Design Matters: Planning for

Healthy Communities

Dr Trevor HancockPublic Health Consultant

Population Health and WellnessMinistry of Health Services

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

How did urban conditions

affect health?

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

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

The health impact

Life expectancy for mechanics and labourers in Manchester in 1842 was 17 years

How did health affect urban

affairs?

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

Health and urban planning

Waste management solid liquid

Water treatment Housing conditions Zoning Various City Departments Urban planning in Canada

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

You are heirs to a great tradition!

Urban planning and health in the

21st century:The emerging

literature

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

Selected planning policy areas(Barton and Tsourou,WHO Europe, 2000)

Housing Economic Open Urban

policy developm’t space Transport formPersonal lifestyles * * ** ** *

Social/community * * * * **influences

Living/working conditions

• Housing ***

• Work ** * *

• Access ** * * ** **

• Food * * *

• Safety * ** * • Equity ** * * ** **

General socio-economic, cultural and environmentconditions

• Air quality * ** * ** *

• Water &sanitation * *

• Soil &solid waste * *

• Global climate * ** * ** **

Selected planning policy areas(Barton and Tsourou,WHO Europe, 2000)

Housing Economic Open Urban

policy developm’t space Transport form

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

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

Travel and other characteristics of four concentric parts of the Toronto region

Core Inner Outer Core ring suburbs Suburbs

Residential density (urbanized portion, 7,340 5,830 2,810 1,830persons/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

Air pollution and health, Ontario, 2000

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

Olympic Games and Air Pollution, Atlanta, 1996

peak traffic count 22.5% peak daily ozone 27.9% asthma emergency events

41.6% other medical events did not

dropSource: “Creating a Healthy Environment” Jackson and Kochtitzky, 2001

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)

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

Climate change and health

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

Mortality by Mode of Transport in Great

Britain, 1983 to 1993Motorcycle 102.9Foot 68.8Bicycle 48.5Water* 9.2Car 4.3Van 2.6Rail 0.9Bus or coach 0.5Air* 0.2

(death rates per billion kms travelled)

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

Traffic deaths v violent

deaths by strangerRisk 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

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)

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)

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.

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.)

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, painBased on Morton, 2000 and

WHO Centre for Urban Health

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

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!

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/yearSource: WHO Europe, Centre for Urban Health

The Health Benefits

of Active LivingReductions 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

Benefits of Parks and Recreation

Personale.g. stress management, self-esteem, health

Sociale.g. promotes involvement and interaction

Economice.g.productive work force, reduced vandalism

Environmentale.g.improved environmental health and awareness

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

Planning for Healthy

Communities

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

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

Encouraging physical activity

Municipal governmentUrban 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

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

Encouraging physical activity/3

Community agencies Provide active recreation

services Encourage/support ‘walking

clubs’ etcCitizens Become active Adopt & maintain trails Turn off TV and get out!

Ditto for your kids!

It takes a whole community to raise healthy

people!

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)

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?

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

Re-establish a BC Healthy Communities

Network? Healthy Living Alliance? Legacies Now!

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.

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”.

Villes et Villages en Sante (July 2002 update) There are currently some 150

municipalities that are members, covering some 50 percent of the population; most of Quebec’s big municipalities and many of its middle sized municipalities are members.

Regular membership, with voting privileges, is restricted to municipalities and is based on the passage of an official resolution by the Municipal Council.

Lessons from the Quebec and Ontario

experience Both organizations are based on

the membership of communities, who constitute the majority of the Board of Directors of both organizations.

Neither organization provides direct funding to communities, but instead provides a wide range of education, training and other supportive and capacity-building services and activities.

In Ontario, a key feature is that two-thirds of the staff are community animators based all around the province and providing services within defined regions.

Both organizations rely on close collaboration and partnerships with other provincial organizations and networks that have shared interests.

Both organizations are heavily dependent on government funding, but at arms length (through the Institute of Public Health in Quebec, as a non-profit charity in Ontario).

In neither case do provincial governments have members on the Board of Directors

A healthy city . . . " . . . is one that is continually

creating and improving those physical and social environments and expanding those community resources that enable people to mutually support each other in performing all the functions of life and in developing to their maximum potential."

Hancock and Duhl, 1986

Healthy Communities

Applies the concepts of health promotion in the settings where people live, learn work and play Homes Schools Workplaces Health care facilities Communities

Healthy Communities

approach Community involvement

The bedrock Political commitment

Local government is a key player Intersectoral partnerships

It takes a whole community . . . Healthy public policy

Creates the conditions for health

Healthy Community model