A century after leading the charge to create the system of land use planning and regulation we know today, public health champions are once again deeply engaged in shaping our built environment — often to undo some of the unintended consequences of practices their predecessors put in motion.
The year 2016 will mark 100 years since New York City officials invoked public health and safety in adopting the first zoning laws to separate noxious industrial uses from residential areas. Around the same time the automobile burst on the scene, and by the end of World War II, the now-universal zoning laws were being used to create separated urban districts connected only by car. By the early 2000s, experts at the Centers for Disease Control (CDC) and elsewhere were beginning to point out the impact on health of this new form of human habitat.
"For decades, we have designed our neighborhoods, towns and cities around the automobile as our primary source of mobility," said Lauren Benet, a spokesman for the CDC National Center for Environmental Health. The dominance of vehicles degraded air quality, created safety problems for people on foot and all but engineered exercise out of existence for daily life. "The reason for this renewed planning/public health partnership is the growing evidence of how community design affects our health in areas such as obesity and physical activity, access to fresh fruits and vegetables, and access to health care and employment opportunities."
To elevate these issues and provide health-conscious policy guidance to planners, designers and local policy- makers, the CDC created the Healthy Community Design initiative. At the time, few in the nation's planning, development or transportation departments were talking much about health, noted Andrew Dannenberg, who led the initiative team while at CDC. That has changed today, he noted, when we see health considerations becoming key drivers in everything from regional transportation plans to discussion of housing design and indoor air quality.
"For example, incorporating walkability features, designing communities so that you can walk to transit, walk or bike to destinations is really popular," Dannenberg said. "I have seen real estate signs that promote trails, sidewalks, walkability and bikeways as an amenity. They may not say ‘health', but that's what it's about."
The CDC and others helped bring the issues to light by conducting a series of "health impact assessments" (HIA) on a range of proposed transportation and development projects. One noteworthy early success was in San Francisco, where the city's health department conducted an HIA on a proposal to demolish 360 low-income apartments and replace them with 1,400 market-rate condominiums. The HIA found that displacing the residents without creating new affordable units would threaten their access to food, increase stress and mental health problems, and raise the risk of homelessness and myriad associated health problems. The HIA led to a revised plan that allowed current residents to remain in 360 rent-controlled units contained in the project.
A health screen for a city's transportation and development plans
In 2007, the city of Decatur, Ga., — a community of 19,000 in the core of metro Atlanta — became the first jurisdiction to perform a health impact assessment on its transportation plan. The result was a plan that addressed the needs of all residents in all parts of the city, as opposed to past plans that mostly focused on the convenience of motorists — many of whom were only passing through, said Amanda Thompson, who led the effort as Decatur's planning director.
"Health was a way to structure an inclusive conversation, because arguments over modes can be really divisive," she said. "People often come to those conversations as, ‘I'm a biker, or ‘I'm a motorist', or ‘I'm a pedestrian'. When you're trying to balance those interests, health is a common denominator. It also helps people wrap their minds around a future that is years off. They can imagine what you might do to make health better — gaining or losing weight over time, what might happen when your parents are older and losing personal mobility, or people needing to get to healthcare. Having that conversation in that frame puts people in same place — so you're not arguing over bike lanes for ‘those people.'"
After that discussion, health — and reducing associated disparities among income groups — became part of city government culture, she said. "The biggest change I saw was with our elected officials and city manager, because it began to trickle down to everything we did. The city manager, who does not bicycle and avoids vegetables, became an avid supporter of providing opportunities for physical activity and access to healthy food." Decatur's example also helped inspire others. Metropolitan Nashville, for example, now uses a health screen in allocating dollars for projects in its metropolitan transportation plan, and regions as diverse as Seattle, San Diego and Detroit are working on similar efforts.
Larry Frank is a researcher whose firm, Urban Design 4 Health, has helped many jurisdictions quantify the impact of planning and development decisions on health. While he has seen communities make enormous strides in many respects, he noted a disturbing trend. "I'm concerned we are not helping the people who need it the most — the poor. We bring good transit service to a neighborhood and make it more walkable, then the values go up and people get pushed out to areas where there's poor transit and it's unsafe to walk. We are making places nicer and safer, but they really aren't helping the people who have the chronic health problems."
