Design Matters: Planning for Healthy Communities

1. Design Matters: Planning for Healthy Communities Dr Trevor Hancock Public Health Consultant Population Health and Wellness Ministry of Health Services

2. Cities and the health of the nation "Many would be surprised to learn that the greatest contribution to the health of the nation over the past 150 years was made not by doctors or hospitals but by local government. Our lack of appreciation of the role of our cities in establishing the health of the nation is largely due to the fact that so little has been written about it..." Jessie Parfitt, 1986

3. How did urban conditions affect health?

4. Manchester's River Irk in 1845 "...a narrow, coal-black, foul-smelling stream...in dry weather, a long string of the most disgusting, blackish-green slime pools are left standing...from the depths of which bubbles of miasmatic gas constantly arise and give forth a stench unendurable even on the bridge forty or fifty feet above the surface of the stream." Frederick Engels

5. Manchester, 1859 "Earth and air seem impregnated with fog and soot. The factories extend their flanks of fouler brick one after another, bare, with shutterless windows, like economical and colossal prisons...Through half-open windows we could see wretched rooms at ground level, or often below the damp earth's surface. Masses of livid children, dirty and flabby of flesh, crowd each threshold and breathe the vile air of the street, less vile than that within...“ Hipployte Taine

6. The health impact • Life expectancy for mechanics and labourers in Manchester in 1842 was 17 years

7. How did health affect urban affairs?

8. Health and urban affairs • Renaissance Italy’s City States had Boards of Health • 1843/4 – Health in Towns Commission and Association, UK • 1875 – The ‘Great’ Public Health Act • “Hygeia: A City of Health” • 1890s – Garden Cities

9. Health and urban planning • Waste management • solid • liquid • Water treatment • Housing conditions • Zoning • Various City Departments • Urban planning in Canada

10. 1912-21 Canada’s Commission on Conservation • “The City Healthy” - 1915 • Thomas Adams and urban planning – 1914 - 1917 • 1915 – Toronto is “The healthiest of large cities” - (MacLean’s Magazine) • 1929 –1938 – Milwaukee “The Healthiest City”, US Chamber of Commerce’s Inter-Chamber Health Conservation Contest

11. You are heirs to a great tradition!

12. Urban planning and health in the 21st century:The emerging literature

13. 3 recent books • Health and Community Design • Frank, Engelke and Schmid • Healthy Urban Planning • Barton and Tsourou/WHO Europe • Urban Sprawl and Public Health • Frumkin, Frank and Jackson

14. Selected planning policy areas(Barton and Tsourou,WHO Europe, 2000)Housing Economic Open Urbanpolicy developm’tspaceTransportform • Personal lifestyles * * ** ** * • Social/community * * * * ** • influences • Living/working • conditions • Housing ** * • Work ** * * • Access ** * * ** ** • Food * * * • Safety * ** * • Equity ** * * ** **

15. Selected planning policy areas(Barton and Tsourou,WHO Europe, 2000)Housing Economic Open Urbanpolicy developm’tspaceTransportform • General socio- • economic, • cultural and • environment • conditions • Air quality * ** * ** * • Water & • sanitation * * • Soil & • solid waste * * • Global • climate * ** * ****

16. Social conditions associated with health outcomes • Neighbourhood living conditions • Opportunities for learning and developing capacities • Community development and employment conditions • Prevailing community norms, customs and processes • Social cohesion, civic engagement and collective efficacy • Health services, incl public health The Community Guide, CDC, 2003

17. Urban Sprawl and Public Health Chapters in Frumkin, Frank and Jackson • Air quality • Physical activity • Injuries and deaths from traffic • Water quantity and quality • Mental health • Social capital • Health concerns of special populations

18. Travel and other characteristics of fourconcentric parts of the Toronto region Core Inner Outer Core ring suburbs Suburbs Residential density (urbanized portion, 7,340 5,830 2,810 1,830 persons/square km) %of households owning one or >cars 49% 75% 87% 96% Travel by car (km/person/day)7.5 10.2 15.0 25.6 Estimated CO2 emissions resulting from travel 1,710 2,280 3,222 5,200 (g/person/day) Source: Gilbert, 1997

