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OCR for page 28
s
Improving Health in the Built Environment:
A Daunting but Doable Challenger
Richard J. Jackson
Our behavior and well-being are influenced by the physical environments in
which we live. These environments, however, particularly in the United States,
are steadily becoming more detached from the natural world, chemically con-
taminated, psychologically oppressive, and hazardous to our health.
Such trends in the built environment will only be exacerbated by an ever-
growing population. In the lifetime of a contemporary middle-aged person, this
country's population has doubled. We have added some 140 million people. And
in the lifetime of a child born today, the population will double again. By the
time that child reaches old age, the nation will have close to 600 million people.
To avoid environmental health catastrophe at that level, and even well below
it we already face some serious issues under present conditions we must
reconsider the ways in which we design our daily landscape so as to reduce and
hopefully even reverse the environmental public health trends we face today.
In modern science, we are good at isolating problems and solving them, and
this focused method has worked very well for us. We cure and prevent disease in
ways that were just a dream one or two generations ago. Yet, we pay a price for
this because our approach to each challenge is very, very narrow we are often
unaware that the failures we encounter have system causes, rather than just
individual. But we cannot address specific issues such as climate change, and
epidemics of asthma, obesity, and diabetes just with piecemeal fixes. The prob-
lems and challenges are networked, not isolated.
A useful term in this regard is "syndemic" two or more epidemics that
interact synergistically, thereby contributing to an excess burden of disease in a
population. The environmental health challenges we are looking at the out-
comes of how we build our environments are in many ways syndemic.
*This chapter is an edited transcript of Dr. Richard lackson's remarks at the workshop.
28
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IMPROVING HEALTH IN THE BUILT ENVIRONMENT
"LANDSCRAPING" DEGRADES ENVIRONMENTAL HEALTH
29
In the first half of the twentieth century, we built skyscrapers and, in the
second half of the twentieth century, we built landscrapers "improvements"
such as huge expanses of highways, interchanges, parking lots, and strip malls.
Among other things, they adversely affect the quality of our drinking water, our
air, our stress levels, and therefore our health.
The best thing we can do for water is to have it infiltrate past trees, which
slows it down and allows it to percolate into the soil. The more infiltration of
water through the soil, the better it is for health.
But in the Atlanta metropolitan area, for example, an average of about 58
acres of these remarkable green objects called trees which not only slow down
the rain and prevent runoff but reduce greenhouse gases and release oxygen-
are cut down every day. At present development rates, New Jersey is about a
generation from being built out right to left, top to bottom and California is
losing about 500 acres a day. The United States has now paved over the equiva-
lent area of the state of Georgia and the resulting impervious surfaces interrupt
the cycle of water returning through the soil and thereby degrade the quality of
the water we ultimately use.
Another issue related to paving things over is the generation of heat. Surfaces
such as asphalt or tar are much hotter, all else being equal, than areas that are
green with plants. Thus, cities create their own "heat islands"; the downtown
areas of most cities run about seven degrees hotter in summer than the surround-
ing countryside not only because of the surface itself but also from the obliga-
tory use of air conditioners in the absence of cooling tree cover.
As it gets hotter, more ozone and other air pollutants are produced in the
atmosphere. So, urban heat is a health threat in several ways directly from heat
stroke, and indirectly from much higher levels of airborne irritants. The risk of
asthma has been growing in a stepwise fashion in the United States. Just about
any school nurse will attest that while asthma in school kids was relatively
uncommon 25 years ago, it' s now a virtual epidemic, with typically a third of the
kids who come in for medical attention suffering from asthma or a related condition.
Consider a Los Angeles study that compared six high schools in low-pollution
areas with six high schools in high-pollution areas. Researchers looked at young
athletes when they entered high school and then again four years later. The kids
from the high-pollution areas had twice the asthma rate as compared to their
low-pollution-area counterparts.
Another illustration: during the Atlanta Olympic Games in 1996, there was
a dramatic reduction a 30 percent decrease in the city's car and truck traffic,
with a consequent 30 percent improvement in air quality. When researchers from
CDC and other local health-research institutions looked at pediatric Medicaid
claims, Kaiser HMO visits, emergency-room cases, and hospital admissions for
asthma, they observed that all had dropped during the Olympic period. After-
ward, the rates went right back up to what they had been before.
