Daniel Parker, MSP Division Operations and Management Consultant
This is a full transcript of the online presentation. For the
presentation itself, go here.
This is Daniel Parker with the Division of Environmental Health in
the Florida Department of Health. Public health and urban planning are
gaining more and more importance in Florida due to large population
increases, post-9/11 fears, and more active hurricane seasons. On the
national front, research continues to show that these fields need to be
closer together to create more healthier built environments and to
respond to public needs.
Florida has been at the forefront of this movement with the use of the
Protocol for Assessing Community Excellence in Environmental Health, or
PACE EH. This community assessment model has been instrumental in
recognizing built environment problems as public health problems.
The results of Floridas PACE EH project have been thought provoking.
When county health department, environmental health officials worked
with communities on PACE EH, they began by asking the community this
question: What are your Environmental Health issues? What we found is
that if you let a community identify their issues, they will identify
what is usually in the realm of urban planning, the built environment,
as a public health issue.
For example, no sidewalks, no bike paths, no street lights, cut off from
other neighborhoods, dilapidated housing, no fire hydrants, heavy
traffic, sewage, flooding, and noise.
These are critical findings. Private health care primarily focuses on
the individual. Public health focuses on the community and thereby the
social aspects of health. We spend a lot of time as public health
officials discussing obesity, getting fit, and using alternative
transportation such as a bike or your feet. We dont spend a lot of time
discussing whether ones community has sidewalks to walk to school, or
whether residents are too fearful of sending their children out into
their neighborhood. It is as if we offer a prescription and only fill
half the bottle.
Here in Florida, these built environment issues are critical. Last year
alone, Florida had 400,000 new residents. The balance between creating
healthy, well-connected new communities, while addressing older,
established, and perhaps forgotten communities is going to be
But it can be done.
It is important for both public health advocates and urban planners
to remember how public health and planning are interrelated. In the
planning field, modern zoning dates back to 1926, to the Village of
Euclid vs. Ambler Realty Co. decision in Ohio. That decision established
that zoning was a proper use of local government to restrict unhealthy
activities. Here was planning and public health together. Eighty years
later, as public health and urban planning work primarily apart from
each other, some writers have asked whether public health outcomes of
planning have been completely forgotten; whether zoning hasnt
exacerbated the current challenges with urban sprawl, isolated
communities, and many social, mental, and public health measures
pointing in the wrong direction.
The feedback from the PACE EH communities, when they are allowed to
define their environmental health issues themselves, is actually very in
line with the definition of Environmental Health given by the Centers
for Disease Control and Prevention in their Healthy People 2010
initiative. A definition that recognizes the interaction between
planning and public health. A structural problem is that most government
programs are created to be limited and very program based. The results
from the communities, and this CDC definition, urges both planning and
public health fields to be wary of a programmatic mind frame. A mind
frame that says, If we dont have a program for it, or a legislative
mandate, or a monetary provider, it is not our business. As public
servants, we need to consider that this broad cross-cutting thinking is
exactly what government should be doing more of. Public health and urban
planning are supposed to see the bigger picture.
When we talk about the built environment, what are we talking about?
Health Canada defines the built environment as all of the buildings,
spaces, and products created, or at least significantly modified by
people. This would include the existence or lack thereof of urban green
space, sidewalks, connected communities, mixed use communities, and so
on. Ask yourself what is the built environment around where you live or
work, how much of it do you use, and for the parts that you dont use,
There are several ways in which the built environment is influencing
public health, including access to healthy food, support for social
capital, or what some would define as civic involvement in ones
community, and opportunities for walking or biking without fear. It is
clear by now that not everyone is going to be reached with the
importance of making good healthy decisions.
And we have to remember that free will and personal responsibility
are still an important determinant, if not the most important
determinant of healthy living. But the public health data calls for
action. In March, 2006, the International Journal of Pediatric Obesity
reported the number of overweight children will increase significantly
by 2010 with great repercussion to health and to economies. Relying on
personal behavioral decisions alone is no longer an option.
The obesity trend is being influenced in several ways, including by
urban planning decisions. Public health and planning has to find and
continually review the interaction between a resident and ones
environment. In February of 2006, researchers with the RAND corporation
say that several factors influence childrens weight, including their
age, hours of television viewing per week and their mothers weight.
Researchers considered additional influencing factors to be access to
parks and playgrounds and whether they live in safe neighborhoods. These
factors echo the response from communities undertaking the Florida PACE
A relevant question to ask is how many urban planners know the public
health statistics of their communities. If one looks at the overweight
and obesity statistics across the United States, the prevalence is
alarming. It is predicted that by 2008, 73% of US adults will be
classified as overweight or obese.