19. Health costs 1,900 premature deaths 9,800 hospital admissions 13,000 emergency room visits 47 million minor illness days Economic costs $600 million in direct medical costs $560 million in direct costs to employers and employees for lost time pain and suffering - about $5 billion $4 billion for the value of the premature deaths Air pollutionand health, Ontario, 2000

20. Olympic Games and Air Pollution, Atlanta, 1996 • peak traffic count ß 22.5% • peak daily ozone ß 27.9% • asthma emergency events ß 41.6% • other medical events did not drop Source: “Creating a Healthy Environment” Jackson and Kochtitzky, 2001

21. Diesel Exhaust • Carcinogenic • Accounts for 90% of air toxics cancer burden • 70-80% from vehicles • May contribute to 125,000 lifetime cancer deaths in USA (STAPPA/ALAPCO, 2000)

22. The built environment and climate change • urban sprawl • energy-inefficient buildings • energy-inefficient technologies • vehicle motors, pumps, lights etc • NB - “pumps are the biggest users of motors, motors use 3/5 of the world’s electricity” - Amory Lovins, RMI

23. Direct effects more frequent heat events (which in urban areas will exacerbate air pollution) more frequent and severe extreme weather events, causing deaths and injuries flooding Indirect effects a wider distribution of insect disease vectors (particularly mosquitos) disruption of ecosystems, particularly agro-ecosystems and oceanic ecosystems Eco-refugees, conflict over resources Climate change and health

24. Mortality by Mode of Transport in Great Britain, 1983 to 1993 Motorcycle 102.9 Foot 68.8 Bicycle 48.5 Water* 9.2 Car 4.3 Van 2.6 Rail 0.9 Bus or coach 0.5 Air* 0.2 (death rates per billion kms travelled)

25. Urban design and traffic injuries • 1 point increase in ‘sprawl index’ over 448 US metropolitan counties = 1.5% in traffic fatality rate = 10x higher in most v least sprawling • Walking and biking fatality rates are higher in sprawling counties • BUT lower in counties - and countries - where walking & biking is common Frumkin, Frank and Jackson, 2004

26. Traffic deaths v violent deaths by stranger Risk of dying in 15 medium and large US metropolitan areas, over 15 years • Traffic fatality rate much higher in suburbs than risk of death by a stranger in the central city • and this would likely be even more true in Canada • so are we really safer moving to the suburbs? Lucy, cited in Frumkin, Frank and Jackson, 2004

27. Physical Activity and Health Status “One of the strongest theories (to explain the radical changes in the health status of Americans) is the significant decline in activity levels . . . today compared with levels from 50 or 100 years ago.” Jackson and Kochtitzky in Creating a Healthy Environment (Sprawl Watch Clearinghouse, 2001)

28. How (In)Active are Canadians? • Only 11% do aerobic activity sufficient to gain cardiovascular benefit (30 minutes at 50% of individual capacity, 3-4 x/week) • 33% of Ontarians are inactive (energy expenditure <1.5 kcal/kg/day)

29. Economic Burden of Physical Inactivity in Canada The costs attributed to physical inactivity for just seven conditions for which it is a known contributor (coronary artery disease, stroke, hypertension, colon cancer, breast cancer, type 2 diabetes and osteoporosis) • 2.5 percent of direct health care costs • 10.3 percent of deaths NB Does not include indirect costs e.g. lost productivity and long or short-term disability.

30. Why Are We Inactive? • Sedentary jobs • Inactive transport • commuting, shopping, etc • Sedentary leisure/housework • TV, internet, etc • powered vehicles (e.g., skidoo, seadoo, ATV, etc.) • power tools (kitchen, garden, repairs, etc.)

31. Deterrents to cycling/walking • Safety from other road traffic • Barriers due to road system • Unpleasant exhaust fumes • Lack of secure facilities for biker • Inconvenience eg., sweat, fatigue, pain Based on Morton, 2000 and WHO Centre for Urban Health

32. Benefits of Physically Active Commuting to Work Among 68 inactive middle aged men and women in a RCT, 1 hour daily PACW for 10 weeks led to increases in • VO2 max 4-5% • Max treadmill time 10.3% • HDL cholesterol 5% Source: Vuori, Oja and Paronen, 1994

33. The Benefits of Walking “Imagine if half the people in Canada who live within walking distance of their work left their cars at home. Their efforts would save approximately 22 million litres of gasoline per year!” Go for Green!

