Creating A Healthy Environment 2
Creating A Healthy
Environment:
The Impact of the
Built Environment on Public Health
“In its broadest sense, environmental health comprises those aspects of human
health, disease, and injury that are determined or influenced by factors in the
environment. This includes not only the study of the direct pathological effects of
various chemical, physical, and biological agents, but also the effects on health of
the broad physical and social environment, which includes housing, urban
development, land-use and transportation, industry, and agriculture.”
—Healthy People 2010,
U.S. Department of Health and Human Services 1
Richard J. Jackson, MD, MPH
Chris Kochtitzky, MSP
Centers for Disease Control and Prevention
S P R A W L W A T C H C L E A R I N G H O U S E M O N O G R A P H S E R I E S
Acknowledgements
Sprawl Watch Clearinghouse would like to thank Jonathan Dushoff, of Princeton University; Peter Engelke, of the City and
Regional Planning Program, College of Architecture, Georgia Institute of Technology; Karen Roof, of the National
Association of County and City Health Officials; Marla Hollander, of the Robert Wood Johnson Foundation; Rich
Killingsworth, of the CDC’s National Center for Chronic Disease Prevention and Health Promotion; Pat Meehan, of the
CDC’s National Center for Environmental Health; Lee Epstein, of the Chesapeake Bay Foundation; Chuck Connerly, of the
Florida State University Department of Urban and Regional Planning; Bob Deyle, of the Florida State University Department
of Urban and Regional Planning; Rebecca Miles, of the Florida State University Department of Urban and Regional Planning;
Rich Shieber, of the CDC’s National Center for Injury Prevention and Control; Bruce Stiftel, of the Florida State University
Department of Urban and Regional Planning; Dorothy Sussman, of the CDC’s National Center for Environmental Health;
Patti Seikus, of the CDC’s National Center for Environmental Health; Don Lollar, of the CDC’s National Center for Birth
Defects and Developmental Disabilities; Maisha Kambon, CDC’s National Center for Environmental Health; Robert
Weissman, of Essential Information and Betsy Garside, of the American Farmland Trust for their help in editing this report
and the Educational Foundation of America whose support made this report possible.
About the Authors
Dr. Richard Joseph Jackson, MD, MPH
Dr. Richard Jackson is the Director of the National Center for Environmental Health of the Centers for Disease Control and
Prevention. During his tenure at NCEH, he has worked to increase support for stronger environmental health protection
efforts throughout federal agencies, to engage CDC and local and state health departments in the genetics “revolution,” and
to increase efforts to improve the nutritional status of people in developing countries. In addition, Dr. Jackson is
collaborating with groups and individuals from many disciplines; planners, architects, engineers, academicians, and policy
makers’ to explore the implications of urban sprawl on the nation’s environmental health.
Jackson received his baccalaureate degree from St. Peter’s College in Jersey City; a Master of Medical Sciences degree from
Rutgers Medical School in New Brunswick; his M.D. from the University of California, San Francisco; and his M.P.H. in
epidemiology from the University of California at Berkeley.
Chris Kochtitzky, MSP
Chris Kochtitzky is the Associate Director for Policy and Planning in the Centers for Disease Control and Preventions
National Center for Environmental Health, Division of Emergency and Environmental Health Services. Mr. Kochtitzky was
hired as senior legislative analyst at the Centers for Disease Control and Prevention’s (CDC’s) National Center for
Environmental Health (NCEH). NCEH is one of CDC’s key centers with responsibilities involving the impact that the
environment (both natural and manmade) has on human health. In his years at NCEH, Mr. Kochtitzky has also served as
Acting Deputy Associate Director of the Office of Planning, Evaluation, and Legislation, which is responsible for strategic
planning and policy analysis within the center.
Kochtitzky received a BA in political science in 1989 from Millsaps College and an MS in planning, with a concentration in
environmental and natural resources planning, from Florida State University in 1992.
About Sprawl Watch Clearinghouse
The Sprawl Watch Clearinghouse mission is to make the tools, techniques, and strategies developed to manage growth,
accessible to citizens, grassroots organizations, environmentalists, public officials, planners, architects, the media and
business leaders. At the Clearinghouse we identify, collect, compile, and disseminate information on the best land use
practices, for those listed above.
Sprawl Watch Clearinghouse is a nonprofit organization based in Washington, DC
Allison Smiley, Executive Director
This report and many other sources of information on sprawl and smart growth are available on the World Wide Web at
www.sprawlwatch.org
Sprawl Watch Clearinghouse • 1400 16th St., NW • Suite 225 • Washington, DC 20036 • 202-332-7000 • www.sprawlwatch.org
Preface
Here at the start of the 21st century our understanding of which factors promote health and which
damage health has grown considerably. The diseases of the 21st century will be “chronic” diseases, those
that steal vitality and productivity, and consume time and money. These diseases-heart disease, diabetes,
obesity, asthma, and depression- are diseases that can be moderated by how we design and build our
human environment. It is now accepted that, in addition to direct hazards from infectious diseases and
environmental toxins, human behaviors play a critical role in determining human health. As we begin to
include consideration of these factors into our health-related decision-making, we must additionally guard
against using too narrow a definition of the environment. Every person has a stake in environmental public
health, and as environments deteriorate, so does the physical and mental health of the people who live in
them. There is a connection, for example, between the fact that the urban sprawl we live with daily makes
no room for sidewalks or bike paths and the fact that we are an overweight, heart disease-ridden society.
Obesity can increase the risk of (adult-onset) type 2 diabetes by as much as 34 fold, and diabetes is a
major risk factor for amputations, blindness, kidney failure, and heart disease. The most effective weight
loss strategies are those that include an increase in overall physical activity. In a recent type 2 diabetes
trial, weight loss and physical activity were more effective in controlling the disease than medication. In
addition, for treatment of relatively mild cases of anxiety and depression, physical activity is as effective as
the most commonly prescribed medications. It is dishonest to tell our citizens to walk, jog, or bicycle
when there is no safe or welcoming place to pursue these “life-saving” activities.