In order to assess all contributing factors, there must first be a
willingness amongst planners to accept that land use decisions can be
influencing these health results.
When one considers changing routine or process, it is helpful to
consider what the outcomes or the goals are supposed to be. In
reflecting on these quotes here, there are several questions to
consider. What is the goal of public health? What is the goal of urban
planning? One may consider that public health and urban planning are
trying to accomplish the same thing. A place where one knows ones
neighbors, where kids can roam free, where active commerce is healthy,
and where the exchange of ideas and pleasantries are made in public, on
common ground. A healthy place.
Consider the built environment from a childs perspective. What is
necessary to instill a sense of community and a sense of awareness for
those who will be the next generation of leaders?
Think back to when you yourself were a child. What places did you
explore? Are those places still there? Do your own children have places
to explore in your neighborhood? In todays America, we cannot imagine
our children doing as Einstein did at the age of four, but what is it
that we can imagine, and then put into action?
Children need space to explore. Planners and public health officials
should consider it a challenge to preserve rich outdoor environments
from which the young will learn. This will require seeing the big
picture and following the smart growth principles of preserving open
space, fostering a strong sense of place, and creating walkable
neighborhoods. Also, combating perceived fears of allowing our children
If we dont think about the overall goal, we will not recognize the
linkage between the built environment and healthy living. And that is to
our own peril. Public service is constantly under attack for what this
speaker believes is the times that we miss understanding this bigger
Missing the linkages means that neighborhoods start falling through the
The Wabasso neighborhood in Indian River is a prime example. Because
there had been no investment and a history of neglect, there was no
social capital. Until Environmental Health began a community assessment
process, this community was forgotten. Even while new development was
going on right next door. A public health message of getting fit and
eating right will fall on deaf ears in a community where the built
environment of housing, water, sewer, sidewalks, and streetlights are
If you are a public health professional, become familiar with the
smart growth principles. A good question to consider is how do each one
of these relate to public health? A walkable neighborhood relates to
public health through the ability to exercise everyday in ones own
neighborhood. A strong sense of place equates to social capital, the
ability to get issues addressed such as drinking water, and
streetlights. If you are a planner, you know these principles. Consider
how these principles impact health. How would mixed land uses promote a
more healthy community?
Within the urban planning realm, there is always much attention paid
to preserving open space and urban green space, perhaps as a buffer
between the urban and the rural. The State of Florida has been
remarkable in its foresight to support a Preservation 2000 Program that
has preserved millions of acres for public use.
There is still a lot of research to be completed to evaluate how the
preservation of open space and farmland relate to public health. This
speaker is reminded of a drive to work that was for many years lined
with pines and cow pastures. This has since been replaced with new
commercial and residential development. This speaker feels that this
change in the built environment, the loss of the tree-lined road and the
open pastures, have a psychological impact. In Richard Louvs new book,
Last Child in the Woods, Gordon Orians, a professor emeritus at the
University of Washington, believes the current research on human health
and structured and unstructured environments suggests that our visual
environment profoundly affects our physical and mental well-being.
In looking at other smart growth principles, providing a variety of
transportation choices has a direct impact on public health. If a safe
route to walk or ride a bike exists, the quicker we can be serious about
the nationwide obesity epidemic. This also reminds the speaker of a
friend who lived in New York. He never felt fearful walking or using
commuter transportation because there was always a crowd. How can we get
a crowd on the streets, or a crowd of kids outside in their own
neighborhoods, or a gaggle of children walking to school? The issue of
fear and safety so permeates our communities right now, this speaker
believes it is not being adequately address by either public health or
Consider the smart growth principle of creating walkable neighborhoods.
The American Journal of Preventive Medicine previewed a study in
February 2005 that related how the built environment, in this case, how
walkable a neighborhood was, to public health recommendations of
physical fitness. The three walkability factors in the study were mix of
shops, homes, and schools, the residential density, and the number of
connecting streets. These are common features of interest to the urban
planning trade, and the results of this study should be closely
considered by land use planners.
