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47^th International Making Cities Livable Conference on True Urbanism: Cities for Health and Well-Being, May 10-14, 2009.

Public Health and Planning Professionals Join Forces

Public health data provide irrefutable arguments for restructuring and reshaping our neighborhoods, towns and cities. The 47^th International Making Cities Livable Conference in Portland, OR, May 10-14, titled "True Urbanism: Cities for Health and Well-Being" brought together elected municipal leaders, professionals in planning, urban design, transportation planning, public health, pediatrics and child development in interdisciplinary sessions, to share information and expertise on how to achieve healthy cities.

Speakers from the health professions and social sciences presented health and development issues related to the built environment. These issues were addressed by planners, urban designers and elected officials who presented for discussion some of the world's most healthy and sustainable planning strategies and design solutions. Public health practitioners presented healthy planning programs and initiatives being implemented through their work with communities.

Impact of sprawl on public health

Much research has identified negative health consequences of sprawl. In a presentation on "Do ‘smart' places have less urban health penalty?" Yingling Fan reported groundbreaking research at the Humphrey Institute of Public Affairs, University of Minnesota, charting the relationship between sprawl and death from a variety of illnesses. The study employed national cross-sectional data to examine the impact of metropolitan-level sprawl on differences in urban and suburban mortality, and longitudinal data to examine changes in urban and suburban mortality over time in Portland, OR.

Their evidence suggests that "sprawl imposes elevated mortality risks upon both urban and suburban residents" and that "Portland's extensive smart growth efforts are associated with improved health benefits and quality of life in the area." Download full paper.

Controlling sprawl in Portland, OR

Long recognized as a US leader in controlling sprawl, Portland's strategies -- urban growth boundaries, a regional growth strategy, transit oriented development, compact walkable neighbourhoods, transportation options, protection of green area, and integration of land use and transportation -- were presented by David Bragdon, President of Portland Metro Planning Council. While compact walkable neighborhoods, public transit and bike use are well accepted goals in the City of Portland, there is often resistance to compact development and infill in surrounding towns within the growth boundary. Download full paper. Metro Council Member Robert Liberty provided an overview of how communities around the US are addressing sprawl, the extent of the problem, and the resistance to change.

Place-based strategies to Encourage Healthy Living: LA County

In 2008, Los Angeles County's Department of Public Health awarded five grants to cities and non-profits to create a policy (such as incorporating a health element into a city's General Plan), along with a built environment change that facilitates physical activity, (such as improved bike paths, traffic calming, or walking trails). Louisa Franco, Policy Analyst for the Policies for Livable Active Communities and Environments (PLACE) Program, L. A. Co. Dept. of Public Health, discussed successes and challenges of this program, and highlighted the critical need for and value of partnerships between local health departments, city planners, and community groups. The PLACE Program helps Pacoima Beautiful, LA County Bike Coalition, and the cities of Long Beach, Culver City and El Monte to promote healthy lifestyles and activity, create access to healthy food and recreation, and complete physical projects to accomplish these goals. Download full paper.

Bicycle-Friendly Planning in Germany

Freiburg, Germany has long been recognized as a model city for walkable, bike-able, child-friendly and sustainable planning. Dr. Sven von Ungern-Sternberg, under whose 20-year leadership as First Mayor in charge of planning, these innovative improvements were introduced, presented strategies, planning and design details used to achieve Freiburg's 260 mile (420 km) network of bike routes.

Most of these routes are completely separate from motorized vehicles and pedestrians. Many were newly constructed along rivers, bridging under highways to avoid intersecting with traffic. Signage, bike rental and repair stores were provided, and a Bicycle Station was constructed at the train station. Sheltered bike parking was created in the city, at schools, apartment buildings, and transit stops. As a result of this investment, (a minor sum compared to the cost of investing in public transit) 28% of all trips in Freiburg are now made by bike.