Respiratory disease, especially asthma, is increasing yearly in the U.S. population. Bad air makes lung
diseases, especially asthma, worse. The more hours in automobiles, driving over impervious highways that
generate massive tree-removal, clearly degrade air quality. When the Atlanta Olympic Games in 1996
brought about a reduction in auto use by 22.5%, asthma admissions to ERs and hospitals also decreased
by 41.6%. Less driving, better public transport, well designed landscape and residential density will
improve air quality more than will additional roadways.
In order to address these critical health problems we must seize opportunities to form coalitions between
doctors, nurses, and public health professionals and others such as architects, builders, planners and
transportation officials, so that we are all “at the table” when environmental decisions are made. Such
decisions include whether to install sidewalks in the next subdivision. It means thinking about what
constitutes safe and affordable housing, safe neighborhoods, providing green space for people to enjoy
where they live and work, and rethinking how we travel from one place to another.
Land-use decisions are just as much public health decisions as are decisions about food preparation.
What, for example, are the implications for children with asthma of building yet another expressway? We
must also question whether a fatality involving a pedestrian isn’t actually the result of poor urban planning,
thoughtless land use, or inferior urban design rather than “simply” a motor vehicle crash. We must be
alert to the health benefits, including less stress, lower blood pressure, and overall improved physical and
mental health, that can result when people live and work in accessible, safe, well-designed, thoughtful
structures and landscapes. We must measure the impact of environmental decisions on real people, and
we must begin, in earnest, to frame those decisions in light of the well being of children, not only in this
country but across the globe.
Richard J. Jackson, MD, MPH
Director, CDC’s National Center for Environmental Health
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Introduction
When people consider factors adversely affecting their health, they generally focus
on influences, such as poor diet or the need for more exercise. Rarely do they
consider less traditional factors, such as housing characteristics, land-use
patterns, transportation choices, or architectural or urban-design decisions, as potential health
hazards. However, when these factors are ignored or poorly executed, the ecosystems in our
communities collapse, people suffer the consequences. We have always known that a 2-hour
commute to work each day on America’s freeways is not a pleasant experience; it is also
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becoming clear that it is an unhealthy experience. We see evidence every day that Americans
exercise less often and suffer higher levels of stress than they did in the past. Yet we often fail
to make the connection between these all-too-common facets of everyday life and how
unhealthy we are. As America increasingly becomes a nation that permits and even encourages
thoughtless development and unmanaged growth, the impact of these factors grows clearer,
and we ignore them at our peril.
Photo: USDA
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Land-use planning and zoning have their roots in
substantially improve the health and quality of
a desire to protect the public’s health. As far
life of the American people. Therefore, in this
back as 1926, the U.S. Supreme Court, in
monograph, we focus mainly on the following:
Village of Euclid vs. Ambler Realty Co., cited
S The relation of land-use decisions to air
public health protection as one of the basic
quality and respiratory health;
responsibilities of local governments, thus giving
S The built environment (including all man-
them a legal mandate to restrict or control land-
made physical components of human
use decisions in a community.2 In this mono-
settlements such as buildings, streets, open
graph, we address some of these land-use
spaces, and infrastructure) in terms of
decisions, discuss how they affect our health,
whether it promotes or discourages physical
and offer some suggestions on how public
activity;
health professionals can collaborate with their
S The impact of urban design on the number
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colleagues in land-use planning and urban
of pedestrian injuries and deaths, particularly
design to help ensure the health and quality of
among children;
life of the people in their communities.
S The choices communities make about the
built environment that improve mobility and
In recent years, public health organizations have
the quality of life for their elderly and
emphasized that public health agencies and
disabled residents; and
programs must not only control disease, but
S The ways that various land-use decisions
also work to prevent it. The World Health
affect community water quality, sanitation,
Organization (WHO) has defined health as “a
and the incidence of disease outbreaks.
state of complete physical, mental, and social
well-being, not just the absence of disease or
A brief summary of other health impacts of
infirmity.”3 The National Academy of Science’s
urban sprawl is also included, with a final
Institute of Medicine has asserted that the public
section that describes some steps that both the
health system should “fulfill society’s interest in
planning community and the public health
assuring conditions in which people can be
community can take to ensure that public health
healthy.”4 Environmental public health initiatives
concerns figure prominently in decisions made
have historically been among the most effective
about the built environment.
approaches for assuring healthy living condi-
tions. In 1854, Dr. John Snow was credited with
taking bold action when he suspected that
contaminated water from a public pump on
Broad Street was causing a deadly cholera
outbreak in London. As a result of this discovery
and Dr. Snow’s actions to remove the handle on
the pump, the cholera outbreak ended. Much of
the improvement in disease death rates in the
last century can be attributed to basic environ-
mental public health actions such as Dr. Snow’s
that resulted in improved sanitation, cleaner air
and water, injury prevention, and protection of
citizens from dangers posed by industrial
pollution in their communities.
We believe that applying public health criteria to
land-use and urban design decisions could
PUBLIC HEALTH/LAND-USE MONOGRAPH S 5
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Land-use and Its Effects on
vehicles accounted for about 58 percent of
carbon monoxide (CO) emissions in the United
Air Quality and Respiratory
States, nearly 30 percent of nitrogen oxides
Health
(NO ), roughly 27 percent of volatile organic
x
compounds (VOCs), and about 9 percent of
Sprawl — uncontrolled, poorly planned,
particulate matter (PM). NO and VOCs
x
low-density, and single-use community
contribute to ground-level ozone pollution,
growth — depends on individual motor
which is known as smog.10, 11
vehicles to flourish. As people move farther and
Research presented on the impact of auto-
farther from cities, they inevitably will travel
mobiles and the transportation sector on human
longer distances to work, shop, and play. From
health at the Third Ministerial Conference on
1960 through 1990, the percentage of workers
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Environment and Health held in London in 1999
with jobs outside their counties of residence
indicated the following:
increased by 200 percent, while the proportion
S Motor vehicle traffic is the main source of
of workers commuting within their counties of
ground-level urban concentrations of air
residence declined.5 This trend contributed to an
pollutants with recognized hazardous
increase in the number of vehicle miles traveled
properties. In Northern Europe, this traffic
in passenger cars — an increase of more than
contributes practically all CO, 75 percent of
250 percent (915 billion miles) from 1960
NO , and about 40 percent of the particulate
through 1997.6 This dependence on the
x
matter (PM10) concentrations.
automobile has only accelerated in recent years.