Schools are part of the built environment. In Florida and across the
nation, there has been a loss of neighborhood schools. Because of sizing
requirements, most new schools are located on the urban periphery,
adding to urban sprawl and making it difficult to bike or walk because
of the distance. This study related how, as neighborhood schools
declined, so did the number of students walking. But the research also
brought up the fear factor. The difficulty in traversing todays roads
and traffic make many parents, and even school officials, prefer to have
students driven. Consider how the built environment here has affected
The research by Allen Dearry with the National Institute of
Environmental Health found that the US average time for driving is 73
minutes a day. This correlates with other research that looks at urban
sprawl, which shows Americans are living and working further and further
apart. The most interesting statistic here is the one that shows that
Americans make only 6% of their trips by walking or biking, while
countries like Italy and Sweden make almost half their trips by walking
The American Journal of Public Health in 2003 and 2004, and the
Institute of Medicine in 2005, looked closer at the connection between
health and the built environment. These articles addressed issues
related to safety, crime, and areas being far from each other. The
Institute of Medicine research is especially interesting as they
advocated the need for professionals who can understand the links
between public health and urban planning.
Once one starts to review the research and literature on the
interaction between heath and the built environment, several themes
become apparent. For a variety of reasons, pedestrian traffic is often
an issue of last consideration. The research also shows that crime and
safety are critical factors in whether people get out and walk or bike
somewhere, yet crime and safety are rarely specified as an urban
planning and public health issue.
Howard Frumkin, the current director of the National Center for
Environmental Health, has been a pioneer in recreating the link between
public health and urban planning. He was one of three authors in 2004
who wrote a book on the subject, suggesting that the rise in asthma,
obesity, antidepressant prescriptions, and medical expenditures can be
connected to land use and community design.
The 2005 Trust for Americas Health report stated that 1 out of 5
Floridians are obese. Consider what this means in health care costs.
Also consider Benjamin Franklins famous saying, An ounce of prevention
is worth a pound of cure. What would a percent difference in the
obesity rate mean in cost savings for health care and insurance? One can
conclude that it might be much more effective, and much cheaper, to
ensure smart growth principles such as promoting mixed uses, and
strengthening existing communities.
Consider what we have seen with the aftermath of Hurricane Katrina.
How many officials would now make the decision to reinforce those walls
and improve that built environment? A 1999 report estimated the cost of
obesity to be $100 billion. How much would this be offset by an
adherence to a smart growth principle such as encouraging community and
The issue of fear came up in three studies completed between 1995 and
2000. All of these studies came from health journals and reports.
Relevant to planners will be the findings related to neighborhood
safety, the presence of enjoyable scenery, and lack of structure or
facilities. A concerted effort between public health and planning to
combat both real and perceived fear should see public health benefits.
The listener might ask which smart growth principle would be applicable
to these studies?
When we talk about crime and safety, we have to ask ourselves is it
of public health significance that people fear for their safety? Is fear
the primary factor that drives sprawl or development in areas outside of
city limits? The post World War II suburbanization has been
characterized by some as white flight. Regardless of whether racism
was a primary factor in the movement outward, the relevant issue today
is whether fear still plays a part in community formation.
The New York Times reported in 2005 on research completed in Tampa
Florida by KB Homes, one of the nations largest home builders. The
results should be of interest to both planners and public health
professionals. When asked what they valued most in their community,
safety is always a primary factor, even in communities where there is
virtually no crime.
How will people respond to an event if they feel the only safe place is
in their home? Is our current urban planning process inadvertently
supporting studies that show us becoming less civic-minded, less social,
and less able to live with each other?
Continuing with this issue of fear, the New York Academy of Medicine,
in an effort to judge the readiness of residents for a terrorism event,
conducted their own survey. Their results showed both a fear and a
disconnect between the public, public health, and planners. This study
was done in 2004, and one can make the conclusion that the events in New
Orleans in 2005 after Hurricane Katrina were synonymous with this
survey. Many communities in New Orleans did not have the means to
evacuate, nor the trust. A community assessment model such as Floridas
PACE EH would have better addressed some of these communities built
environment issues, built more trust between communities and their
public officials, and have responded better to calls for evacuation. And
remember, it meets the Smart Growth principles of strengthening existing
communities, and encouraging community and stakeholder collaboration.
The USA Today in December, 2004 touched on the fear epidemic, finding
parents as well as some schools not wanting their children walking to
school. We can have free range chickens but we are making less and less
room in our urban planning process for free range kids.
In a 1980s study of Livable Streets by Donald Appleyard, a Professor
of Urban Design at the University of California, Berkeley, he found that
traffic has a great impact on how social we are. The lower the traffic
along the streets we live on, the higher our number of friends and
acquaintances. The heavier the traffic, the fewer our friends and
acquaintances in the neighborhood.
Before traffic impacts to a community, the places people associate
are free and open.
