Designing our environment to improve our health

Main Category: Public Health
Article Date: 17 May 2004 - 0:00 PDT

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The United States Federal Centers for Disease Control (CDC) is backing efforts to extend the influence of local and regional public health officials over decisions affecting the built environment.

Richard Jackson, now an adviser to CDC chief Julia Gerberdring and formerly head of the CDC's National Centre for Environmental Health, says: 'Health workers are just beginning to understand that the environments we spend our lives in were built and designed by someone and those decisions affect our wellbeing. Curative medicine alone is inadequate to deal with the tsunami of chronic diseases for which, in reality, the patient is the doctor. Lives, health and behaviour are shaped by our built environment in many ways.'

The CDC is calling for changes to building and planning codes to favour environments that will encourage exercise and allow people to connect with others. 'We need to build communities that include sidewalks, bike routes and a variety of housing types and sizes,' says Mr Jackson. So far the rhetoric has not been matched by federal and state funding.

Consequently, broad engagement with planning and development decisions and with Active living health improvements is patchy, but 'pioneers' are emerging. Freelance health consultant Karen Roof says: 'There is no direct funding stream for health officials for this work. Money comes from healthy schools and diabetes prevention and other programmes so it has to be pulled together in a complex way.'

She told PHN: 'Incorporating the built environment is not fully accepted by the clinically-dominated public health and health care worlds. Health officials recognise that it's necessary but most find it difficult. They are used to data and epidemiology.'

But Marla Hollander, director of Active Living Leadership, says. 'The number of public health professionals engaging with community design is growing exponentially.' The San Diego-based ALL supports local health professionals with services, including webcasts, networking, cost-benefit analyses of physical activity, and help with writing Active living plans. Its purpose is to help government leaders create and promote policies, programmes and places to enable active living,' says Ms Hollander.

The most serious challenges for health professionals in the USA are diabetes and obesity. One-in-three children born here this year will develop type 2 diabetes on present trends, according to the CDC. And the 2003 estimates indicate that 38.7 per cent of non-Hispanic black women are obese, as are 28 per cent of 40 to 59-year-olds overall.

So with one in four adults now clinically obese, attention has switched to exercise levels, especially among children. Most houses built in the last 50 years in the USA are on separate plots, many on estates designed with just one route in and out. Walking anywhere from home is difficult to impossible.

Yet there are signs of change. In their latest annual survey of prospective home buyers, the National Association of Realtors reported that between 30 and 40 per cent wanted a home that offered something different. Traditional neighbourhoods are back in vogue. According to Ms Roof, formerly responsible for education and training at the Washington DC-based National Association of City and County Health Officials, public health professionals are ideally positioned to make the link between community design and diet and exercise initiatives.

Dr Susan Turner, Walton county public health director in Florida, heads a department which has studied land use at a number of levels in recent years. Last year, Dr Turner launched a radical children's health improvement programme targeting under-fives after finding that 50 per cent of children in the area were overweight by the time they began attending kindergarten at age five.

The programme, aimed at day care centres, focuses on physical activity and diet and engages parents as well as their children. Physical activity features strongly and at the end of the day, as parents arrive, they are asked by their children to sign their colouring-in sheets on fruits and vegetables.

Dr Turner says: 'We targeted the day care centres as our environmental staff inspect their food service and our nurses immunise them so it followed for us to go in with proactive exercise and healthy living. Our goal is to reduce the [number] who are overweight at kindergarten and our strategies are to increase fruit and vegetable consumption and physical exercise and reduce TV watching.'

'The scheme reachs around 800 children across the county,' says Dr Turner. 'They focus on a different fruit and vegetable each month using song and dance and there are taste tests. There is a health message for each day on the colouring sheet and the child gets a reward if the parents sign it.'

A year on, elements are still being added. 'We are introducing periodic weight and height measures for all children, if their parents agree, and are linking to literacy with books about physical activity and nutrition, for children to take home to read with their parents,' says Dr Turner. She says there is strong backing for health improvement from the Walton county commissioners and from Florida's health department, with funding from local, state and federal sources.

Carol Maclennan, environmental policy coordinator at Tri-County Health Authority in Colorado, described her role in another initiative, intervening in planning and zoning decisions. 'The goal is to routinely incorporate sound public health principles into planning and development activities,' she says. But she warned that even if influence is welcomed by planning officials, funding is essential to consolidate public health assessment and advice into the processes.

'Other health departments are only reviewing mandated issues like septic tanks. Budgets are incredibly tight,' she says. 'Many will not get into community design issues. I've been trying to encourage my counterparts to expand their review work. In Tri-County, the board really supports this. I don't know how we can sustain and evolve this without a direct funding source.'

Moving beyond a regulatory role is a hurdle for some health professionals but Ms Maclennan says: 'We have always thought here that we should do preventative as well as regulatory activity. We began to comment on air and run-off protection issues early on, even though there is no broad statute in our state on pollution prevention.' She told PHN: 'It is key to getting influence at an early stage. I now focus on air quality, chronic disease and exercise. I am getting more confident in my comments now as we become more knowledgeable about our health data and planning and design codes.'

Not content with supporting local planning officers at development reviews and with written comments, Ms Maclennan made health a critical factor at a 4,000 home development at Sky Ranch where the developer sacked his original builder and redesigned the scheme to fully incorporate active living. 'The lead planning officer thought our involvement was key to keeping the negotiations going,' says Ms Maclennan.

But a survey of planning officials in cities and counties in 2002 found that there is still some distance to travel. While 100 per cent considered comments on waste water issues to be very important, only 6 per cent felt a health view was needed on masterplans. This year Ms Maclennan will give priority to collaborative work with the metropolitan planning organisation for the Denver region to further health's influence over big picture strategies.

Marla Hollander says professionals have largely forgotten the roots of city design. 'It's time for these people to come together and ask, "are we where we want to be?",' she says. 'Local public health professionals need [more] training on the built environment. Planning and engineering professionals need to think about health. Public health professionals can remind them of that regularly and be the voice which protects health and wellbeing.'

Dr Susan Turner adds a plea for an index of health issues that could be used to assess development proposals. But there is one stumbling block. 'Although the Centers for Disease Control are making the case for the expanded public health role,' concludes Ms Maclennan, 'the health profession generally doesn't yet see with any clarity its crucial role.

Source: www.publichealthnews.com