease linked in part to the first bullet; asthma; problems with mental health and health disparities that distinguish some of us from others of us within populations. I’m going to go through these very quickly to survey them for those who are not in the health fields and I’m going to invite all of us to think as I do this about what would be the infrastructure and planning physical environment responses that might help us address these problems if we wanted to do that.

The overweight, sedentary lifestyle is very well known.

This [referring to slide] was on the cover of Newsweek magazine, one of our popular news magazines. Very low levels of leisure time physical activity, very low levels of utilitarian physical activity characterised the States and I now understand that even with lower levels of car ownership and with better infrastructure for pedestrians, the same problem may plague Glasgow as well.

This shows the percentage of people from various groups who have reported achieving recommended levels of leisure time physical activity. You can see that no group gets to above about 40% irrespective of social class. We are a sedentary society.

Partially in relation to that problem, overweight and obesity have increased in recent years. This is about the mid seventies. So during this post World War II 50 or 60 years the average level of weight rose slowly until about half way through that period and then began rising more rapidly. The CDC has developed maps that show the levels of obesity in each of our 50 states. Here’s the first map from 1990. The colour code shows you the prevalence of obesity.

Here is ’91, ’92, ’93. The darker blue is 15-19% of the population obese.

Now ’96, ’97 – the yellow is now over 20% – ’98, ’99, 2000.

And we are now seeing states in the last years for which data are available with more than 25% of the population formally categorised as obese. So this is a very rapidly galloping epidemic. There are multiple causes for it, but one thing we can say is that genetic change doesn’t happen this fast so we are looking at environmental and behavioural factors here.

Those showed you adult data; childhood data parallel the adult data. Here we see from the 60’s to the 90’s the increase in the prevalence of childhood overweight and this is especially worrisome because heavy children become heavy adults.

Injury is the second major public health problem that I want to flag for us. This is a cause of death chart. The red, blue and green boxes all represent acute injury deaths.

Each column is an age group and you can see that among children the blue boxes which are unintentional injuries are the leading cause of death. The red boxes are homicide and the green boxes are suicide, fortunately less common, but if we just focus on the blue boxes there are enormously important causes of death and of suffering and of expense.

Cardiovascular disease is a third issue. I won’t give a lecture on cardiovascular disease, but we all know that this is a common problem in developed countries and becoming much more common in developing countries as well.

This slide shows the prevalence of various risk factors in men and women – hypertension, obesity, high cholesterol and the presence of multiple risk factors. You can see that these are very common problems to the point that a majority of people have at least one of these risk factors. Cardiovascular disease accounts for about 40% of US deaths; about a million deaths per year in our country. Stroke is very common, myocardial infarction and heart failure, other cardiovascular diseases. It’s clear that if we wanted to design communities that would address this problem we would have to design ways to reduce and control risk factors and I’ll come back to that in just a few minutes.

Diabetes is a common problem and a growing problem, if you pardon the pun. One of the risk factors for diabetes is overweight and so there is a link between this epidemic of overweight and the epidemic of diabetes that also rated the cover of Newsweek magazine.

Asthma is becoming more prevalent for reasons that aren’t clear. The hygiene hypothesis holds that perhaps we don’t have enough exposure to antigens and germs early in life when our immune system is being entrained: that really is not clear at this point. What is clear is that asthma is increasing in prevalence as you can see here. The discontinuity in the graph from 1980 to 2002 represents a change in the questions that we used in our national survey to assess the presence of asthma, but despite that break in the graph the overall trend is clear – asthma is a very common disease. The prevalence of lifetime asthma is shown here in various groups. Female and male are the top two. Mexican and Puerto Rican are minority populations within our country and the point of showing you this is to emphasis that asthma prevalence differs a great deal by ethnicity. I’ll come back in just a minute to talking about health disparities as one of our major challenges. Nowhere is it more startling than it is for asthma.

We turn to mental health. Depression is a common mental health problem in a variety of surveys – from 15 to 20% of people suffer depression at some time in their lives. It’s a treatable condition, but a condition that can be manipulated by changes in environmental, social and behavioural factors as well. Talking about mental health and talking about depression raises the question of happiness and I know this harkens back to Professor Layard’s speech in this very seminar series last year. This has been a topic of keen interest for us in the States because during this last 50 or 60 years, a time of rapidly increasing per capita income and GNP shown by the red curve, levels of happiness have not increased. Now we all strive to get more stuff and to accumulate wealth as if that would make us happy, but it seems that it doesn’t necessarily make us happy. One wonders about other factors that have been changing over the last 50 years that might have impeded the growth of happiness in parallel with the growth of resources that we’ve had. It turns out, as Layard’s book tells us, for those who are at or near the poverty level more wealth does make people happier, but above that there seems to be very little correlation between more resources and more happiness inviting us, compelling us, to think about other social circumstances that might make all of us happier which after all is the goal of many of our social enterprises.

