Designing healthy places: land use planning and public health.(Report)

Abstract

Health systems everywhere are currently struggling with the burden of 21st century public health problems, most notably chronic disease and injuries. In light of growing concerns about the sustainability of the health care system, interest has been growing in exploring how different types of urban design can promote health and influence the prevention of population-level factors that contribute to disease and injury. The evidence demonstrates that there is an association between land use planning and the health of populations. The most researched area to date for connecting land use planning and public health is the impact of urban design on levels of physical activity. Low density suburban neighbourhoods contribute significantly to physical inactivity. The design of these neighbourhoods and their distance from daily destinations (groceries, services) typically requires a high degree of automobile dependence and decreases opportunities for active transportation, such as walking, cycling and use of public transit. The evidence shows that people who live in walkable communities (those that have mixed land uses, connected streets and higher population density) walk more and drive less than those who live in suburban communities. This paper highlights the links between land use planning and public health and makes the case for public health input into land use decision-making processes.

Les systemes de sante de partout dans le monde sont actuellement aux prises avec le fardeau des problemes de sante publique du 21e siecle, notamment les maladies chro-niques et les blessures. A la lumiere des preoccupations grandissantes concernant la viabilite du systeme de sante, on observe un interet accru pour examiner de quelle maniere la conception des villes peut promouvoir la sante et influer sur la prevention des facteurs qui contribuent aux maladies et aux blessures au niveau de la population. Les elements de preuve indiquent qu'il y a un lien entre I'amenagement du territoire et la sante des populations. Le secteur le plus etudie a ce jour pour etablir un lien entre I'amenagement territorial et la sante publique est I'incidence du design urbain sur I'activite physique. Les quartiers residentiels des banlieues a faible densite de population contribuent grandement a I'inactivite physique de leurs habitants. La conception de ces quartiers et leur eloignement des destinations quotidiennes (magasins d'alimentation et services) entrainent une utilisation importante de la voiture et reduit les occasions d'utiliser des moyens de deplacement actifs comme la marche, le velo et les transports en commun. Les elements de preuve indiquent que les personnes qui habitent dans des collectivites ou il est possible de marcher (celles ou I'amenagement du territoire est diversifie, qui possedent des rues reliees les unes aux autres et une plus grande densite de population) marchent generalement davantage et prennent moins souvent la voiture que celles qui habitent dans des collectivites de banlieue. Les auteurs de cet article mettent en lumiere le lien entre I'amenagement territorial et la sante publique et font la promotion de la prise en compte des questions de sante publique dans les processus decisionnaires en matiere d'utilisation du territoire.

Keywords

Built environment, land use planning, public health, chronic disease, social effects

Introduction

On the surface, land use planning and public health may seem like disparate fields of professional practice. Yet these two areas share a common history, and there are calls to reconnect professionals in these areas as one way of addressing pressing population health issues of the 21st century. Over the past few decades, urban planning has moved beyond thinking primarily about 'mains and drains' and public health has moved beyond thinking primarily about 'bugs and drugs' (Schechter 2003). These changes highlight common interest in the impact of built environments on health, and the role good urban design policies play in creating positive health outcomes at the population level (Knox 2003).

The desire for rebuilding a connection between public health and urban planning has been coming from many quarters, strengthened by recent evidence showing the myriad ways through which the design of built environments impacts the health of entire populations (Knox 2003). The purpose of this paper is to explore the linkages between public health and land use planning and examine the impacts of land use planning decisions on the health of populations.

Research on the connections between built environments and public health is expanding rapidly, with new studies emerging regularly. Given the rapid pace of growth in this area, a systematic review of this literature is outside the scope of this paper, as is a detailed analysis of particular studies. Rather, the emphasis is on identifying key research articles that highlight associations between land use planning and public health.