Bringing it all together: Seattle's Yesler Terrace
Officials at the Seattle Housing Authority (SHA) are seeking to counter just those concerns with the ambitious redevelopment of Yesler Terrace, a 1940s-era public housing project near downtown that was Seattle's first. In a prime location within striking distance of half the jobs in surrounding King County and a commanding view of Mt. Ranier, Yesler's 561 subsidized units could easily have given way to pricey condos. The SHA instead is working to create a model, mixed-income community on the 30-acre site, where 1,800 of the planned 5,000 housing units will be subsidized for low- and moderate-income residents and health is embedded throughout the planning and design.
As SHA began planning the complex redevelopment, officials noted a 2011 survey of residents in which fewer than half described their health as "good" or "excellent", noted Tom Eanes, senior development program manager for Yesler Terrace. They set about incorporating a wide range of measures to improve health, from features promoting physical activity and healthy eating to using asthma-reducing construction and adding community health workers and programs.
Physical activity and active transportation
The former Yesler Terrace sat isolated on a forbidding hill, with no walking connections to the adjacent First Hill neighborhood and its hospitals, or to the International District and its green grocers. The new design creates connections with "hill climbs" featuring wheelchair-accessible switchbacks and other walkways. The connections also will allow residents to reach a new streetcar line that itself connects to light rail. The housing authority also will provide subsidized access to point-to-point bicycle rentals under the city's Pronto bike-share system.
"We designed a half-mile ‘Green Street' loop through the neighborhood," Eanes said. "That connects to a 1.8- acre, central neighborhood park in the middle, and then three pocket parks — about an acre total — distributed throughout the neighborhood. The street has wide sidewalks, landscaping on both sides of the sidewalk, with places to pause and rest. There are eight exercise stations along the loop. You can run around the Green Street loop, pausing at the exercise stations. Elderly people can easily go out for a pleasant walk, which is extremely good for physical and mental health." Community healthcare workers embedded at the development are organizing a community walking group to promote healthy social interaction and exercise.
Breathe Easy construction
Many units in Yesler Terrace will be "Breathe Easy Homes," using construction and ventilation approaches that SHA developed with the King County Health Department and tested in a previous development called High Point. That experiment found that for asthma sufferers living in these homes, the share making an urgent asthma-related clinical visit within a three-month period declined by a whopping two-thirds.
Breathe Easy homes are built with moisture-reduction features, enhanced ventilation systems, and materials that minimize dust and off-gassing (from carpet and paint, for example) and result in reduced exposure to mold and rodents. Improved indoor air quality will be a major health benefit to residents with allergies and respiratory conditions, Eanes said.
Access to health care
Planning for health has to go beyond the location, arrangement, design and construction of buildings — all part of the Yesler Terrace plan — and into programming of on-site services, said John Forsyth, SHA's community services administrator. SHA has linked up with a local healthcare provider, Neighborcare, to provide several community health workers to assist residents with "navigating the health care system, getting connected with primary care, actively engaging in their care plans, and ensuring insurance coverage," as a program brochure explains. They also provide regular health screenings for chronic illnesses, checking blood sugar levels, blood pressure, etc. In addition, a neighborhood clinic has been established in the adjacent elementary school. "We also are doing an annual survey every year for five years, asking people about their health and care needs. At end of the survey they can ask for a visit from a community health care worker."
Yesler Terrace also will provide about an acre of community gardening space, Forsyth said. Raising your own food and working with others in the process is good for physical and mental health as well as social engagement, he added. Not only will the healthful produce be available for residents' consumption, but they also will have access to cooking classes to learn more about maintaining a healthy diet that is also tasty.
"From the outset in planning Yesler, health has been a key consideration, in all components of it, from planning and design to construction," said Kerry Coughlin, SHA's communications director. "To do that effectively, you have to look at both the built environment — indoor and outdoor — and the programmatic environment. It was hard at first, but it becomes a way of thinking after awhile."
David A. Goldberg is the vice president of communications for Action for Healthy Food, a national non-profit working to reduce the quantity of sugar and other unhealthful substances in our food supply, and formerly was the founding communications director for Smart Growth America. In 2002, Mr. Goldberg was awarded a Loeb Fellowship at Harvard University, where he studied urban policy.