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Design Matters: Planning for Healthy Communities

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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 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. ********************************************* 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. ********************************

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 ******************** 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

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