Design Guidelines for Healthy Cities: The SLIM DOWNtown project, Manhattan, KS

Responding to the opportunity of a redevelopment project in Manhattan, KS, Susanne Sieple-Coates, Professor of Architecture at Kansas State University, emphasized that it will take more than walking trails, traffic calming and bike lanes to promote active living. The environment has to be composed of "attractive and enjoyable places that entice people to walk and bicycle instead of using their cars. More specifically", emphasized Siepl-Coates, "urban environments must consist of ... places that are compact, mixed-use and small-scaled in nature; places that ... allow citizens to experience themselves as members of their community." Based on this vision, the SLIM DOWNtown project developed design guidelines based on Christopher Alexander's Pattern Language to formulate a vision for a walkable and bikable Manhattan. The 77 recommended patterns included such elements as linked plazas and public squares, living above stores, eyes on the street, farmers market, brick streets and sidewalks, art in the public realm, etc. Download full paper.

Active Living by Design: Portland, Oregon

Noelle G. Dobson, MPH, Oregon's Public Health Institute, Portland, OR presented the program's "collaborative efforts to encourage healthy communities through policy, environmental, and social change." These efforts, suggested Dobson, "can serve as a model for other communities" to encourage physical activity and healthy eating."

The program's four broad goals are: to prepare and sustain a network of diverse partners; to impact urban planning and policy decisions at the City, County, and Metro level; to impact built environment changes in community settings to improve active living infrastructure; and to recruit and support local partners. Download full paper.

Building a City-Level Fitness Index

Brenda Chamness reported on the American College of Sports Medicine's American Fitness Index^TM designed to provide comparative data linking health to community/environmental indicators.

The research ranked 50 metropolitan areas according to their health scores. Of special interest to planners, urban designers and city officials are the environmental and community characteristics identified as supporting healthy living in those cities with high scores (e.g. Washington-Arlington-Alexandria), and characteristics that hinder healthy living in those cities with low scores (e.g. Oklahoma City, OK). Download full paper.

Health and nature

Dee Merriam, FASLA, Community Planner at the National Center for Environmental Health, Centers for Disease Control and Prevention, (CDC), in Atlanta, reviewed the research linking health with views of and access to nature, and stressed the importance of planning implications of this research, such as creating nearby parks, maintaining urban tree canopy, and supporting green infrastructure.

Reducing vehicle miles traveled lowers deaths from asthma and car crashes. Non-motorized travel, improved mass transit, and environments that support an active life style increase physical activity. This in turn reduces incidence of heart disease, cancer, stroke, COPD and diabetes - all of which are linked to the current obesity epidemic. Dee Merriam showed how increased physical activity can be achieved through planning, urban design and streetscape, and outlined tools available through codes, ordinances, standards and design guidelines.

Urban Parks and Trails

Landscape Architect Charles Anderson presented Seattle's award winning Trillium Urban Nature Projects, transformed from six left-over urban nature spaces. "From Seattle schools using the sites as outdoor classrooms for environmental education to public and private agencies and companies that donated thousands of volunteer hours, the Trillium Projects speak of community, where plants, wildlife, and people grow together."

Julianna Delgado, Associate Professor of Urban and Regional Planning in Pomona presented plans to connect extensive revitalization projects along the Los Angeles and San Gabriel rivers to form "a comprehensive, regional trailway system, especially through communities in need of open space and quality recreation sites." Download full paper.

Improving Equity and Health through The Built Environment

John C. Hu, Faculty of Health Sciences, Simon Fraser University made significant connections between inequalities of health and land use/urban design issues. He pointed out that access to health care is determined by factors such as distance, transportation cost, and time. "These factors are invariably impacted by planning decisions involving density, public transit, walkability, and mixed-use." Download full paper.

These issues were amplified by Daniel Iacofano, Principal in Moore Iacofano Goltsman, Berkeley, CA, who presented an overview of the firm's policy framework for The Inclusive City: Design Solutions for Buildings, Neighborhoods and Urban Spaces to address the needs of all city residents. Download full paper.

Planning for food and health

Trevor Budge, from La Trobe University, Australia reported that while substantial initiatives exist at the local and community level linking land use planning to issues of food and health, none of the comprehensive metropolitan planning strategies have paid more than lip service to the "significance of agricultural production at the urban edge and the need for urban form and transport planning to consider health outcomes." Controlling and limiting sprawl are core policies, he asserts, but planning for "food security and urban agriculture, and linking urban form and design to health outcomes are now critical future agenda items for metropolitan planning". Download full paper.

