Healthy Communities, Green Communities

by Howard Frumkin, MD, DrPH

Blueprints Winter & Spring 2008/2009
Volume XXVII, No. 1-2

Almost 2500 years ago, the legendary Greek physician Hippocrates wrote his classic Treatise on Air, Water, and Places. He offered careful observations on how towns and cities were situated, on wind, sunlight, soil, ground cover, and topography,and on how these factors influenced the health of residents. Writing as both physician and geographer, he knew the importance of place for health.

More than two millennia later, Frederick Law Olmsted had the same insight. The father of landscape architecture, he was keenly attuned to human health, even serving as secretary general of the United States Sanitary Commission (forerunner of the Red Cross) during the Civil War. In such projects as New York’s Central Park— the “lungs of the city”—and Boston’s Back Bay Fens—a landmark act of civil engineering, sewage management, and health protection—he saw his creations as acts of public health. Working as both designer and health activist, he, too, knew the importance of place for health.

These are insights that we are rediscovering today. The major causes of death, suffering, and disability have changed greatly since Olmsted’s time. Heart disease, cancer, strokes, injuries, asthma, diabetes, obesity, and depression have edged out such conditions as tuberculosis, dysentery, influenza, and pneumonia. Our population is far larger, and older, than it was a century ago. Are we creating healthy places to help address these challenges?

Perhaps not. For the last few generations, traditional town planning principles have given way to a pattern known as urban sprawl. With suburban growth, cities have expanded over vast geographic areas. Land-use patterns at the urban edge have changed, from traditional farm and forest to residential subdivisions. Land-use mix has declined; housing developments are built far from schools, stores, and workplaces. Land-use density has also declined; some communities can measure land-use in acres per family rather than families per acre. Traditional downtown areas have given way to long stretches of multi-lane roads lined by strip malls and big-box stores, set back on vast parking lagoons. Transportation systems have changed as well, with the vast majority of trips—even short ones—made by automobile, and with a concomitant drop in walking, bicycling, and transit use. Amenities that were routine in an earlier age—sidewalks, plazas, parks—are too often omitted from recent developments.

Revealing Statistics

Health professionals love hard evidence. Fortunately, we have considerable evidence to point the way to healthy community design. Consider these examples:

The SMARTRAQ (Strategies for Metro Atlanta’s Regional Transportation and Air Quality) study in metro Atlanta followed more than 10,000 adults, assessing their neighborhood characteristics, their means of travel, and certain health outcomes. Greater land-use mix, more walking each day, and less time in the car each day were each associated with a lower risk of obesity. Landuse and transportation patterns predict physical activity, and physical activity is important for health.

A study in Atlanta during the 1996 Olympic Games took advantage of a natural experiment. Atlantans were urged to refrain from driving during the 17 days of the games. Many complied, and peak morning traffic counts dropped by 22.5%. Peak daily ozone levels promptly dropped by 27.9%. And acute asthma events in children dropped by as much as 44.1%. All three parameters returned to their baseline at the conclusion of the Olympics. Transportation affects air quality, and air quality affects health.

In sprawling communities where people spend much time in their cars, motor vehicle fatality rates and pedestrian fatality rates are high. This is a pressing public health challenge—motor vehicle crashes are the leading cause of death among young people nationwide. Not surprisingly, reducing driving can help prevent these tragedies. In fact, when gasoline prices rise, people drive less, and highway death rates decline—an effect that seems to have operated to save lives during the summer of 2008. With less driving come fewer traffic deaths.

Common sense suggests that parks are an asset for communities. They provide a venue for physical activity, social interaction, and relaxation, which all promote health and well-being. But a recent study of parks in Copenhagen provided further evidence of health benefits. People who live near parks not only use the parks more frequently than those at a distance, but they have lower stress levels and weigh less—an effect not fully explained by visits to the park. Nearby greenspace is salutary.

Community design, then, can do a great deal to promote health. Good sidewalks and trails, nearby destinations, parks and other green space, safety, and the presence of other people all promote walking and bicycling. Transit use does the same; in fact, nearly a third of transit users get recommended levels of physical activity just by walking to and from their transit stops. To support these design features, many of the principles of “Smart Growth” are relevant: density, connectivity, mixed land use, vibrant activity centers, transportation alternatives, preservation of green spaces. Community design is increasingly recognized as a public health strategy.

A Virtuous Circle in Design and Planning

One appeal of this approach is the synergy it offers. We don’t have a pill that prevents heart disease, cancer, asthma, diabetes, depression, and injuries. (If we did, we’d be adding it to the water supply!) But we do have community design strategies that offer all of this and more. The simple act of a child walking to school—with all the precursors, environmental and behavioral, that lie behind it—reduces the risk of each of the conditions listed above. The simple intervention of planting trees in a community offers many of these health benefits, directly and indirectly. At a time when health care costs are rising and health care coverage eludes many Americans, such synergistic preventive strategies are more important than ever.

The beauty of this synergy extends beyond direct health benefits. In many cases, the interventions that define healthy communities also define green communities—the focus of the National Building Museum’s current exhibition Green Community. Shifting transportation from driving to walking, bicycling, and transit does more than promote health; it improves air quality, and reduces carbon dioxide emissions. Building more compact communities, balanced by the preservation of green space, does more than promote health; it protects waterways and floodplains, conserves rural and agricultural land, and promotes biodiversity. At a smaller scale, “green” buildings that utilize sustainably produced, non-toxic materials and effective insulation do more than improve indoor air quality; they reduce energy consumption, which in turn reduces pollutant and CO2 emissions from power plants.

The benefits of green, healthy communities do not accrue only to those who live in them, or even to their contemporaries. They accrue over time. We are increasingly reckoning with long-term limits on such resources as water, petroleum, and soil. As climate change unfolds, the consequences of past energy-use patterns will be felt by future generations. The decisions we make today—not only in community design, but in energy, transportation, agriculture, and a host of other realms—will have implications for our grandchildren and their grandchildren.

The UN Commission on Environment and Development in 1987 defined sustainable development as that which “meets the needs of the present without compromising the ability of future generations to meet their own needs”—a recognition that we need to be good stewards, for the sake of those who will follow us. This is a recognition found in many cultures and credos. The Great Law of Peace of the Hau de no sau nee (the Six Nations Iroquois Confederacy) mandated that chiefs consider the impact of their decisions on the seventh generation yet to come. Contemporary religious leaders have called for “creation care”—stewardship of the Earth as both a religious obligation and an obligation to future generations. Ethicists have asserted intergenerational justice as a moral basis for action on climate change. We need to think to the future.

Green communities, then, are in many ways healthy communities—promoting good health and well-being directly for those who reside in them, indirectly for their neighbors, and indirectly for those who come after. They offer a wide range of health benefits, corresponding to the major contemporary causes of morbidity and mortality. They offer “co-benefits” that extend beyond health to the environment and the economy. Those who care about health, and those who work in design, architecture, and planning, can celebrate their growing convergence of interest, and the enormous opportunities to collaborate in achieving shared goals: green, healthy, and sustainable communities for all people. 

Dr. Howard Frumkin, a physician and epidemiologist, is director of the National Center for Environmental Health and the Agency for Toxic Substances and Disease Registry at the Centers for Disease Control and Prevention. 

Watch video from past Museum programs that featured Howard Frumkin

For the Greener Good "Can the Suburbs Kill You?"
Sustainable Communities "Creating Healthy Communities"

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