After traffic impacts, people begin to adapt to their new environment
by moving indoors and socializing less outside. The breakdown of the
Will McDonough, a world renowned architect and designer and winner of
three Presidential awards, spoke in 2003 at the Sixth National
Environmental Public Health Conference. He talked about nature and urban
design and challenged public health professionals to think and act
boldly. He reminded those present of what was in the Declaration of
Independence; life, liberty, and the pursuit of happiness.
This editorial that appeared in the New York times in 2005 was a
reminder of McDonoughs message.
Planners ask yourselves what kind of communities are you trying to
attain? Public health officials, what is the goal of public health?
Dr. Catherine OBrien, with York University in Toronto, has written
extensively on urban planning, public health, and happiness. In this
graph, Dr. OBrien demonstrates how the rise in the U.S. gross national
product has not equated to perceived happiness. She states in a 2005
paper on Planning for Sustainable Happiness, that links between health
and happiness have yet to influence transportation and urban planning
policy and practice.
We have discussed the loss of social capital, or civic involvement,
and its relation to getting built environment issues addressed. Here is
another way of understanding this important issue. In 1996, Robert
Putnam, author of the critically acclaimed, Bowling Alone, wrote an
article to assess why Americans were dropping out, and becoming more and
more civically disengaged. He reviewed data on all the factors common
thought has portrayed as being the problem:
Being too busy, economic hard times, suburbanization, the movement of
women into the paid labor force, the stresses of two-career families,
divorce, changes in the economy such as the rise of chain stores, branch
firms, and the service sector, disillusion with public life, cultural
revolt against authority, civil rights, television, the electronic
revolution, and other technological changes.
Only one of these factors was consistent with the evidence, and that is
the amount of time spent watching television. The average American in
1995 watched television roughly four hours per day, absorbing 40 percent
of their free time. The author relates televisions arrival with
reduction in participation in social, recreational, and community
activities among people of all ages. Controlling for education, income,
age, race, place of residence, work status, and gender, TV viewing is
strongly and negatively related to social trust and group membership.
A study from the Kaiser Family Foundation in 2005 indicates that the
amount of TV watching has remained steady. Among young people, TV
watching is steady, but now being multi-tasked with other media.
So, why is this important to public health and urban planning?
The data we have reviewed suggests that obesity, physical fitness, fear,
crime, and the loss of social capital can all be related to an
inadequate built environment. Public health and urban planning should
therefore focus on each of these issues together to get residents
outside and re-involved. Their greatest competitor to doing this is
If we can be successful in considering the things discussed in this
presentation, the result is going to be a paradigm shift for how we view
public health. That is, that community design, transportation, and
social capital all impact public health and should therefore be
addressed by public health with urban planners.
There are several specific activities underway in Florida that will
help bring planning and public health together. There is increased
interest in health impact assessments as a part of development
procedures. There has been a Memorandum of Agreement drafted between the
states leading public health, planning, and environmental agencies.
Divisions of Health focused on environmental health and family health
have begun working closer together to address safety and physical
fitness. And health officials have spoken at and written for planning
Bringing public health and urban planning together will require
several things. A community assessment model such as the PACE EH, which
has been proven to address built environment issues and smart growth
principles, needs to become common place.
Public health officials and planners need to not view themselves not as
regulators, but educators. If we dont see the bigger picture, who will?
The fear factor needs to be studied as it relates to human health, urban
planning, and social outcomes.
In order to assist planners, we need more public health data.
We have several counties in Florida where public health officials sit on
planning commissions, development review committees, and other public
entities. This also needs to become a regular part of public health
Planners need to find ways to inject public health into the process. A
good start would be to review available public health data for existing
communities, and to support community assessments where the community
The mental health connection to the built environment needs more
rigorous review, including changes in the built environment and the
coinciding effect on public health.
We as planners and public health officials need to take ownership in
this issue. The research shows that the built environment impacts
health. The challenge is to create built environments that are smart,
safe, user-friendly, and attractive, that will compete head-on with the
drive in-doors, and will show public health and civic involvement
In Richard Louvs new book, Last Child in the Woods, Howard Frumkin, the
Director of the National Center for Environmental Health at CDC,
recommends that environmental-health research be done in collaboration
with architects, urban planners, park designers, landscape architects,
pediatricians, and veterinarians.
A great place to do this is through a community assessment process such
as the PACE EH.
-For more information on our Florida PACE EH Pilot Project, please visit
our website. This is Daniel Parker with the Florida Department of
Health, Division of Environmental Health.