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Kaid Benfield’s Blog

Why doesn't the public health community get it about walkability?

Kaid Benfield

Posted September 1, 2010

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  (Centers for Disease Control)

With the exception of some real heroes in the field such as Dick Jackson and Howie Frumkin, I simply Can Not Get public health advocates interested in how the shape of the built environment affects health.  I’ve been trying for at least a decade.  The field, at least in the environmental community, is built on toxicity of substances and emissions, not environmental factors affecting fitness.  So it simply is not a matter of professional expertise or interest to my health-advocate friends.  And that’s a real shame, because their presence in the debate could make such a difference.

Research proves that sprawl is significantly associated with inactivity and obesity, now perhaps the nation's foremost public health menace.  The results of overweight and obesity include increased coronary heart disease, type 2 diabetes, cancers (endometrial, breast, and colon), hypertension, dyslipidemia, stroke, liver and Gallbladder disease, sleep apnea and respiratory problems, osteoarthritis, and gynecological problems (abnormal menses, infertility).  Research also shows that walkable neighborhoods and transit improve fitness and the health of communities.  Sure sounds important to me.

Finding the synergies between, say, smart growth and health to forge a more holistic approach to our environmental well-being is what sustainable communities should be about, in my humble opinion.  I’m not going to stop trying.

I focus on this today because of a provocative article by Steve Miller posted on Eric Britton’s World Streets.  I know they won’t mind if I quote the writing extensively, but please visit the site and read it in its entirety.  Here’s part:

“To the extent that transportation impacts global warming (it produces about a third of global greenhouse gases), or the livability of our neighborhoods (the transformation of urban villages into isolating suburban sprawl, and perhaps even the pulling apart of today’s multi-generational families, can be partially blamed on the automobile), or the growing diabetes epidemic (significantly caused by obesity which is significantly caused by lack of physical activity)…then how we move around matters.

“In the public health world, the environmental equivalents to road structure are the systemic patterns that make some things easy to do – the ‘default choices’ – and others more difficult. Nearly two-thirds of US adults are overweight, and nearly half of that group is obese. But our ‘obesogenic environment’ surrounds us with opportunities to remain physically passive while we eat too much of faux-foods deliberately manufactured to trigger our evolution-based biological craving for fat, salt, and sugar. ‘Everyone knows that you shouldn’t eat junk food and you should exercise,’ says Kelly D. Brownell, the director of the Rudd Center for Food Policy and Obesity at Yale. “But the environment makes it so difficult that few people can do these things.

“And, as we all know, like New Year resolutions, dieting doesn’t work. ‘If you take a changed person and put them [back into] the same environment, they are going to go back to the old behaviors,’ says Dr. Dee W. Edington, the director of the Health Management Research Center at the University of Michigan. ‘[But] if you change the culture and the environment first, when you get [personal] change it sticks.’

“As another health researcher has pointed out, ‘Personal life-style is socially conditioned. . . . Individuals are unlikely to eat very differently from the rest of their families and social circle. . . . It makes little sense to expect individuals to behave differently than their peers; it is more appropriate to seek a general change in behavioral norms and in the circumstances which facilitate their adoption.’

“Unfortunately, neither in transportation nor public health have the full implications of this reality been fully absorbed. During the recent debates over national healthcare some of the fiercest attacks were against the ‘nanny state’ proposal to encourage bicycling or the ‘anti-free market’ idea of influencing the food system. On the other hand, the fact that primary prevention and systemic health promotion were even part of the national debate was (minimally) encouraging.

“And a new paper by the new Director of the Centers for Disease Control (CDC), Dr. Thomas R. Frieden, might provide the basis for renewed strategic thinking in both fields, although transportation advocates will have to start by translating some of its ideas and language into their own framework and jargon – a task that the following hopefully begins . . .”

Well worth reading and considering, here.

Move your cursor over the images for credit information.

Kaid Benfield writes (almost) daily about community, development, and the environment.  For more posts, see his blog's home page. 


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Tracy MoaveroSep 1 2010 12:33 PM

One organization that does a great job of making the connections is PolicyLink. They tie together the health and environmental issues of walkability with economics and reducing poverty. They also combine policy research and community organizing, so they work "outside the box" in more ways than one.

