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s Improving Health in the Built Environment: A Daunting but Doable Challenger Richard J. Jackson Our behavior and well-being are influenced by the physical environments in which we live. These environments, however, particularly in the United States, are steadily becoming more detached from the natural world, chemically con- taminated, psychologically oppressive, and hazardous to our health. Such trends in the built environment will only be exacerbated by an ever- growing population. In the lifetime of a contemporary middle-aged person, this country's population has doubled. We have added some 140 million people. And in the lifetime of a child born today, the population will double again. By the time that child reaches old age, the nation will have close to 600 million people. To avoid environmental health catastrophe at that level, and even well below it we already face some serious issues under present conditions we must reconsider the ways in which we design our daily landscape so as to reduce and hopefully even reverse the environmental public health trends we face today. In modern science, we are good at isolating problems and solving them, and this focused method has worked very well for us. We cure and prevent disease in ways that were just a dream one or two generations ago. Yet, we pay a price for this because our approach to each challenge is very, very narrow we are often unaware that the failures we encounter have system causes, rather than just individual. But we cannot address specific issues such as climate change, and epidemics of asthma, obesity, and diabetes just with piecemeal fixes. The prob- lems and challenges are networked, not isolated. A useful term in this regard is "syndemic" two or more epidemics that interact synergistically, thereby contributing to an excess burden of disease in a population. The environmental health challenges we are looking at the out- comes of how we build our environments are in many ways syndemic. *This chapter is an edited transcript of Dr. Richard lackson's remarks at the workshop. 28

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IMPROVING HEALTH IN THE BUILT ENVIRONMENT "LANDSCRAPING" DEGRADES ENVIRONMENTAL HEALTH 29 In the first half of the twentieth century, we built skyscrapers and, in the second half of the twentieth century, we built landscrapers "improvements" such as huge expanses of highways, interchanges, parking lots, and strip malls. Among other things, they adversely affect the quality of our drinking water, our air, our stress levels, and therefore our health. The best thing we can do for water is to have it infiltrate past trees, which slows it down and allows it to percolate into the soil. The more infiltration of water through the soil, the better it is for health. But in the Atlanta metropolitan area, for example, an average of about 58 acres of these remarkable green objects called trees which not only slow down the rain and prevent runoff but reduce greenhouse gases and release oxygen- are cut down every day. At present development rates, New Jersey is about a generation from being built out right to left, top to bottom and California is losing about 500 acres a day. The United States has now paved over the equiva- lent area of the state of Georgia and the resulting impervious surfaces interrupt the cycle of water returning through the soil and thereby degrade the quality of the water we ultimately use. Another issue related to paving things over is the generation of heat. Surfaces such as asphalt or tar are much hotter, all else being equal, than areas that are green with plants. Thus, cities create their own "heat islands"; the downtown areas of most cities run about seven degrees hotter in summer than the surround- ing countryside not only because of the surface itself but also from the obliga- tory use of air conditioners in the absence of cooling tree cover. As it gets hotter, more ozone and other air pollutants are produced in the atmosphere. So, urban heat is a health threat in several ways directly from heat stroke, and indirectly from much higher levels of airborne irritants. The risk of asthma has been growing in a stepwise fashion in the United States. Just about any school nurse will attest that while asthma in school kids was relatively uncommon 25 years ago, it' s now a virtual epidemic, with typically a third of the kids who come in for medical attention suffering from asthma or a related condition. Consider a Los Angeles study that compared six high schools in low-pollution areas with six high schools in high-pollution areas. Researchers looked at young athletes when they entered high school and then again four years later. The kids from the high-pollution areas had twice the asthma rate as compared to their low-pollution-area counterparts. Another illustration: during the Atlanta Olympic Games in 1996, there was a dramatic reduction a 30 percent decrease in the city's car and truck traffic, with a consequent 30 percent improvement in air quality. When researchers from CDC and other local health-research institutions looked at pediatric Medicaid claims, Kaiser HMO visits, emergency-room cases, and hospital admissions for asthma, they observed that all had dropped during the Olympic period. After- ward, the rates went right back up to what they had been before.