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ENSURING ENVIRONMENTAL HEALTH IN POSTINDUSTRIAL CITIES
Some have alleged that these results are inconclusive that people may
have been diverted by the Olympics and simply didn't have the time or inclina-
tion to go to the doctor. But no comparable decreases were observed during that
period for nonrespiratory diseases.
DRIVEN TO DEPRESSION, OR WORSE
The "landscraping" trend cited above largely to serve cars, of course has
effects that go well beyond degradation of the water and air and the increased
incidences of related diseases. We spend more and more time in our cars-
commuting time to work, for example, has gone up 14 percent in just the past 10
years and this is not merely tedious and fuel-consum~ng. The more time spent
in one's car, the greater are the actuarial risks of automotive-related death.
Every 66 miles driven confers upon us a lottery ticket a one-in-a-million
chance of dying in a car crash. It isn't much better being a pedestrian (see
Figure 5-1~. We have not designed our cities for pedestrians in general, and it
Automobile fatality rates by city, 1998
(excluding pedestrian fatalities; deaths per 100,000/year)
lit
~ _)
FIGURE 5-1 Sprawl cities, where people spend more time driving, have higher rates
than cities with greater density (fatality rates per 100,000 people per year). New York and
Philadelphia, both of which are "walking" cities, have rates of about 2.5 and 5,
respectively; while heavily "freewayed" Dallas and Atlanta have much higher rates at
approximately 11 and 13. SOURCE: Chart created from National Highway Traffic Safety
Administration, 2002.
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IMPROVING HEALTH IN THE BUILT ENVIRONMENT
31
has gotten considerably worse with the spreading reign of the automobile. As
shown in Figure 5-2, pedestrian fatality rates are higher in sprawl cities than
they are in denser cities. When we build with low density, the amount that
people walk goes down and the amount that they drive goes up. For example,
parents spend more time chauffeuring their children around, children who most
often would rather walk in the first place, if only they had the option.
I believe that this removal of autonomy from a child's environment actually
has adverse developmental effects. Children need to be presented with tasks that
are reasonable, ones that they can overcome and build on. As renowned pediatncian/
child psychiatrist Herbert Needleman has said about young children, "It is the
job of a child to taste, touch, and feel its environment, to immerse itself in its
environment." School age children need continuing challenges of mastery. Every
parent and teacher knows that it is important to present to the learning child tasks
that are doable, where they can succeed, but not too easily. I worry about the
infantilization of the school age child that occurs when he must be driven to the
library, to sports games, to the store, or to everything else. It cannot be good for
Pedestrian fatality rates by city, 1998
(deaths per 100,000/year)
~1
~ l '
~c,
~ rat
—7
""new - i\ \
FIGURE 5-2 How we build our cities and the lack of walkable environments may con-
tribute to pedestrian fatalities. Sprawl cities, where people spend more time driving, have
higher rates than cities with greater density (fatality rates per 100,000 people per year).
New York and Philadelphia, both of which are "walking" cities, have rates of about 2.33
and 1.88, respectively; while heavily "freewayed" Dallas and Atlanta have much higher
rates at approximately 4.28 and 6.44 respectively. SOURCE: National Highway Traffic
Safety Administration, 2002.
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ENSURING ENVIRONMENTAL HEALTH IN POSTINDUSTRIAL CITIES
children to lose the ability to actually carry out the basic tasks of their lives
themselves and to do so at their own pace, to have space and time for reverie,
talking, and increasing independence.
Children are taken to school. In many places, they no longer have phys-ed
classes. Children are expected to stay in the cafeteria during lunchtime, often-
times not allowed to run around because of one modern security problem or
another. At the end of the day they get back on the school bus or in a car to go
home, where parents also concerned with security may place further limits
on their autonomy. It's probably no coincidence, then, that we are looking at an
epidemic of methylphenidate (Ritalin) consumption (see Figure 5-3) or that three
million children in the United States suffer from depression.
Of course, not all these prescriptions or cases of depression come only from
how we design and build our communities that is, for automobiles rather than
for human beings but even if it affects, say, only 5 to 10 percent of children in
such ways, that is still an enormous number of kids. Clearly, this is an important
area for further research.