Bob Van MeterSep 1 2010 01:57 PM

The San Francisco Federal Reserve and the Robert Woods Johnson Foundation convened community development folks and public health people on July 13th in Washington and a large part of the discussion was on the impact of the built environment and fitness. Among the more interesting speakers from the public health world were David Fleming from the Seattle King County Public Health Department and Leonard Syme from UC Berkley. There is a video of the conference and other materials at the this web site Angela Gover Blackwell from PolicyLink was there and spoke effectively as well. The premise of the conference is that there is an emerging convergence about the importance of place and a lot of potential for collaboration between community developers and those concerned about public health. PolicyLink has clearly been in the forefront on this work but they are not alone.

Tony DeLuciaSep 1 2010 02:44 PM

Oh, I think we get it all right, but haven't come to grips with the fact that our role is not leading at every turn, but being a real part of a multidisciplinary team...take economic development challenges and opportunities that align health outcomes and prosperity of neighborhoods, towns, cities, regions, etc., ...for the most part we are clueless and should not be in the driver's pun intended.

Kaid @ NRDCSep 1 2010 04:05 PM

You are absolutely right about the Robert Wood Johnson Foundation, which, along with the CDC, has done more to expose the links between health and the built environment than anyone. It is amazing how much they have accomplished.

And I am a big fan of PolicyLink for all sorts of reasons, not just this one. I only wish more mainstream environmental advocates would also get a clue.

E. RaynaultSep 2 2010 10:17 AM

For several years, the American Public Health Association (APHA) has addressed the public health impacts from the built environment and from transportation networks, while also embracing and promoting the health benefits stemming from expanded walking, cycling and transit facilities.

For example, in 2006 APHA’s National Public Health Week ( focused on children and the built environment; the tagline was “Designing Healthy Communities: Raising Healthy Kids.” Physical activity – such as walking and biking – was a principal theme for both APHA and its public health partners. More recently, we released a report titled The Hidden Health Costs of Transportation that delineates health impacts and costs associated with transportation systems.

We completely agree that research indicates walkable and bikeable neighborhoods and access to transit improve community health. Much of this research has been published in our American Journal of Public Health (AJPH) ( Notably, the Frieden paper mentioned is found in the AJPH (April 2010, Vol 100, No. 4). A cursory search of the term “walkability” yields more than a dozen AJPH articles dating back to 2003. In fact, the theme of the AJPH in September 2003 (Vol 93, No. 9) was the built environment; it contains Richard Jackson’s article titled “The Impact of the Built Environment on Health: An Emerging Field” and Howard Frumkin’s article “Healthy Places: Exploring the Evidence.” We hope that these resources are useful to readers.

We are privileged to educate health advocates about the intersection of transportation and health this fall at our Annual Meeting in Denver, Colorado. We have scheduled numerous, innovative sessions and papers on topics related to public health, the built environment and transportation, such as:
o Federal Surface Transportation Bill: An opportunity to support physical activity and healthy communities
o Land use and transportation equity is health equity: Strategies used by a healthcare organization to connect the dots
o Getting from here to there: Traffic, transportation policies, and public health

Via these and other education and advocacy activities, APHA - and its health partners across the country – is encouraged that the public health community’s energetic presence in this debate will bring many beneficial changes in the nation’s transportation practices.

Ken SmithSep 2 2010 11:10 AM

There is an emerging movement across the country to build healthy, vibrant, resilient, and sustainable communities. It looks like you never talked to people in the public health community who work in community health. Nor have you looked at the Healthy Communities initiatives in the Division of Adult and Community Health at the CDC. Poor research!

Marya MorrisSep 2 2010 11:33 AM

I'd like to offer a dissenting and somewhat more positive view.

Ten years ago when RWJF first became engaged in health/built environment issues we (RWJF grantee orgs, incl. APA, NACCHO, ICMA, NCSL) could count on one hand the number of county health agencies that were tuned into the health/community design relationship and that were working collaboratively with planners, housing, transportation types, etc. to better understand and ultimately interject health considerations into land use and transportation decisions and spending.

As part of a RWJF contract earlier this year, I looked into what national and regional NGOs as well as state and county health departments are doing TODAY on these issues. My analysis included walkability/active living programs but also other buitl env-related health determinants like poverty, disinvestment, violence, & safety.

Turns out there has been substantial increase in the number of health/land use/transportation initiatives within regional, county, and local govts. There has also been a lot of tech assistance/training support (e.g., PolicyLink, Prevention Institute, NACCHO, APA, others) and a ton of research (e.g., Univ. of MN Design for Health) on which interventions work and why. (Those also turn out to be very hard questions to answer.) Many but not all of these efforts are looking to health impact assessments as a key tool for broader acceptance/understanding of how BE affects health.