S Approximately 36,000 to 129,000 adult
For instance, according to the Sierra Club, the
deaths a year can be attributed to long-term
average American driver spends 443 hours each
exposure to air pollution generated by traffic
year behind the wheel — the equivalent of 55
in European cities.12
nine-hour days or 11 work weeks.7 Residents of
cities that have grown more over the last decade
Also presented at the conference were results
have also experienced a greater increase in the
from a recent study of the health effects of air
average time spent traveling in a car than
pollutants from traffic in Austria, France and
residents of cities where growth has remained
Switzerland and their related costs. This study,
stable. From 1992 through 1996, the increase in
using comparable methods, found that air
the number of annual person-hours of delay
pollution caused 6 percent of total mortality in
spent in an automobile in Los Angeles was 9
the three countries, more than 40,000 deaths
percent; in Atlanta 44 percent; in Orlando 62
per year. About half of all mortality caused by air
percent; and in Kansas City 81 percent.8
pollution was attributed to motorized traffic.
This corresponds to about twice the number of
This increase in driving time results in an
deaths due to traffic accidents in these countries.
increase in air pollution and in the incidence of
When researchers analyzed the data from the
respiratory diseases. Despite tremendous
study they found that automobile-related
progress in reducing U.S. air pollution since the
pollution was responsible for more deaths than
passage of the Clean Air Act almost 30 years
traffic accidents. The economic burden of the
ago, cars and trucks are still a major source of
health impact of automobile pollution was
pollution, because even though individual cars
estimated at more than EUR 27 billion
pollute less, the number of cars and trucks and
(approximately $23.8 billion in U.S. dollars).12
the number of miles people drive increases.9
According to a recent report completed by the
Data from studies conducted in the United
Congressional Research Service, in 1997, on-road
States strongly suggest significant links between
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air pollution and negative health outcomes such
Children with asthma are believed to be
as asthma. The President’s Task Force on
particularly sensitive to air pollution.13 As many
Environmental Health Risks and Safety Risks to
as 25 percent of children in America live in areas
Children reports that:
that regularly exceed the U.S. Environmental
“Many common air pollutants, such as ozone,
Protection Agency’s (EPA) limits for ozone,
sulfur dioxide, and particulate matter are
more than 25 percent of which comes from auto
respiratory irritants and can exacerbate asthma.
emissions.13 Asthma rates among children in the
Air pollution may also act synergistically with
United States more than doubled from 1980
other environmental factors to worsen asthma.
through 1995, from 2.3 million17 to 5.5 million.18
For example, some evidence suggests that
Reducing children’s exposure to environmental
exposure to ozone can enhance a person’s
pollutants such as ozone will reduce the
responsiveness to other inhaled allergens.
frequency and severity of their asthma attacks,
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Whether long term exposure to
will reduce their depen-
these pollutants can actually
dence on medication for
contribute to the development of
asthma management, and
asthma is not yet known.”13
will improve their overall
lung function.13 The
For instance, in the summer of
significant contribution of
1997, smog pollution was
automobile use to the
responsible for more than 6
overall air pollution
million asthma attacks, 159,000
problem seems clear. As
visits to emergency rooms for
the American population
treatment of asthma attacks, and
drives longer distances, these
53,000 asthma-related hospitaliza-
problems will most likely only
tions.14 Results of a study
worsen. Therefore, it seems
conducted by the Centers for
imperative that new
Disease Control and Prevention
transportation options be developed and
(CDC) during the 1996
implemented in order to help alleviate the
Olympic Games in Atlanta, at
public health problems related to worsening
which time vehicular traffic was
air quality in the United States.
kept at artificially low levels by city authorities,
showed that the peak daily ozone concentrations
decreased 27.9 percent and peak weekday
morning traffic counts dropped 22.5 percent; at
the same time the number of asthma emergency
medical events dropped by 41.6 percent. Non-
asthma medical events did not drop during the
same time period.15 Results that support the
Atlanta findings were found in a 1999 study of
adverse health effects associated with ozone in
the eastern United States. This study, conducted
by ABT Associates, found that during a single
ozone season, asthma attacks that were directly
attributed to excessive ozone pollution numbered
approximately 86,000 in Baltimore, 27,000 in
Richmond, and 130,000 in Washington, D.C.16
PUBLIC HEALTH/LAND-USE MONOGRAPH S 7
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The Built Environment and
Physical Activity
People who participate in regular physical
activity reap substantial health benefits.