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30 ENSURING ENVIRONMENTAL HEALTH IN POSTINDUSTRIAL CITIES Some have alleged that these results are inconclusive that people may have been diverted by the Olympics and simply didn't have the time or inclina- tion to go to the doctor. But no comparable decreases were observed during that period for nonrespiratory diseases. DRIVEN TO DEPRESSION, OR WORSE The "landscraping" trend cited above largely to serve cars, of course has effects that go well beyond degradation of the water and air and the increased incidences of related diseases. We spend more and more time in our cars- commuting time to work, for example, has gone up 14 percent in just the past 10 years and this is not merely tedious and fuel-consum~ng. The more time spent in one's car, the greater are the actuarial risks of automotive-related death. Every 66 miles driven confers upon us a lottery ticket a one-in-a-million chance of dying in a car crash. It isn't much better being a pedestrian (see Figure 5-1~. We have not designed our cities for pedestrians in general, and it Automobile fatality rates by city, 1998 (excluding pedestrian fatalities; deaths per 100,000/year) lit ~ _) FIGURE 5-1 Sprawl cities, where people spend more time driving, have higher rates than cities with greater density (fatality rates per 100,000 people per year). New York and Philadelphia, both of which are "walking" cities, have rates of about 2.5 and 5, respectively; while heavily "freewayed" Dallas and Atlanta have much higher rates at approximately 11 and 13. SOURCE: Chart created from National Highway Traffic Safety Administration, 2002.

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IMPROVING HEALTH IN THE BUILT ENVIRONMENT 31 has gotten considerably worse with the spreading reign of the automobile. As shown in Figure 5-2, pedestrian fatality rates are higher in sprawl cities than they are in denser cities. When we build with low density, the amount that people walk goes down and the amount that they drive goes up. For example, parents spend more time chauffeuring their children around, children who most often would rather walk in the first place, if only they had the option. I believe that this removal of autonomy from a child's environment actually has adverse developmental effects. Children need to be presented with tasks that are reasonable, ones that they can overcome and build on. As renowned pediatncian/ child psychiatrist Herbert Needleman has said about young children, "It is the job of a child to taste, touch, and feel its environment, to immerse itself in its environment." School age children need continuing challenges of mastery. Every parent and teacher knows that it is important to present to the learning child tasks that are doable, where they can succeed, but not too easily. I worry about the infantilization of the school age child that occurs when he must be driven to the library, to sports games, to the store, or to everything else. It cannot be good for Pedestrian fatality rates by city, 1998 (deaths per 100,000/year) ~1 ~ l ' ~c, ~ rat 7 ""new - i\ \ FIGURE 5-2 How we build our cities and the lack of walkable environments may con- tribute to pedestrian fatalities. Sprawl cities, where people spend more time driving, have higher rates than cities with greater density (fatality rates per 100,000 people per year). New York and Philadelphia, both of which are "walking" cities, have rates of about 2.33 and 1.88, respectively; while heavily "freewayed" Dallas and Atlanta have much higher rates at approximately 4.28 and 6.44 respectively. SOURCE: National Highway Traffic Safety Administration, 2002.

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32 ENSURING ENVIRONMENTAL HEALTH IN POSTINDUSTRIAL CITIES children to lose the ability to actually carry out the basic tasks of their lives themselves and to do so at their own pace, to have space and time for reverie, talking, and increasing independence. Children are taken to school. In many places, they no longer have phys-ed classes. Children are expected to stay in the cafeteria during lunchtime, often- times not allowed to run around because of one modern security problem or another. At the end of the day they get back on the school bus or in a car to go home, where parents also concerned with security may place further limits on their autonomy. It's probably no coincidence, then, that we are looking at an epidemic of methylphenidate (Ritalin) consumption (see Figure 5-3) or that three million children in the United States suffer from depression. Of course, not all these prescriptions or cases of depression come only from how we design and build our communities that is, for automobiles rather than for human beings but even if it affects, say, only 5 to 10 percent of children in such ways, that is still an enormous number of kids. Clearly, this is an important area for further research. THE HAZARDS OF OBESITY The limited freedom to walk also bears some responsibility for our epidemic of overweight. In 1991, the percentage of obese adults (with Body Mass Indexes FIGURE 5-3 The number of doses of methylphenidate (Ritalin) dramatically increased from 1987 to 1998 in the United States. This is, in contrast to the small increase in other countries, on the rise in the United States. Source: U.S. Drug Enforcement Agency (DEA), 2000. Reprinted with permission.

