1. Design Matters: Planning for Healthy Communities
Dr Trevor Hancock
Public Health Consultant
Population Health and Wellness
Ministry of Health Services

2. 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
Parfitt, Jessie (1987) The Health of a City: Oxford, Oxford; Amate Press

3. How did urban conditions affect health?

4. 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
From Chapter 12, "Manchester and the Industrial City" in Mark Girourd's book Cities and People.

5. 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
From Chapter 12, "Manchester and the Industrial City" in Mark Girourd's book Cities and People.

6. The health impact
Life expectancy for mechanics and labourers in Manchester in 1842 was 17 years
Life expectancy of a working man in Salford in the 1870s could be as little as 17 years.
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In 1842 the reformer Chadwick reported that a Manchester worker's average life expectancy was 17 years, whereas that of an agricultural worker was 38.
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7. How did health affect urban affairs?

8. 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
Sources
Hancock, Trevor (1997) "Healthy Cities and Communities: Long tradition, hopeful prospects" National Civic Review 86(1): 11-21
Hancock, Trevor (1993) "The evolution, impact and significance of the Healthy Cities/Communities movement" J. Public Health Policy, pp. 5-18, Spring
References
Armstrong, Alan (1959) Thomas Adams and the Commission of Conservation Plan Canada 1(1), 14-32
Ashton, John (Ed) (1992) Healthy Cities. Milton Keynes, UK. Open University Press
Butterworth, William (1930) Inter-Chamber Health Conservation Contest Am J Public Health p’s
Cassedy, James (1962) Hygeia: A Mid-Victorian Dream of a City of Health, J. Hist. Med. 17(2),
“It is not so much the city beautiful as the city healthy that we want for Canada” - Dr Charles Hodgett, Public Health Advisor, Commission on Conservation, in Annual Report (p.270H) Ottawa: Commission on Conservation
Leavitt, Judith W. (1982) The Healthiest City: Milwaukee and the Politics of Health Reform Princeton, Princeton University Press
Richardson, Sir Benjamin (1875) Hygeia: A City of Health London: MacMillan

9. Health and urban planning
Waste management
solid
liquid
Water treatment
Housing conditions
Zoning
Various City Departments
Urban planning in Canada

10. 1912-21 Canada’s Commission on Conservation
“The City Healthy”
Thomas Adams and urban planning –
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

11. You are heirs to a great tradition!

12. Urban planning and health in the 21st century: The emerging literature

13. 3 recent books Health and Community Design Healthy Urban Planning
Frank, Engelke and Schmid
Healthy Urban Planning
Barton and Tsourou/WHO Europe
Urban Sprawl and Public Health
Frumkin, Frank and Jackson

14. Selected planning policy areas (Barton and Tsourou,WHO Europe, 2000)
Selected planning policy areas (Barton and Tsourou,WHO Europe, 2000) Housing Economic Open Urban policy developm’t space Transport form
Personal lifestyles * * ** ** *
Social/community * * * * **
influences
Living/working
conditions
Housing ** *
Work ** * *
Access ** * * ** **
Food * * *
Safety * ** *
Equity ** * * ** **
Other planning policy areas include building regulations; social services and benefits; energy, water and drainage; urban regeneration
Hugh Barton and Catherine Tsourou (2000) Healthy Urban Planning London: Spon Press and WHO Europe

15. Selected planning policy areas (Barton and Tsourou,WHO Europe, 2000)
Selected planning policy areas (Barton and Tsourou,WHO Europe, 2000) Housing Economic Open Urban policy developm’t space Transport form
General socio-
economic,
cultural and
environment
conditions
Air quality * ** * ** *
Water &
sanitation * *
Soil &
solid waste * *
Global
climate * ** * ** **

16. 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
Anderson, Laurie et al (2003) “The Community Guide’s Model for Linking the Social Environment to Health” Am J Prev Med 24 (3S)
This article also summarizes some 200 community-based interventions to promote health-enhancing social environments.