Let me talk about disparities briefly just to emphasise, as I mentioned before, that asthma various greatly across social, ethnic and racial groups. Hypertension varies across racial and ethnic groups, as shown on this graph of white, African American and Mexican American prevalence: there and you can see differences in the hypertension prevalence. Coronary hearth disease, stroke and cancer vary a great deal by ethnicity and by race, partially due to stress, partially due to environmental and behavioural circumstances.

Housing, as one of the upstream determinants of health, varies greatly by ethnic and racial group as well. If we just look across the bottom row here, these are white people, black people, Hispanic people in the States. You can see here the proportions of families that were unable to pay rent, mortgage or utility bills during a one-year period. That proportion is about twice as high in minority populations as in white populations. So it’s not only the health outcomes that we study, but the upstream determinants of health that we know are important, vary greatly. These disparities in health have to be a central concern of public health.

So a very partial list of current health challenges include sedentary lifestyles, injury, cardiovascular disease, asthma, mental health, health disparities and it is clear that if we think about those and if we think forward over the horizon, this poses a number of environmental design challenges. In the US the census bureau predicts that our population will double by the year 2100. I don’t know that the projections are for Scotland, but presumably population is growing as well. Global temperature will be warmer by two or three degrees by 2050 or 2100, petroleum will become increasingly scarce and expensive, forcing us to look at different energy sources or different patterns of energy use. Water will become increasingly scarce in many areas. Health care costs will be rising. So a number of long term trends form the context into which we have to place current health patterns as well.

If we want to design communities to meet these challenges, to make people healthier and happier and more fulfilled, what are some of the design considerations that need to be on our minds? We need to have room for lots of people because populations are growing, but we have to use the available space wisely because we are running out of space in many cases. We need good places for old people because the population is aging, a very important demographic shift. We need to decrease greenhouse gas emissions and take other steps to control global climate change. We need to decrease petroleum dependence not only because of the political instability that that dependence denotes, but also because it is a finite resource. We need to promote active lifestyles because people are too sedentary and that’s bad for their health. We need to prevent injuries, cardiovascular disease and asthma through safer infrastructure, through cleaner air, and so on. We need to promote mental health and wellbeing. Community design features that do those things would respond to current and future public health challenges. And we need to rectify health disparities. So that is the assignment for all the urban planners in the room, thank you very much!

How are we doing at designing communities to meet these needs? Now here I’m going to take the liberty to tell you about how we are doing in the US. You’re doing much better than we are, but I think that the trends that the US exemplifies can be seen elsewhere. Australia and Canada followed this pattern fairly closely and many parts of Europe are beginning to display this pattern. So I come as an emissary from as bad as it gets to tell you what to watch out for. [Laughter]

This is the current prevailing pattern of urban growth in the United States. This is urban sprawl: the vast geographic expansion of cities over broad areas. This is Denver, Colorado. In the background is the Rocky Mountains which we think were placed by God in order to prevent the infinite expansion of Denver to the Pacific Ocean. [Laughter]

On a smaller scale we see changes in traditional land use patterns from forest and farmland to residential land, as you see here. The conversion happens at the edge of every city on a regular basis. We see low density use of land, so that instead of having 10 or 20 families per acre you might have a family per one or two acres as you see here. Now, that low density has implications for transportation and the planners in the room know very well that land use and transportation are inextricably linked. The people who live in houses like this will never walk or bicycle to any destination because it’s too far away. The low density land use signifies long trip distances and so for them the highway is the lifeline. They need access to a road system and they need to use automobiles because we have created an automobile dependant system of transportation as a consequence of land use decisions.

In order to support that mode of transportation we commit these ungodly acts of civil engineering as you see here. [Laughter] This was a recent newspaper headline in Atlanta. Now this is not a joke, this is actually a current plan in Atlanta because we have not enough road capacity so the existing north-south artery in Atlanta is contemplated to be expanded to 23 lanes. This will be longer or wider than an aircraft carrier is long. Despite this pattern of highway construction that prevails in the States, we don’t have enough highway capacity in any major city and every morning rush hour and every afternoon rush hour looks like this in every major city. In fact the term rush hour is quaintly obsolete; it doesn’t last an hour, it lasts two or three hours in most cases.