According to the Surgeon General the
most significant are as follows:
S Lower mortality rates for both older and
younger adults. Even moderate increases in
activity are helpful;
S Lower risk for heart disease and stroke;
S Prevention or delay of the onset of high
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blood pressure and actual lowering of blood
pressure among people with hypertension;
and parks) and fears about safety. Overall, CDC
S Decreased risk for colon cancer;
reports that higher levels of perceived neighbor-
S Lowered risk for noninsulin-dependent
hood safety are associated with higher levels of
diabetes;
physical activity, with the differences being
S Weight loss and redistribution of body fat;
greatest among racial or ethnic minorities and
increase in muscle mass;
people older than 65 years of age.21 Thus, people
S Relief of the symptoms of depression and
are more likely to use parks, paths, and
anxiety and improvement of mood; and
bikeways when they are easy to get to and are
S Apparent improvement in health-related
safe and well maintained.
quality of life by enhancing psychological
well-being and by improving physical
Conversely, people tend to get less exercise as
functioning among people with poor health.19
outlying suburbs are further developed and the
distances between malls, schools, and places of
The built environment presents both opportuni-
employment and residence increases. Many
ties for and barriers to participation in physical
theories have attempted to explain the radical
activity, thereby influencing whether or not we
changes in the health status of American
exercise. According to a recent survey about
society, but one of the strongest theories is the
research studies,20 one of the more important
significant decline in activity levels among
determinants of physical activity is a person’s
Americans today compared with levels from 50
immediate environment (one’s neighborhood).
or 100 years ago.23 According to the U.S.
One study examined environmental variables,
Surgeon General’s Report on Physical Activity in
such as the presence or absence of sidewalks,
America,19 changes in our lifestyles and
heavy traffic, hills, street lights, unattended
communities have played the greatest role in the
dogs, enjoyable scenery, frequent observations
decline of activity levels among Americans.
of others exercising, and high levels of crime.
Millions of Americans drive to and from work
Positive environmental determinants of physical
and use a car to run almost every errand. In
activity included enjoyable scenery (presence
1977, children aged 5 to 15 years walked or
associated with more activity), whereas the
biked for 15.8 percent of all their trips; by 1995,
greatest perceived barrier was the lack of a safe
children made only 9.9 percent of their trips by
place to exercise.20 Research by CDC and others
foot or bicycle — a 37 percent decline.24 Results
21, 22 has also indicated that two of the main
of a study in South Carolina showed that
reasons given as reasons for not exercising are
students are four times more likely to walk to
lack of structures or facilities (such as sidewalks
schools built before 1983 than to those built
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more recently.25 This would seem to point to
factor in the incidence of overweight and
some basic change in the “walkability” of newer
obesity. From 1976 through 1994, the prevalence
schools, possibly because these schools aren’t
of U.S. adults who were overweight or obese
as geographically close to the students they
rose from 47 percent to 56 percent, and by 1999
serve or because the school’s property and its
had risen to 61 percent.26 More disturbing,
environs were designed to meet the needs of
however, was the fact that the prevalence of
automobiles rather than the needs of pedestrians
overweight children and adolescents almost
and bicyclists.
doubled during this same period.27 Some
researchers have estimated that as many as
In addition, many different types of urban design
300,000 premature chronic disease deaths each
encourage sedentary living habits. For example,
year are due to obesity.28
parking lots are built as close as possible to final
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destinations in order to increase convenience and
Figures 1-3 show the alarming increase in
safety for motorists. While older cities and towns
obesity prevalence among adults in the United
were planned and built based on the practical
States during a single decade.
idea that stores and services should be within
walking distance of residences, the design of
Major health care costs are also associated with
most new residential areas reflects the supposition
the lack of physical activity and concomitant
that people will drive to most destinations.
rises in obesity rates. In 1995, the direct health
Work, home, school, and shopping are often
care costs of obesity were estimated at $70
separated by distances that not only discourage
billion.29 Adding to that figure the estimated
walking but may even necessitate the use of a
direct health care costs of physical inactivity
car in order to reach any destination safely.
($37 billion),29 we can conservatively attribute an
overall health care burden of more than $100
Sedentary living habits also contribute to poor
billion to obesity and low levels of physical
health outcomes because they are a significant
activity in the United States each year.
Figure 1
PUBLIC HEALTH/LAND-USE MONOGRAPH S 9
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Figure 2
Figure 3
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Urban Design and Pedestrian
Several regulatory and design strategies can be
applied to make communities safer for both
and Bicyclist Safety
child and adult pedestrians and bicyclists. These
strategies include (1) setting and enforcing lower
Another important issue is the impact of speed limits in residential areas; (2) protecting
urban design on a number of injuries
pedestrians in crosswalks by using traffic
involving pedestrians and bicyclists.
signals; (3) instituting and enforcing “traffic-
According to a recent report by the Surface
calming” measures, such as traffic circles or
Transportation Policy Project, in 1997 and 1998,
speed bumps; (4) providing sidewalks and
13 percent of all traffic fatalities — 10,696 people
pedestrian walkways; (5) providing crossing
— were pedestrians. Approximately 1,500 of
guards and bike paths in areas where most
these victims were children, while 22 percent
pedestrians are children, (e.g., near schools,
were older than 65 years of age, even though
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parks, and playgrounds) and (6) providing
only 13 percent of the population is elderly 30.
overpasses, underpasses or tunnels for
Although Americans make fewer than 6 percent
pedestrians and bicyclists to bypass particularly
of their trips on foot, 13 percent of all traffic
dangerous roads and intersections. Inherent in
fatalities occur among pedestrians; of the
each strategy is a refocusing of design goals
pedestrian deaths for which information is
toward pedestrians and, to a degree, away from
recorded, almost 60 percent occurred in places
motorists.
where no crosswalk was available.30 The report
concluded that the most dangerous metropolitan
areas for walkers were newer, sprawling, southern
and western communities where transportation
systems are more focused on the automobile at
the expense of other transportation options.
A study conducted in New Zealand asserted that
there are several potentially modifiable environ-
mental risk factors for
injury to child pedestrians.
Particularly strong
associations were found
between the risk for
pedestrian injuries and
high traffic volume. The
risk for injury to children
living in neighborhoods
with the highest traffic
volumes was 13 times
that of children living in
the least-busy areas.