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IMPROVING HEALTH IN THE BUILT ENVIRONMENT 33 [BMIs] greater than or equal to 30) was no higher than 14 percent in any state; in 1995, the populations of about half of the states were 15-19 percent obese; and by 2001, half were at 20-24 percent and a few had hit 25 percent or beyond. Obesity is a lot more than cosmetic. It's a risk factor for heart disease, cancer, gallbladder disease, and a long list of other disorders. And in addition to all the suffering and premature death, there are substantial economic costs that are mostly, though not entirely, medical. For example, my colleagues and I calculate that the obesification of the American public raises the airlines' jet-fuel costs some $200 million per year just in the United States alone. Most notably, being obese is a risk factor for type II diabetes a very seri- ous problem that can cause the loss of eyes, kidneys, feet, and ultimately life itself. It used to be rare for a pediatrician to see a child with type II diabetes. Now, it is up to 30 to 40 percent of the pediatric diabetes practice. It has become very common (Figure 5-4~. Among adults, one is 20 times more likely to get type II diabetes if he or she is obese. For the very obese, it is about 40 times. Ironically, the best treatment for type II diabetes is not insulin or other drugs. The best treatment, which has fewer complications and works better than any drug in existence, is weight loss and physical exercise. Designing environ- ments in which people can move around is not only a treatment (and prevention) for diabetes; there are numerous other health benefits. For example, better envi- ronments raise one's serotonin level and they are effective in reducing depres- sion. Better environments are as good as certain antidepressant drugs. WHERE PEOPLE WANT TO BE The bottom line is that we in public health need to reach out to the people who do the urban planning and architecture and to those who govern our com- munities. Professionals who deal with issues of community design have just as much relevance, and probably more relevance, in addressing the diseases of the twenty-first century than those of us who are sealed off in the medical communi- ty fighting the adverse effects, after the fact, of the diseases made more common or more severe by the way we build our environments. The proper vision which directly applies to Pittsburgh is that just as our rivers ought to be swimmable, drinkable, and fishable. Riversides (and their neighborhoods) ought to be walkable, Likable, and runnable. You don't have to tell children to go outside and get some exercise if there are safe and attractive places to run around with their friends: parks, trails, basketball courts, water- courses, and playing fields. We all want to be in places like that. Creating safe and attractive environ- ments for people to make themselves healthy will do a whole lot more than our waving our fingers at them and lecturing them to shape up. This is a daunting but doable challenge. When I was a young medical student, it seemed that the problem of lead poisoning was insurmountable; lead

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34 ENSURING ENVIRONMENTAL HEALTH IN POSTINDUSTRIAL CITIES Diabetes and Gestational Diabetes Trends Among Adults in the U.S., BRFSS 1993-94 A.... , by No Data <4% 6%-8% 8%-10% 0% Diabetes and Gestational Diabetes Trends Among Adults in the U.S., BRFSS 2001 No Data ~<4% ~4%-6% ~6%-8% \) 8%-10% >10% FIGURE 5-4 The incidence rates of diabetes in the United States have been rapidly growing in recent years. In 1993, only 4 states reported diabetic rates between 8 and 10 percent of their population. In contrast, by 2001, 25 states reported a diabetic rate between 8 and 10 percent, while 15 states reported an incidence rate greater than 10 percent of the population. SOURCE: Mokdad et al, 2003.

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IMPROVING HEALTH IN THE BUILT ENVIRONMENT 35 was everywhere in the food, in the paint, in the gasoline. Yet over time we removed lead from our environment, and as a result we have seen a dramatic drop in the average blood-lead levels in the United States. Similarly, whenever any major environmental issue comes up such as the landscraping/polluting/disease-causing network of problems noted above many people will say it is insurmountable, that it's just too big. Yet while the lead- poisoning problem was also "just too big," we have made wonderful progress. The same can be true of environmental health in Pittsburgh and the nation if we reclaim the land and water and air for human habitability, fitness, and fulfillment.