This is an artist’s conception of the city of Baltimore in the year 2025 after the beltway around the city has been newly widened to 1,472 lanes [laughter]. For those who know the geography a little bit the state to the north of Maryland is New Jersey and up there you see the New York beltway which is even farther north than New Jersey, but the beltway has now expanded so that the state of New Jersey has now become the New York beltway. The human implications of this pattern are shown in this car where the child says “mummy when are we going to home?” and mummy says “we spend 60 hours a week in our car, honey, this is our home”.

Meanwhile as we expand cities outwards, converting greenspace to residential property, spending vast sums on transportation infrastructure and on all the other infrastructure – the sewage lines, the water lines, the electric lines – back in the central city we have perfectly good infrastructure like this that goes abandoned. So this is an inefficient use of public funds and a foregone opportunity to house people in perfectly good housing.

Now coming down to the neighbourhood scale, the predominant form of neighbourhood in suburban development is called the loop and lollipop neighbourhood for reasons that you can see here. Low connectivity is a hallmark of this kind of development. To get from this house to this house, a distance of maybe 50 or 100 feet, you need to take a trip like this. This is designed for cars more than for people. It may have an appeal for parents of young children because living on a cul-de-sac here obviates the danger of through traffic – traffic might endanger the children who are playing outside – but at a certain point this becomes dysfunctional as I will come back to in just a few minutes. The curvaceous streets on the other hand are not designed to slow traffic down, they’re designed to move traffic efficiently and that’s not a good thing for children who may be playing there.

Another feature of the residential development is low land use mix, so that in a picture like this you see nothing except housing. Anybody in one of these houses who wants to get a quart of milk or a loaf of bread or a newspaper has to take a journey by car because there is no retail space anywhere near here. Commutes have to be by car because there are no work places anywhere near here, this is purely residential. We have segregated the different land uses. Here it is schematically. On the bottom of the slide is a traditional grid like development, and at the top is a more conventional suburban development pattern that typifies the last 50 years. About 50% of our population now lives in suburban areas that look more like the upper panel than the lower panel. So here you’ve got a mixture of land uses: you’ve got single family housing, apartments, a retail mall, more apartments, the school is over here imbedded in the neighbourhood. Up here separate parcels of land were developed independently by developers in most cases – private efforts. Here is the single family housing development separated from the apartments, separated from the school and over there is the retail mall. So a child in this house who wants to go back to school to play sports one afternoon simply comes out of the house, travels along a sidewalk (these grid like streets typically have sidewalks) and arrives at the school. A child equidistant from his school who wants to go from here back to school has to travel out to the feeder road, along the feeder road and back into the school requiring an automobile trip, requiring in turn that mum or dad drives him or her – exactly what you don’t want to have to happen when you’re 13 or 14 years old and you want that independence.

Now coming down to an even smaller scale, here is a particular interest of mine. I’ll give you a multiple choice quiz question now. A medium security prison, a UFO that has just landed, a warehouse, or a school? When I present this in the States everybody always says “oh yeah, it’s a school”. More and more of our schools look like this now. A typical pattern for schools in suburban communities is to buy a large parcel of land out at the edge because that’s where the land is affordable and available and to build the school on that large parcel of land. That triggered a cover story in Governing Magazine, a magazine that goes to state and local elected officials.

The cover story as you can see is called ‘Edge-ucation: the compulsion to build schools in the middle of nowhere’. This is a corollary of the land used and transportation patterns that I have been describing. Here is an example.

This is the Marshall High School in Marshall, Minnesota built truly on a greenspace. This is the Hubbard Lake Elementary School in a suburban area in Michigan. Its motto is, I kid you not, “outstanding in its field”. [Laughter] No child for the useful life of this school will ever walk or bike to school. We do know how to do the alternative; we build, and built for many decades, neighbourhood schools that were imbedded in residential communities to which children can walk and bike. Such schools could also function of centres of social activity after school hours and be sites of social capital for the community, but that is a disappearing pattern.

Coming down to the street level, streets typically look like this large street of roads designed to move a lot of traffic; very hostile to pedestrians. Build really for one use. The main virtue of streets like this other than moving traffic is that they allow us to play a fun game called ‘find the victim’. If you look carefully you can see the victim back there, the intrepid pedestrian who takes his or her life in hand by crossing the street.

Coming down finally to the smallest scale I want to talk about: sidewalks and paths. I have made a careful study of sidewalks and paths across my country, off the record, and I have discovered that there is a clandestine national “Never Walk” campaign. So I’ve studied the features of that campaign and I’m here to tell you about them today. Thirteen different strategies.