Child-Friendly Strategy

To ensure that the built environment is healthy for all, conference organizer Suzanne Crowhurst Lennard opened the conference by proposing that neighborhoods and cities should be designed to be healthy for children. "If our neighborhoods and cities are unhealthy or lack livability, children are the first to suffer - and they suffer more deeply." She stressed that we should "take children as the golden rule by which we measure appropriate planning solutions. If we consider how all our city-making decisions affect the lives of children, we shall begin to create healthy, sustainable cities for all." Download full paper.

Perry Bigelow, Founder and President of Bigelow Homes, presented an exemplary model of a child-friendly new neighborhood at HomeTown Aurora, IL. Houses are grouped around pedestrian "Living Courts" where little children play safely close to home and engage with neighbors. Streets are traffic calmed, with wide sidewalks, raised pedestrian crossings and jogged traffic lanes to ensure slow moving traffic, so older children can safely explore their whole neighborhood. Numerous parks, large and small, each with its own special character, provide natural play areas. They are faced by homes with bay windows and front porches, creating "eyes on the park."

Child Development and the Built Environment

We must be concerned not merely to prevent cities and suburbs from having a detrimental effect on children's health, but rather to contribute to their optimal development as full human beings, emphasized Crowhurst Lennard. The built environment should provide all children with safe routes, a hospitable built environment, and places where they can interact with nature and community in a variety of ways on a daily basis. She illustrated how children's development of motor skills, autonomy, spatial skills, social competence, empathy, responsibility, self confidence, verbal skills, curiosity, mental dexterity, creativity, abstract thought, practical understanding of the world, sound judgment, appreciation of beauty, joy and wonder are all deeply influenced by the physical environment in which they live.

Karen Peterson, Professor, and Coordinator for Early Learning Programs at Washington State University Vancouver combined the fields of child development and environmental design to explain how adults can best design, create, and construct public space for children aged five to eight. "Children are curious and cautious, spontaneous and intentional, present time invested, and dependent on shielding adults". They need environments with a strong sense of place to foster a sense of community and belonging. "Crafting cities that are livable for children", asserts Peterson, "means creating places that build a genuine sense of knowing that ‘I belong here' and ‘this is my place, too.'" Download full paper.

No Child Left Inside

Sue Smith, National Director of Education for Keep American Beautiful, congressionally appointed to the U.S. Environmental Protection Agency for Environmental Education, discussed programs throughout the country that connect children to nature and the outdoor world.

Outdoor environments should stimulate discovery, experimentation with cause and effect, and playful social interaction, asserted Avery Goldstein, California State University Long Beach. She focused on how to design natural outdoor areas to foster children's free play and discovery, and showed how designs can emphasize unstructured creative exploration with diverse materials. Planting beds encourage children's nurturing behaviour and collaborative relationships with participating adults. Involving children and adults in the design of outdoor play areas develops a sense of ownership and self esteem. Download full paper.

Suzanne R. Smith and Jane D. Lanigan, Dept. of Human Development, Washington State University Vancouver focused on how to ensure that young children have contact with nature both out of doors and in the classroom. Outdoor play areas "challenge young children's motor skills, reduce sedentary behaviour, and encourage creative play, exploration and social skills." Improvements in childcare outdoor areas can be made gradually and often at a relatively low cost to include "diversity of the physical environment, natural elements, fixed and portable equipment or materials, and adult structured activity." Download full paper.

Preventing Childhood Obesity

Margaret Everett, Ph.D., Portland State University, Angie Mejia, MA, Oregon Health & Science University and Olivia Quiroz, Multnomah County Health Department reported on the Healthy Eating Active Living (HEAL) Coalition's program "to promote community health and prevent childhood obesity by addressing barriers at local, regional and policy levels, with particular attention to the built environment." The program engages parents, community health workers, and numerous community organizations in the promotion of physical activity and healthy eating." It also addresses the environmental factors that contribute to obesity and related health disparities. The program seeks to "implement strategies that influence community norms and lead to the adoption of policies that make it easier for the community at large to eat well and be physically active." Download full paper.