17. 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

18. 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 1,830
persons/square km)
%of households
owning one or >cars 49% 75% 87% 96%
Travel by car
(km/person/day)
Estimated CO2 emissions
resulting from travel 1,710 2,280 3,222 5,200
(g/person/day)
Source: Gilbert, 1997

19. Air pollution and health, Ontario, 2000
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
Health costs
1,900 premature deaths
9,800 hospital admissions
13,000 emergency room visits
47 million minor illness days

20. Olympic Games and Air Pollution, Atlanta, 1996
peak traffic count ß 22.5%
peak daily ozone ß 27.9%
asthma emergency events ß 41.6%
other medical events did not drop
Source: “Creating a Healthy Environment” Jackson and Kochtitzky, 2001

21. 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)
State and Territorial Air Pollution Program Administrators and the Association of Local Air Pollution Control Officials (2000) Cancer Risk from Diesel Particulate: National and Metropolitan Area Estimates for the United States Washington DC: STAPPA/ALAPCO

22. 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
Amory Lovins - “An Eight-Fold Way Towards Faster Energy Efficiency” - Keynote, the June 2001 Summer Study of the European Council for an Energy-Efficient Economy,

23. 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

24. Mortality by Mode of Transport in Great Britain, 1983 to 1993
Motorcycle
Foot
Bicycle
Water*
Car
Van
Rail
Bus or coach
Air*
(death rates per billion kms travelled)
Source: Central Statistical Office, 1996 * The data for water and air travel include Northern Ireland.

25. 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

26. Traffic deaths v violent deaths by stranger
Risk 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

27. 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)

28. 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)

29. 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.
(Katzmarzyk, Gledhill and Shephard, 2000)

30. 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.)

31. 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, pain
Based on Morton, 2000 and
WHO Centre for Urban Health

32. 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 %
Max treadmill time %
HDL cholesterol %
Source: Vuori, Oja and Paronen, 1994

33. 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!

34. 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 billion/year
Source: WHO Europe, Centre for Urban Health

35. The Health Benefits of Active Living
Reductions 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

36. Benefits of Parks and Recreation
Personal
e.g. stress management, self-esteem, health
Social
e.g. promotes involvement and interaction
Economic
e.g.productive work force, reduced vandalism
Environmental
e.g.improved environmental health and awareness

37. Commuting time & social capital
A 1 hour commute each way
= a 40 hour work week every 4 weeks, or
work weeks a year
This is a large loss of family and community time
= a large loss of social capital

38. Planning for Healthy Communities

39. 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

40. 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

41. Encouraging physical activity
Municipal government
Urban 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
See
Frumkin, Howard; Frank, Lawrence and Jackson, Richard (2004) Urban Sprawl and Public Health: Designing, Planning and Building Healthy Communities Washington DC: Island Press
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Prevention that works - Physical activity
encouraging walking while not requiring attendance at a recreational facility;
community-wide campaigns, involving large scale, high intensity, high visibility programs
modified physical education in school
individually adapted health behaviour change
social support in community contexts
creating or enhancing access to places for physical activity
Prevention that works - Reducing obesity
reducing sedentary behaviour (or promote active living) in obese children
using diet, physical activity and behavioural strategies for adults, in combination where possible
integrating lifestyle changes over a long period of time
Source: - “Prevention that Works” – A Review of the Evidence Base for Chronic Disease Prevention ( Population Health and Wellness, Ministry of Health Services, 2004)

42. 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

43. Encouraging physical activity/3
Community agencies
Provide active recreation services
Encourage/support ‘walking clubs’ etc
Citizens
Become active
Adopt & maintain trails
Turn off TV and get out!
Ditto for your kids!

44. It takes a whole community to raise healthy people!

45. 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)

46. 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?

47. 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

48. Re-establish a BC Healthy Communities Network?
Healthy Living Alliance?
Legacies Now!

49. 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.
Source: Healthy Cities Projects in the WHO African Region - Implementation Manual World Health Organization, Regional Office for Africa Brazzaville, 2002

50. 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”.

51. 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.

52. 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.

53. 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.

54. 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

55. 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

56. 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

57. 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

58. Healthy Community model