• The first is not to build sidewalks. This is a very typical look for a suburban road in the States. You can see by looking at the side that some people insist on walking anyway. These are people who probably don’t have cars, in this case this is a feeder road called Buford Highway which happens to be where my office of CDC is located. It’s also a heavily Hispanic area, so these are members of minority groups who can’t afford cars and they have to walk. Well the fact that that happens requires 12 more strategies to prevent people effectively from walking.

· The second is to build repellent sidewalks. A sidewalk that looks like this has nothing interesting to look at along the way, it has no shelter from the sun, there is no buffer between the pedestrian and the sidewalk and the traffic on the roads so it’s a very unappealing place to walk and it’s no wonder that nobody is walking there.

· The third strategy is to allow sidewalks to disintegrate. They look like this. This is a statement of public will about the role of walking.

· You can also build treacherous sidewalks. This is a sidewalk that inclines down directly into traffic. This is useful in the Never Walk campaign because if a mother or father is pushing a carriage with a baby in it and loses hold for just a second, the carriage will roll into traffic removing from the gene pool people who might grow up to become walkers if they were to survive.

• Obstructing sidewalks is a very effective way of sending a message to would-be pedestrians about how we feel about their walking. [Laughter] This is very close to the university where I taught for 15 years. There was a storm that came through… we are in the Southern United States so the warm weather over the Caribbean generates hurricanes that then come up overland and they periodically sweep through and knock down trees. So this tree came down and the highway department, which is terrific, came out within hours with chainsaws. Now they could have sawed off the tree at this point, but because they are part of the national Never Walk campaign they sawed the tree off here to prevent anybody from walking there.

• Using creative design is a very effective method. Based on my medical perspective, I call this sidewalkcus interruptus. This one is just dislocation. [Laughter]

• Crosswalks are what we build to guide pedestrians across streets. The best thing to do with crosswalks is to make them go nowhere because if the crosswalks go nowhere as these ones do, then no-one ever has any incentive to walk on a crosswalk.

• Combining multiple strategies at a time of economic shortages is very efficient. Here you have disintegration and obstruction. Here you have sidewalkcus interruptus and obstruction.

• It’s important for the planners to remember never to place an interesting or useful destination within walking distance of where anybody lives. If you live in a place like this, then there is no reason you would ever walk even if there were sidewalks because there is no destination to get to.

• Being explicit is a good idea. This is the entrance to a gated community. I don’t know if you have gated communities here. This is the fastest growing residential configuration in the US. It’s an interesting sociological phenomenon reflecting a free flowing sense of menace out there. It may be 9/11 related or related to competitiveness in the world, or the declining fortunes of our country in other ways, but many people are moving into gated communities. This is an entrance to one and if you look carefully at the side it says “No Pedestrians” so you’re not allowed to arrive here on foot. You have to arrive here by motor vehicle. That is a very explicit way to discourage walking.

• Zealous law enforcement helps. This woman in Los Angeles received a ticket for $114 for talking too long to cross a street. She began shuffling with her cane across a particular road in the San Fernando Valley when the light was green, but was unable to make it to the other side before it turned red and got a ticket for that. The intrepid reporter went out on Friday to observe for him or herself. The light changed too quickly even for high school students to make it across without running. It went from green to red in 20 seconds. So here is a legal support for the national never walk campaign.

• Enshrining the labour saving device is a useful strategy. This is the lobby of the Hyatt Regency Hotel in Bethesda, Maryland. I picked the Hyatt Regency because it’s one of the signature hotel chains worldwide and I picked Bethesda because that’s where our National Institutes of Health are so all of us who go in to serve on advisory committees are familiar with this hotel. We care a lot about health. In the main lobby, this is the concierge desk, this is the beautiful setting with ferns and balconies. The main shrine in the middle of the lobby is the elevator. If you try to find staircases they are a clandestine affair hidden behind a concrete block wall that are difficult to get to and to which the doors may be locked. So this really bespeaks social values--contrast to traditional architectural devices like these that not only invite you but seduce you into walking up stairs working physical activity into your daily life.

• The 13^th strategy is to make everything car accessible, this is to make it appealing never to get out of your car. We are the land of the drive-through. We have drive-through pharmacies; we have drive-through dry cleaners; we have drive-through liquor stores. Now notice that drive-through is always spelled ‘thru’ in recognition of the fact that busy drivers have better things to do than contend with complicated constructions like ‘ough’ [laughter].

We have drive-through bakeries; w