Walking School Buses

In a survey of Walking School Buses (WSBs) in the Auckland, New Zealand, Robin A. Kearns, from The University of Auckland reported that many respondents insisted that children are entitled to walk to and from school, and that dangerous driving, intersections that cannot be safely navigated, and deteriorating pedestrian infrastructure - are unacceptable.

Routine walking in groups helps to break down social isolation associated with auto-dependent lifestyles, Kearns observed, and alerts adult participants to "costs and dangers associated with allowing motor vehicles to dominate the public spaces of everyday life." WSBs can be regarded as stepping stones towards children's independent mobility and significantly reduced car use. "If these twin goals were achieved," Kearns observed, "formalized WSBs might not be needed." Download full paper.

Collaboration between public health and planning professions

What do urban and transportation planners know about the impact of planning on health and well-being? Where can professionals in public health and planning find common objectives? These questions were addressed in research undertaken by New Zealand's Public Health Advisory Committee on Urban Environments and Health, reported by Kerrie Duncan, Policy Analyst and Robin Kearns, PHAC member and Lead Sponsor of the project.

They found that urban and transportation planners know about the impact of planning on physical activity and nutrition, and are aware of how planning strategies can reduce community health inequalities. There is a significant level of interest in these issues in both public health and planning professions; both regard these as priority areas, but need to understand each other better and develop common objectives. "Further work that focuses on the role of public health practitioners and their influence and understanding of community planning also warrants exploration." Download full paper.

A Perfect Storm

Richard J. Jackson, MD, Professor and Chair of Environmental Health Sciences at UCLA brought the conference to a resounding close. We are at a "Perfect Storm", Jackson warned, where social, health, economic and environmental challenges are all colliding.

"Imagine the overweight ten-year old boy who is put into a weight loss program" Jackson urged. "He is referred to an overweight clinic, soft drinks are banned from the house, the TV is removed from his bedroom, sports and exercise are encouraged. Two months later he has lost one pound; he can't change the food at school, the day is too full, there is no time for exercise, and there is no place to walk. Two months later he is given four medications to control hypertension, obesity, cholesterol and depression, at a monthly cost of $385. The environment is rigged against the patient - and the doctor."

Health care expenditures have skyrocketed to 16.3% of the GDP in 2007 and are expected to rise to 19.5% by 2017, observed Jackson, and yet life expectancy is declining in some parts of the country. This is connected to the fact that we have now paved over 60,000 square miles of the country - the equivalent area of Georgia. Miles driven per capita has more than doubled in one generation. Atlanta is considering widening I-75 to 23 lanes. Meanwhile, for every age group from 3 to 33, traffic crashes were the leading cause of death. Automobile fatality rates vary from city to city. Atlanta has the highest fatality rate, while New York, where many people walk or take transit, has the lowest. If national fatality rates were the same as New York 24,000 lives would be saved; if they were the same as Atlanta, an additional 15,000 lives would be lost.

Obesity rates have ballooned in the last ten years. Now, in three states 30% of adults are obese. In California 17% of children under five are obese, and 21.7% of children five to twenty are overweight. Poorer neighbourhoods are more at risk because they contain more fast food restaurants. Following the increasing obesity, diabetes has soared. It is now estimated that one in three children born in 2000 will have diabetes before they are 40, shortening their life by 13 years.

The more time spent in the car results in the higher probability of obesity. More walking leads to less obesity. The Atlanta study by Lawrence Frank demonstrated that higher density land use and more connectivity was linked to more walking and less obesity.

Our population is aging, and medical and social security costs are increasing dramatically. Older people living in walkable neighbourhoods, however, walk more and maintain their health.

The policy of closing neighbourhood schools and building larger new schools on cheaper land outside the town has increased dependence on school bussing. This removes the opportunity for most children to walk to school.

We are acutely aware of our current economic challenges: businesses and factories are closing, unemployment soars and will continue to stay bad until after the recession has ended. In the last great depression we put people to work on massive construction projects - the Empire State Building, the Golden Gate Bridge and the Hoover Dam, to mention only a few.