Restricting curb parking at
specific crossing points
may be an effective
approach to reducing
children’s injuries in this
arena.31
Photo: Hugh Morris
PUBLIC HEALTH/LAND-USE MONOGRAPH S 11
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Environmental Barriers for
For elderly citizens and people with disabilities,
these issues are not simply about convenience
the Elderly and People with a
or even quality of life; rather, they are critical
Disability
health issues. Without access in the community,
these groups cannot adequately participate in
Free and easy movement through public areas physical activity, establish a community of
in the communities where we live is some-
support, or get to or use health care facilities.
thing most people take for granted and, if
asked, would probably claim as a right. However,
Thus, lack of physical access in a community
people with disabilities often find that they cannot
becomes a factor leading to illness and even
move easily from place to place and that they
death.33 Efforts to address these barriers through
have trouble gaining access to medical and other
“universal design” have begun to show significant
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basic health care and social services. People with
success. The concept of universal design maintains
disabilities are even more vulnerable to “environ-
that — “…all products, environments and
mental barriers” than children or the elderly.
communications should be designed to consider
Environmental barriers are defined as the “physical
the needs of the widest possible array of users.
attributes of buildings, facilities, and communities
Universal design is a way of thinking about
which by their presence, absence, or design
design that is based on the following premises:
present unsafe conditions and/or deter access
varying ability is not a special condition of the
and free mobility for the physically handicapped.”32
few but a common characteristic of being
These attributes can include the absence of ramps
human, and we change physically and intellectu-
for wheelchairs, lack of depressed curbs (periodic
ally throughout our life. Usability and aesthetics
breaks in curbs that act as ramps), narrow
are mutually compatible.34
doorways that cannot accommodate various
As land-use and urban-design decisions are made,
assistive devices (such as wheelchairs, motorized
planners, architects, and engineers must keep in
scooters, walkers, etc.), and lack access to mass
mind the needs of all community members. It is
transit routes or other public services.
easy to see that if citizens in an urban setting
Often, something as simple as the lack of a
such as Houston have encountered environmen-
sidewalk or curb cut keeps people with disabilities
tal barriers to mobility and accessibility, people
from getting any physical activity at all. A study
living in suburban or rural settings may face
in Houston, Texas, for example, found that three
even greater challenges. Residents of the urban
out of five disabled and elderly people do not
areas of most major cities in the United States
have sidewalks between their residences and the
such as Houston have access to some type of
nearest bus stop.33 An even greater percentage
mass transit and can also find residential
of these households lack depressed curbs in
housing that permits some amount of pedestrian
their neighborhoods (71 percent) and bus shelters
access to needed shopping and service facilities.
by the nearest bus stops (76 percent). Although
In suburban parts of these cities and certainly in
close to 50 percent of the elderly and disabled
more rural areas of the country, mass transit is
live within two blocks of a bus stop, the lack of
nonexistent, and distances to commercial facilities
sidewalks, curb cuts, and bus shelters actually
make pedestrian access impossible. Such
makes use of the transportation system by these
circumstances can therefore make life very
people impossible. Fewer than 10 percent of the
difficult for anyone who cannot drive or does
disabled and elderly use public transportation in
not have easy access to an automobile, with the
Houston. In addition, fear of crime prevents
pronounced hardships experienced by the elderly
close to two-thirds of the elderly and disabled
and disabled.
from walking to the bus stop at night.33
12 S PUBLIC HEALTH/LAND-USE MONOGRAPH
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The Impact of Uncontrolled
1994 were preceded by extreme rainfall events.
Outbreaks due to surface water contamination
Growth on Water Quality
were most strongly and most immediately
related, while outbreaks due to groundwater
Uncontrolled growth and the loss of
contamination were most often delayed by a
greenspace that often accompanies it
month or two. These findings can, in some
can drastically affect both surface and
part, be attributed to the increase in impervious
groundwater quality. Between 1970 and 1990,
surfaces in areas of population concentration,
central Puget Sound experienced a 38 percent
thereby rendering the land incapable of
increase in population, while the amount of land
absorbing and filtering the amount of water that
developed in that same period rose by 87
falls during these extreme weather events.37
percent. This large-scale alteration of the natural
landscape had profound effects on water
○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○
An additional threat to water quality posed by
resources and quality. Under natural conditions,
sprawling uncontrolled growth is the overuse of
rainfall is either intercepted by vegetation or
septic systems in low-density suburban and rural
percolates slowly through the soil to receiving
residential development that results in groundwa-
waters. In urbanized areas, rainfall that once
ter contamination. For instance, according to the
filtered slowly downhill becomes surface runoff.
1990 United States Census, approximately 26
It flows across compacted earth and impervious
percent of Florida’s population was served by
man-made surfaces (e.g., asphalt, concrete,
onsite sewage treatment and disposal systems
rooftops often covered with oil and other
(OSTDS). More than 1.8 million systems were
pollutants) and is channeled into storm drains.
estimated to be in use statewide. Since 1990,
This disruption of the natural hydrologic cycle
approximately 40,000 new systems have been
causes stormwater runoff to reach streams and
installed each year. By comparison, in 1998, the
rivers more quickly than these water bodies can
Department of Health only issued 3,651 OSTDS
absorb it and also before it has had an adequate
abandonment permits where establishments
chance for filtration of pollutants through the
were being connected to a central sewer system.