If anything I would say that many counties and cities stalled once they spent a few years addressing walkability and active living issues (either comprehensively or on a demonstration basis) and need to think and act broadly to address the other built environment determinants of health. Also a lot of the focus has shifted to food systems issues (e.g., food deserts) and climate change which is great but it doesn't mean we are done promoting policy and practical collaboration among health, planning, transpo, redevelopment, law enforcement, housing, etc. on walkability, safety, injury prevention, etc.

Maybe can call the next phase of the movement Efficient Routes to Lunch.

eric brittonSep 2 2010 12:50 PM

Thanks for the kind way you referenced this Kaid. It reminds me that we shoudl bge doing more together. Next? Regards/Eric Britton

Jim BoumanSep 2 2010 01:28 PM

“Unfortunately, neither in transportation nor public health have the full implications of this reality been fully absorbed. During the recent debates over national healthcare some of the fiercest attacks were against the ‘nanny state’ proposal to encourage bicycling or the ‘anti-free market’ idea of influencing the food system.

Just because "fiercest attacks" mentioned above were made, that's no reason to blame public health advocates, leader, and practitioners. It is the cheese doodle magnates, soda pop pushers and greaseburger 'n' fries lobby that makes that push.

And if the lobbyists pour money into congressional races and presidential races. That's what produced paralysis in any discussion of how profiteering is killing us. Public Health gets short shrift at every turn. It's not sexy, gets no high=powered lobbyists to shill for it.

Don't point a finger at PH for an alleged failure to absorb the full implications. It is war; and the advocates of grease and salt and sugar have all the guns.

Kaid @ NRDCSep 2 2010 04:54 PM

I think the commenters have a point here. My frustration is not really with "the public health community" and I shouldn't have labeled it as such. My frustration is really with the public health wing of the environmental community, which is not representative of the public health world writ larger.

Nancy ThompsonSep 2 2010 07:45 PM

While I nearly always agree with you, Kaid, in this instance I think that you're wrong and that the component of the public health community that worries about obesity is quite aware of the build environment issue. Local foundations right up to Robert Wood Johnson are really on this bandwagon, to the extent that I fear they will drive obese people into shame rather than into walkable communities.

Yes, the environmental scientists who worry about public health from the standpoint of chemical exposure, etc. are probably clueless. But given the exponential expansion of interest in this topic over the last few years, that too might fade.

Kaid @ NRDCSep 3 2010 12:29 PM

I agree with your first paragraph, Nancy. I should have been more clear and specific.

Janani SrikantharajahSep 3 2010 02:28 PM

Kaid, the sentiment in your post is exactly the reason Prevention Institute was founded over thirteen years ago. Our executive director tells a story of the early days when he was working on tobacco policy and he had to explain to his boss why handing out brochures on how to quit smoking didn’t qualify as quality prevention. Public health has come a long way since those early years. While we are still doing some education around the fact that prevention is not brochures but rather, that prevention is changing the community environments that we live in and the norms that dictate and reinforce particular behaviors, we are also working with a host of innovators to develop the systematic practice of prevention.

In the past year we’ve seen a remarkable groundswell of interest in quality primary prevention – addressing the underlying, community level factors that lead to injuries, illnesses and inequities so they don’t occur in the first place. It is not “minimally encouraging” that prevention was in national health reform – this was a HUGE success. A success that creates the first ever national funding stream that will distribute funds directly to communities to address the built environment and norms.

We certainly can’t afford to stop pushing for change but it’s important to recognize that many practitioners in public health and beyond (and there are many more voices than the two very notable and accomplished men mentioned in this piece) work hard day to day to make prevention happen. The next step is indeed building better bridges between fields that have historically functioned in silos (public health, medicine, environment, transportation and planning, education). Specifically around transportation policy, the Healthy Eating Active Living Convergence Partnership, a collaborative of national health funders, has played a leadership role in building better linkages between health, equity and transportation by commissioning a series of white papers examining these linkages that was compiled into the book, Healthy, Equitable Transportation Policy. The opportunities laid out in this book emphasize the notion of convergence and ways various sectors (including the environment sector) can support health and equity goals through transportation policy. These are exactly the types of crosscutting strategies that can turn the tide on rates of chronic disease AND address a host of other illnesses, injuries and inequities.

Kathleen FurtadoSep 6 2010 03:06 PM

I absolutely agree that our built environment determines our health to a degree that is not yet acknowledged. This short YouTube video from Copenhagen shows how we could easily make changes in US cities that would encourage physical activity and social interaction.

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