Environmental challenges have been increasing steadily. During the last 25 year the global average temperature has rapidly increased. It is essential to mitigate this effect by reducing the release of greenhouse gasses to the atmosphere, but now, we also have no choice but to adapt to the inevitable changes in storm patterns, sea level, agriculture, habitable land and temperature.

Where do we go from here?

"Where do we go from here?" asked Dr. Jackson, and outlined some answers. Be mindful about what we eat, and take steps to change our eating patterns. We consume so much high fructose corn syrup that a one cent tax per spoonful would yield $18 billion per year that could help mitigate the damaging health effects. School gardens, farmers markets, healthy food vending at transit stops, and more agricultural education are important contributions.

Walking or biking to school increases concentration, improves mood, alertness, memory and learning and enhances creativity. Instead of creating larger schools that require bussing we must focus on improving small schools within neighbourhoods and making them safe, accessible and healthy.

Create more parks and green space. A 10% increase in urban parks will result in a 4°F decrease in urban surface temperature. In 2007 Mayor Bloomberg announced a plan to ensure a park or playground within a 10 minute walk for every New Yorker. In 2008 Governor Schwarzenegger signed the first-in-the-nation legislation to reduce greenhouse gasses through land use.

Build better buildings, complete streets and walkable, healthy cities. Wide sidewalks, bike lanes, narrow traffic lanes, medians, roundabouts and street trees encourage walking and biking. And make places at the heart of the community where people love to come together. As was demonstrated in Vauban and Rieselfeld, Freiburg, under the leadership of Dr. Sven von Ungern-Sternberg, it is possible to create new neighbourhoods where all can live without a car.

How we can work together

During the last few years, the academic fields of public health and planning have made great strides in interdisciplinary collaboration. According to a report on A Model Curriculum for the Built Environment and Health in the January issue of the American Journal of Preventive Medicine, six faculty members currently offer graduate courses that bring together public health and planning students. In 2003, the American Public Health Association reported no articles dealing with land use issues in relation to public health; in 2008 however, 82 articles on these issues were published.

The Centers for Disease Control and Prevention are now actively involved in promoting ways to design and build healthy places. Tools include health elements in General Plans. Fourteen California cities now include health elements in their general plans that will powerfully orient government actions for decades.

In June 2009 the American Academy of Pediatrics published a policy statement on "The Built Environment: Designing Communities to Promote Physical Activity in Children". The International Making Cities Livable Council (IMCL) and the National Town Builders Association (NTBA) wholeheartedly support the AAP policy statement, and offer a tool for achieving this goal. IMCL and NTBA are partnering to help guide the development of a "Child-Friendly Community" Certification program that gathers together under one umbrella all the guidelines necessary to design and restore neighborhoods that encourage children's physical and emotional health and well-being - neighborhoods that offer children the free range and daily contact with nature and community they require. Qualifying projects will be officially certified and celebrated as "Child-Friendly".

To follow up on the overweight boy discussed at the beginning of Dr. Jackson's presentation: if he now lives in a neighbourhood built or adapted to recommended health standards, and walks or bikes to school, after two years he will have normal blood sugar and cholesterol levels, good energy and mood levels. The family car will run 1,280 miles less per year, saving 64 gallons of gas (a saving of $704), and he will have made new friends and be learning better. Download full paper.

Conclusion

With the support of irrefutable findings from the health sciences it is clear that the principles of True Urbanism as codified by IMCL - compact walkable mixed use neighborhoods, a human-scale built fabric providing eyes on the street, daily access to nature and to social life in hospitable public places, public events such as farmers markets and festivals that generate social life, and public transit that provides all ages with access to social and cultural resources - must be adopted throughout the country. These principles are essential for developing social life and community, for raising healthy and socially adept children, for increasing well-being for all ages, for reducing carbon footprints, for establishing social and economic sustainability, and for improving the social and physical health of people of all ages, especially children.

We shall continue to look to the health and social sciences to reinforce our resolve to make necessary changes in zoning, design guidelines and planning practice, and to influence decision makers as to policies that need support. These principles must be incorporated into general plans and design guidelines in cities, towns and neighborhoods if we are to achieve healthy and sustainable communities in the future.