ground (the flush of auto contaminants from
It is estimated that OSTDS discharge 450
malls and other large parking areas that runs
million gallons per day of partially treated,
into surface water bodies during the initial period
nondisinfected wastewater.38
of a heavy rainfall contributes significantly to the
non-point source loading of pollutants entering
streams).35 Undisturbed forested lands generally
have the highest capacity to absorb
water and subsequently the lowest
rates of stormwater runoff. In
contrast, impervious surfaces have
the highest runoff rates. The volume
of stormwater that washes off one-
acre parking lots is about 16 times
greater than that of a comparable size
meadow.36
According to research published in
2001 by Johns Hopkins University,
more than 50 percent of waterborne
disease outbreaks between 1948 and
Photo: USDA
PUBLIC HEALTH/LAND-USE MONOGRAPH S 13
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Other Potential Health
blowing dust, and pesticide overspray
potentially can have negative health effects
Effects of Land-use
on the occupants of the residential
Decisions
development.43
S As sprawl-type development pulls people
Land-use decisions and the built
and resources away from central cities,
environment affect the way humans act
those left behind can experience many
and interact, with myriad impacts on public
negative consequences. School districts
health. Sprawl and overdevelopment is closely
pressed to save money are often enticed by
correlated with a range of harmful public
donations of unknowingly contaminated
impacts:
property or seek out the cheapest land they
S In a study of conflict and violence in and
can find. Some of these properties, called
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around public housing in Chicago,
“brownfields,” are touted as the answer to
researchers found that the residents of
all of the problems facing financially
buildings with surrounding greenspace had a
strapped school districts. Brownfields,
stronger sense of community, had better
defined by EPA as abandoned, idled, or
relationships with their neighbors, and
underused industrial and commercial
reported using less violent ways of dealing
facilities where expansion or redevelopment
with domestic conflicts, particularly with
is complicated by real or perceived environ-
their partners.39
mental contamination,44 can, in some
S Urban heat islands increase the demand for
instances, be the only type of property a
cooling energy, increase the health risks
school district feels it can afford. The land
associated with heat-related illnesses and
is cheap, and in some cases EPA may enter
deaths, and accelerate the formation of
into agreements with prospective purchasers
smog. Heat islands are created when natural
of property, providing a covenant not to sue
vegetation is replaced by heat-absorbing
for existing contamination.45 Some groups
surfaces such as building roofs and walls,
feel that the supposed community benefit of
parking lots, and streets. This phenomenon
cleaning up and reusing an abandoned site
can raise air temperature in a city by
is outweighed by the risks posed if, when
between 2-8°F.40, 41
these sites are redeveloped, they are only
S Sprawl increases the risk of flooding.
cleaned up to standards set for commercial
Development pressures lead to the destruc-
or industrial property, rather than residential
tion of wetlands, which are natural flood-
property standards which are more
absorbing sponges. In the last 8 years,
stringent.46
floods in the United States killed more than
850 people and caused at least $89 billion
in property damage. Much of this flooding
occurred in places where weak zoning laws
allowed developers to drain wetlands and
build on floodplains.42
S Residential development next to farmland
can pose unique health and quality-of-life
concerns as well. In this “zone of conflict,”
which might extend one-third of a mile from
residential development, the spillover effects
of agriculture, such as excess noise,
Washington Post
14 S PUBLIC HEALTH/LAND-USE MONOGRAPH
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Planners, Architects,
School Case Study
Engineers, and Public Health
Marion, OH
Professionals Can Make a
Military Dump
Difference
River Valley High School and Middle
The challenge facing those with responsibility for
School stand on the former site of the
assuring the health and quality of life of
US Army’s Marion Engineering Depot,
Americans is clear. We must integrate our
part of which served as a dumping
concepts of “public health issues” with “urban
ground in the 1950s. In 1990, commu-
planning issues.” Urban planners, engineers, and
architects must begin to see that they have a
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nity members formed a group in
critical role in public health. Similarly, public
response to alarming rates of leukemia
health professionals need to appreciate that the
and rare cancers among former students.
built environment influences public health as
Their efforts led to an investigation that
much as vaccines or water quality.
revealed widespread campus contamina-
tion. Today, no one may exit back doors
In a recently published list of the 10 most
of the middle school or access several
important public health challenges for the new
playing fields. Recently a bond issue
century, CDC Director Jeffrey Koplan, MD,
passed to fund a new school, but
included at least four that are significantly linked
students remain on the contaminated
to some of the land-use and urban design issues.
site until completion.46
They are: (1) integrating physical activity into our
daily lives; (2) cleaning up and protecting the
environment; (3) recog-nizing the contributions
of mental health to overall health and well-being;
and (4) reducing the toll of violence in society.28
Specific actions from the public health sector to
address these issues might include the
following:
S Supporting research to determine the impact
that changes in the built environment can
have on public health, such as the addition
of greenspace, sidewalks, and bike paths,
and the reduction in impervious surfaces.
Just as traffic studies are completed to ensure
that road capacity can support new growth,
so too should the public health community
conduct research to determine the air quality
impacts that increasing numbers of
automobiles in use in a community have on
its air quality. Just as engineers use data
that have been collected over time in other
places to determine the diameter of sewer
pipe needed to serve a section of a
PUBLIC HEALTH/LAND-USE MONOGRAPH S 15
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community, so too should public health
making land-use planning decisions, so too is
officials use data on pedestrian injury
there an expanded role for urban designers and
patterns to create new urban design
planners to begin to view themselves as a
techniques.
previously untapped force for public health. It is
S Participating in local planning processes,
time for the planning community to remember
such as comprehensive planning meetings,
its roots in public health protection — to
zoning hearings, and urban planning
remember that in the beginning many, if not
workshops known as charrettes (intense,
most, land-use decisions were made to separate
community-based, local planning and
people from land-uses and industrial processes
problem-solving workshops where local
that posed a threat to their health or safety.
leaders and decision-makers develop
consensus vision of the desired future of
To reclaim their role as public health protectors,
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their community). Just as the developers,
the planners and urban designers might take the
the neighbors, the school board, and the
following actions:
planners have their say in land-use
S Balancing the potential public health
decisions, so too should physicians and
consequences of their choices with other
public health officials have the opportunity
considerations. “Smart growth” doesn’t
to provide input. It is their role to ask the
mean “no growth,” but it does mean
questions such as “Why aren’t there any
planned, controlled growth. The health
sidewalks in a new subdivision?” or “What
impacts of land-use decisions need to
is the air quality impact that is expected
receive at least as much consideration in
from a widening of the local highway?” and
development decision-making processes as
to press for evidence to substantiate any
economic impacts.
claims upon which any new growth and
S Designing communities around people rather
development are based.
than around automobiles. Reviving the
S Working with planners and other land-use
concept that the end result of urban design
professionals to provide them with the
should be improved quality-of-life and that
strong public health arguments they need to
where people live as it relates to where they
support “smart-growth” designs and
work, shop or go to school can have a
initiatives.
dramatic impact on their health and quality
of life.