Land use planning and public health

Historical relationship

The 19th century practice of public health was strongly connected to land use planning in North America. As early industrialization brought about sharp demographic shifts, including increased urbanization and resultant crowding in urban areas, interest grew in the development of new regulatory measures to protect public health from the adverse effects of urbanization (Schilling 2005). While public health and land use planning are now viewed as separate fields of professional practice, originally public health, city planning and civil engineering in North America "... evolved together as a consequence of late 19th century efforts to reduce the harmful effects of rapid industrialization and urbanization, particularly infectious diseases" (Coburn 2004). For instance, public health officials were instrumental in the introduction of infrastructure and technology to properly dispose of sewage and bring clean drinking water into people's homes.

These 19th century concerns about public health not only strongly influenced urban infrastructure planning, but also contributed to shaping the dominant view of health and cities. As Perdue et al. (2003) note, by the early 20th century, the belief that cities and urban concentrations were unhealthy had become established orthodoxy. Because of this, separation of land uses and deconcentration of population were viewed as an effective means of improving " ... public health, safety, morals, and general welfare" (Perdue 2003). Overtime, beliefs about 'healthy' land use shaped during the industrial period became codified into zoning regulations as land use planning legislation developed. The impacts of these beliefs on planning and land use on population health are still being felt today.

For example, the 'urban sprawl' that is currently attracting a lot of attention in North America is one vestige of the 19th century focus on population deconcentration, and separation of industrial, commercial and residential land use. The creation of zoning practices emphasizing segregated land uses is in many ways a response to earlier conditions in urban North America. Current North American 'urban hygiene' conditions are generally much safer, and the most serious threats to public health are very different. For example, the root causes of the chronic disease 'epidemic' of the 21st century (e.g., physically inactive populations) stand in stark contrast to the factors implicated in the transmission of communicable diseases in the 19th and early 20th centuries (e.g., diseases spread via contaminated drinking water). The impact of land use planning on chronic disease will be discussed in greater detail later in this paper, but is noted here as an example of the residual impact of planning history on the health status of populations today.

Current context

There are many factors influencing the current calls for reconnecting public health with land use planning. To begin with, there is little doubt that the prevalence of chronic disease is one of the most significant public health issues of the 21st century. The Chronic Disease Prevention Alliance of Canada (CDPAC Online) asserts that heart disease now accounts for 38 per cent of all deaths among Canadians each year. The Public Health Agency of Canada (PHAC Online 2003) estimates that about one-half of the Canadian population lives with chronic disease and this accounts for approximately two-thirds of direct health care costs in Canada. Obesity and physical inactivity are two risk factors for chronic disease, and--as demonstrated in the next section of this paper--there is evidence of an association between these risk factors and the design of the built environment.

There is also an association between land use patterns and injuries. Unintentional injuries, especially those involving motor vehicle collisions, are also a major source of hospitalizations and mortality. Design of transportation systems has a demonstrated impact on motor vehicle-related injuries, both for pedestrians and motorists (Pruss-Ustun 2005).

The impact of environmental design on chronic disease and injury is often discussed by comparing different types of urban design and assessing their differing health impacts. For the purposes of this paper, two particular types of design are referenced in the research literature. Traditional' or 'urban' design, typically found in older neighbourhoods, is characterized by relatively high population densities, the prevalence of mixed land use--incorporating both commercial and residential usage--and high street connectivity achieved through a grid layout. Recent planning trends towards incorporating the key tenets of this type of design are often referred to as 'new urbanist' approaches.

In contrast, 'suburban' design began to predominate as a form of land use planning just after World War II. During this period strong housing demand spurred rapid new residential development. In addition, increasing availability of (and reliance on) automobiles for personal transport made it possible for suburban development to expand into areas previously outside the boundaries of accessibility via public and active forms of transit. Notable characteristics of suburban design include low population densities, an emphasis on curvilinear streets connected to major arterial roads providing entry and exits into the neighbourhoods, and zoning regulations favouring single-family residences. Suburban neighbourhoods, with their single-use zoning and low population densities, were originally developed as 'clean' and 'healthy' residential alternatives to crowded and dirty urban environments. Today, suburban development has resulted in many neighbourhoods with a large proportion of unconnected street networks (cul-de-sacs) and a reduced number of intersections replacing the traditional grid design. This type of suburban design is often referred to colloquially as 'urban sprawl' or 'suburban sprawl'.

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