34. Costs of Transport/ Benefits of Walking • Total external costs of transport, 17 European countries, 1995 = 7.8% of GDP • If all sedentary adults in the US walked regularly, estimated savings could be $US 4.3-5.6 billion/year Source: WHO Europe, Centre for Urban Health

35. Reductions in Coronary heart disease Cancer (colon, breast) Obesity (leads to diabetes) Osteoporosis Arthritis Depression/ anxiety/stress Cognitive impairment Injuries related to MVAs/other power uses The Health Benefits of Active Living

36. Benefits of Parks and Recreation Personal e.g. stress management, self-esteem, health Social e.g. promotes involvement and interaction Economic e.g.productive work force, reduced vandalism Environmental e.g.improved environmental health and awareness

37. Commuting time & social capital • A 1 hour commute each way = a 40 hour work week every 4 weeks, or 11 - 12 work weeks a year • This is a large loss of family and community time = a large loss of social capital

38. Planning for Healthy Communities

39. Urban Design for Health • Denser, mixed use/New Urbanism • walk to stores, amenities • bike to work/school/ recreation • support public transit • Bike/walk friendly • sidewalks • bike lanes/trails • snow clearing policy • Public transit designed in

40. A Medical Miracle? “At its best, Smart Growth is like a medicine that treats a multitude of diseases - protecting respiratory health, improving cardiovascular health, preventing cancer, avoiding traumatic injuries and fatalities, controlling depression and anxiety, improving wellbeing. In the medical world, such an intervention would be miraculous. In the worlds of land use and transportation, it is a thrilling, and attainable, opportunity.” Frumkin, Frank and Jackson, 2004

41. Encouraging physical activity Municipal government Urban planning/design • Higher density • Mixed land use • Bike/walk friendly • Accessible and attractive paths, trails • Safety • Transit Parks and Recreation Services • ‘Active living’ programs • Services for those with low incomes

42. Encouraging physical activity/2 School boards • Curriculum • Make exercise fun and normal • ‘Walking school bus’ Businesses • Encourage ‘active commuting’ • Discourage free parking, esp downtown • Support active living (e.g stairs) • Adopt & maintain trails

43. Encouraging physical activity/3 Community agencies • Provide active recreation services • Encourage/support ‘walking clubs’ etc Citizens • Become active • Adopt & maintain trails • Turn off TV and get out! • Ditto for your kids!

44. It takes a whole community to raise healthy people!

45. Municipal governments:Policy and environments Use the public health provisions of the Community Charter, e.g. • Smoking by-laws • Public works (drinking water, sewage, waste disposal) • Traffic and roads (safety) • Housing quality (health, safety)

46. and more • Public transit (air quality, safety, physical activity) • Parks and Rec (physical activity, mental health, environment/ habitat) • Planning/Land use (air quality, physical activity, urban food systems) • other examples?

47. Some emerging developments • Public Health Act • Links to local governments • Requirements for planning for health • Core public health functions • Healthy communities, • Input to community planning • Healthy Living Alliance • Regional/local Alliances

48. Re-establish a BC Healthy Communities Network? • Healthy Living Alliance? • Legacies Now!

49. A global movement In every WHO Region • EURO - more than 600 Healthy Cities programmes • WPRO - approximately 170 cities • AMRO - estimated to be more than 300. • EMRO - Many countries have established national Healthy Cities networks - Healthy village programmes are now very popular in the Region • SEARO - ongoing Healthy Cities programmes exist in all Member States • AFRO - a number of cities have begun Healthy Cities activities.

50. Ontario Healthy Communities Coalition,(Sept 2004 Update) • Established in the late 1980s, and currently involves 166 active healthy community groups and coalitions within 98 locations. • Mission - “to work with the diverse communities of Ontario to strengthen their social, environmental, and economic wellbeing”.