The public health and medical community must
S Changing existing zoning codes to
play an active role in the land-use and develop-
encourage multiuse land-development
ment decisions made in their community. It is
patterns that make it possible to work,
their role to make policy makers and planners
shop, and go to school within walking
aware of the health impacts of the decisions they
distance of people’s homes. The influence
make. It is also critical that when they find that
of last century’s community designers on
no data or analyses exist to answer the questions
our communities and on the behavior
that they raise, they push researchers and policy
choices that we make everyday was
makers to collect the information they need and
seriously underestimated. The obesity
conduct the research to ensure that all of the
epidemic in the United States was never
impacts of various land-use decisions are known
imagined by those who made it difficult, if
before irrevocable actions are taken.
not impossible, to walk to the grocery store
and to school and who also made it far
Just as there is an expanded role for health care
easier to drive to the shopping mall or the
workers and public health professionals in
movie theater across town then to walk to
16 S PUBLIC HEALTH/LAND-USE MONOGRAPH
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such neighborhood establishments.
Public health professionals and those in
S Changing existing building codes to
architecture, urban design, and planning have
encourage building and site design that is
much in common. The challenge now is for each
accessible to people who have various
profession to learn from each other how best to
degrees of mobility. It is a clear, if largely
address the needs of the communities they
unrealized, fact that the more each member
serve, to determine what answers each has that
of society is able to participate and
the other needs, to create a common language,
contribute, the better off society is. [Not
and to initiate the opportunities to use it.
only would those who were previously
hampered by the inaccessibility feel better,
To meet these challenges, we need a broader
but they also need less help to participate in
view of those factors influencing public health
society and be more able to contribute to
and a much better understanding of the
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their communities.] And all of this could be
interdisciplinary nature of the problem. We need
possible if appropriate design choices are
a collaborative and concerted effort to influence
made which, in most cases, would not cost
both public health policy and other public policy
appreciably more or negatively affect others.
on these issues in order for positive changes to
S Encouraging greenspace development that
take place that will improve the health and
promotes community, reduces violence, and
quality of life for all Americans.
improves mental health. The mental and
physical health benefits of community parks
and other green spaces have been
demonstrated. The question that remains is
whether communities want to spend money
up front to create an environment that
prevents violence and increases psychologi-
cal well-being or whether they want to
spend money after the fact to address the
violence and stress which results from
communities without parks and communal
areas.
Photo: Hugh Morris
PUBLIC HEALTH/LAND-USE MONOGRAPH S 17
References
1. Department of Health and Human Services (US). Healthy people 2010. Volume 1. Washington: DHHS; November 2000.
p.8-3.
2. Village of Euclid v. Ambler Realty Co., 272 U.S. 365 (1926) (USSC+).
3. World Health Organization. (No date). Definition of health [Online]. Available: http://www.who.int/aboutwho/en/
definition.html [2001, August 6].
4. Institute of Medicine (US). The future of public health. Washington: National Academy of Sciences; 1988. p. 7.
5. Department of Transportation (US), Bureau of Transportation Statistics. (No date) Journey-to-work trends in the United
States and its major metropolitan areas, 1960-1990. [Online]. Available: http://ntl.bts.gov/DOCS/473.html [2001, August 6].
6. Department of Transportation (US), Bureau of Transportation Statistics. (1999) The national transportation statistics report
1999. [Online]. Available: http://www.bts.gov/ntda/nts/NTS99/data/Chapter4/4-11.html [2001, August 6].
7. Pope, C. Solving sprawl. (1999) The Sierra Club rates the states [Online]. Available: http://www.sierraclub.org/sprawl/
report99/index.asp [2001, August 6].
8. Texas Transportation Institute (1999). Urban roadway congestion annual report 1998. Table 1-54 [Online] Available: http://
199.79.179.77/ntda/nts/NTS99/data/Chapter1/1-54.html [2001, August 6].
9. Environmental Protection Agency (US). Emission facts. Washington: U.S. EPA, Air and Radiation Office, Office of Mobile
Sources; EPA420-F-99-040. [1999, November].
10. National Council for Science and the Environment. (1999) Congressional Research Service Report for Congress. Air quality
and motor vehicles: An analysis of current and proposed emission standards [Online]. Available: http://www.cnie.org/nle/air-
36.html [2001, August 6].
11. Environmental Protection Agency (US). National air quality and trends report; Washington: US EPA, Office of Air and
Radiation; EPA 454/R-98-016 [1997, December]
12. World Health Organization, European Region. (1999) Third ministerial conference on environment and health, London
[Online]. Available: http://www.who.dk/london99/transporte.htm [ 2001; August 6].
13. The President’s Task Force on Environmental Health Risks and Safety Risks to Children. Asthma and the environment: A
strategy to protect children (2000) [Online]. Available: http://www.epa.gov/children/whatwe/fin.pdf [2001, August 6].
14. Clean Air Network and U.S. Public Interest Research Group Education Fund. (2000) Danger in the air: Smog days in 1999
[Online]. http://www.pirg.org/reports/enviro/smog/index.html [2001, August 6].
15. Friedman, MS, et al. 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.
16. ABT Associates. Adverse health effects associated with ozone in the eastern United States. Washington: (1999).
17. Centers for Disease Control and Prevention. Surveillance for asthma–United States, 1960–1995. Mor Mortal Wkly Rep
CDC Surveill Summ 1998;47(No.SS-1):1-28.