THE HAZARDS OF OBESITY
The limited freedom to walk also bears some responsibility for our epidemic
of overweight. In 1991, the percentage of obese adults (with Body Mass Indexes
FIGURE 5-3 The number of doses of methylphenidate (Ritalin) dramatically increased
from 1987 to 1998 in the United States. This is, in contrast to the small increase in other
countries, on the rise in the United States. Source: U.S. Drug Enforcement Agency (DEA),
2000. Reprinted with permission.
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IMPROVING HEALTH IN THE BUILT ENVIRONMENT
33
[BMIs] greater than or equal to 30) was no higher than 14 percent in any state; in
1995, the populations of about half of the states were 15-19 percent obese; and
by 2001, half were at 20-24 percent and a few had hit 25 percent or beyond.
Obesity is a lot more than cosmetic. It's a risk factor for heart disease,
cancer, gallbladder disease, and a long list of other disorders. And in addition to
all the suffering and premature death, there are substantial economic costs that
are mostly, though not entirely, medical. For example, my colleagues and I
calculate that the obesification of the American public raises the airlines' jet-fuel
costs some $200 million per year just in the United States alone.
Most notably, being obese is a risk factor for type II diabetes a very seri-
ous problem that can cause the loss of eyes, kidneys, feet, and ultimately life
itself. It used to be rare for a pediatrician to see a child with type II diabetes.
Now, it is up to 30 to 40 percent of the pediatric diabetes practice. It has become
very common (Figure 5-4~. Among adults, one is 20 times more likely to get
type II diabetes if he or she is obese. For the very obese, it is about 40 times.
Ironically, the best treatment for type II diabetes is not insulin or other
drugs. The best treatment, which has fewer complications and works better than
any drug in existence, is weight loss and physical exercise. Designing environ-
ments in which people can move around is not only a treatment (and prevention)
for diabetes; there are numerous other health benefits. For example, better envi-
ronments raise one's serotonin level and they are effective in reducing depres-
sion. Better environments are as good as certain antidepressant drugs.
WHERE PEOPLE WANT TO BE
The bottom line is that we in public health need to reach out to the people
who do the urban planning and architecture and to those who govern our com-
munities. Professionals who deal with issues of community design have just as
much relevance, and probably more relevance, in addressing the diseases of the
twenty-first century than those of us who are sealed off in the medical communi-
ty fighting the adverse effects, after the fact, of the diseases made more common
or more severe by the way we build our environments.
The proper vision which directly applies to Pittsburgh is that just as our
rivers ought to be swimmable, drinkable, and fishable. Riversides (and their
neighborhoods) ought to be walkable, Likable, and runnable. You don't have to
tell children to go outside and get some exercise if there are safe and attractive
places to run around with their friends: parks, trails, basketball courts, water-
courses, and playing fields.
We all want to be in places like that. Creating safe and attractive environ-
ments for people to make themselves healthy will do a whole lot more than our
waving our fingers at them and lecturing them to shape up.
This is a daunting but doable challenge. When I was a young medical
student, it seemed that the problem of lead poisoning was insurmountable; lead
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ENSURING ENVIRONMENTAL HEALTH IN POSTINDUSTRIAL CITIES
Diabetes and Gestational Diabetes Trends Among
Adults in the U.S., BRFSS 1993-94
A....
, · by
No Data
<4%
6%-8%
8%-10%
0%
Diabetes and Gestational Diabetes Trends Among
Adults in the U.S., BRFSS 2001
No Data ~<4% ~4%-6% ~6%-8%
\)
8%-10%
>10%
FIGURE 5-4 The incidence rates of diabetes in the United States have been rapidly
growing in recent years. In 1993, only 4 states reported diabetic rates between 8 and 10
percent of their population. In contrast, by 2001, 25 states reported a diabetic rate between
8 and 10 percent, while 15 states reported an incidence rate greater than 10 percent of the
population. SOURCE: Mokdad et al, 2003.
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IMPROVING HEALTH IN THE BUILT ENVIRONMENT
35
was everywhere in the food, in the paint, in the gasoline. Yet over time we
removed lead from our environment, and as a result we have seen a dramatic
drop in the average blood-lead levels in the United States.
Similarly, whenever any major environmental issue comes up such as the
landscraping/polluting/disease-causing network of problems noted above many
people will say it is insurmountable, that it's just too big. Yet while the lead-
poisoning problem was also "just too big," we have made wonderful progress.
The same can be true of environmental health in Pittsburgh and the nation if
we reclaim the land and water and air for human habitability, fitness, and
fulfillment.
Representative terms from entire chapter:
built environment