18. Massey JT, Moore TF, Parsons VL, Tadros W. Design and estimation for the National Health Interview Survey, 1985-1994.
Hyattsville: Department of Health and Human Services (US), National Center for Health Statistics; 1989. (PHS)89-1384. (Vital
and health statistics; series 2; no. 110).
19. Department of Health and Human Services (US). Physical activity and health: A report of the surgeon general.
Washington: (1996).
20. King AC, et al. Personal and environmental factors associated with physical inactivity among different racial-ethnic groups
of U.S. middle-aged and older-aged women; Health Psych 2000;19(4):354-64.
21. Centers for Disease Control and Prevention. Neighborhood safety and the prevalence of physical inactivity –selected states,
1996. Mor Mortal Wkly Rep 1999:48(7):143-6.
22. Pate RR, et al. Physical Activity and Public Health: A Recommendation From the Centers for Disease Control and
Prevention and the American College of Sports Medicine. JAMA 1995;273(5):402-7.
23. Nestle M, Jacobson MF. Halting the obesity epidemic: A public health policy approach. Public Health Rep 2000;115(1):12-24.
18 S PUBLIC HEALTH/LAND-USE MONOGRAPH
24. Corless J, Ohland G. Caught in the crosswalk: Pedestrian safety in California [Online]. Available: http://www.transact.org/
ca/caught99/caught.htm [2001, August 6].
25. Kouri C. Wait for the bus [Online]. Available: http://www.scccl.org/nletter/2000summer/schools.htm [2001, August 6].
26. Centers for Disease Control and Prevention.) (No date). Prevalence of overweight and obesity among adults: United
States, 1999 [Online]. Available: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm [2001, August 6].
27. Centers for Disease Control and Prevention. (No date). Prevalence of overweight among children and adolescents: United
States, 1999 [Online]. Available: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overwght99.htm [2001, August 6].
28. Koplan JP, Fleming, DW. Current and future public health challenges. JAMA 2000;284(13):1697.
29. Colditz, GA. Economic costs of obesity and inactivity. Med Sci Sports Exerc 1999; S664-5.
30. Surface Transportation Policy Project (2000). Mean streets 2000: A transportation and quality of life campaign report
[Online]. Available: [2001, August 6].
31. Roberts I, et al. Effect of environmental factors on risk of injury of child pedestrians by motor vehicles: A case-control
study. BMJ 1995;310(6972):91-4.
32. Crum S, Foote KE (1996). Environmental and architectural barriers: How accessible is the urban environment? (1996)
[Online]. Available: http://www.colorado.edu/geography/gcraft/warmup/barriers/barriers.html [2001, August 6].
33. Gilderbloom JI, Markham JP. Housing quality among the elderly: A decade of changes. Int J Aging Hum Dev1998; 46(1).
Also available at http://www.louisville.edu/org/sun/housing/cd_v2/Bookarticles/Ch1.htm [2001, August 6].
34. Adaptive Environments Center. Adaptive Environments & Universal Design (No date) [Online]. Available: http://
www.adaptenv.org/universal/default.asp [2001, August 6].
35. State of Pennsylvania, 21st Century Environment Commission (No date). Redefining progress: recommendations from the
21st century environment commission to Governor Tom Ridge [Online]. Available: http://www.21stcentury.state.pa.us/2001/
redefining_progress.htm [2001, August 6].
36. 1000 Friends of Washington. Sprawl (No date) [Online]. Available: http://www.1000friends.org/sprawl.htm [2001, August
6].
37. Curriero FC, Patz JA, Rose JB, Lele S. The association between extreme precipitation and waterborne disease outbreaks in
the United States. Am J Public Health 2001;91(8):1194-9.
38. Florida Department of Health. Departments of Community Affairs and Department of Environmental Protection. (1999)
Onsite sewage treatment and disposal in Florida: Draft background paper for the Governor’s study of onsite sewage treatment
and disposal systems [Online]. Available: [2001, August 6].
39. Sullivan WC, Kuo FE. Do trees strengthen urban communities, reduce domestic violence? In U.S. Department of
Agriculture, Forest Service, Southern Region. Forestry Report RB-FR 56, January 1996 [Online]. Available: http://
www.urbanforestrysouth.org/pubs/Tech_bulletin/tb4.htm [2001 August 6].
40 Gorsevski V, Taha H., Quattrochi D, Luvall J (No date) Air pollution prevention through urban heat island mitigation: An
update on the urban heat island pilot project [Online]. Available: http://www.ghcc.msfc.nasa.gov/uhipp/epa_doc.pdf [2001,
August 6].
41. Blum LN, et al. Heat-related illness during extreme weather emergencies. JAMA 1998;279(19).1514.
42. The Sierra Club (No date). Sprawl fact sheet [Online]. Available: http://www.sierraclub.org/sprawl/factsheet.asp [2001,
August 6].
43. American Farmland Trust (No date). Alternatives for future urban growth in California’s Central Valley: The bottom line for
agriculture and taxpayers [Online]. Available: http://www.farmlandinfo.org/fic/ft/cv/cv-intro.html [2001, August 6].
44. USEPA Office of Solid Waste and Emergency Response Glossary of Terms. [Online] Available: http://www.epa.gov/
swerosps/bf/glossary.htm#brow [1997, September 30].
45. United States Environmental Protection Agency, Office Solid Waste and Emergency Response. Brownfields Economic
Redevelopment Initiative Quick Reference Fact Sheet. EPA 500-F-00-241 [Online] Available: http://www.epa.gov/swerosps/bf/
html-doc/econinit.htm [2000, October].
46. Child Proofing Our Communities: Poisoned School Campaign. Poisoned schools: invisible threats, visible actions (2001)
[Online]. [2001, August 6].
PUBLIC HEALTH/LAND-USE MONOGRAPH S 19
Sprawl Watch Clearinghouse
1400 16th St., NW • Suite 225
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202-332-7000
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