Richard Jackson, MD, MPH, is professor and chair of environmental health sciences at the School of Public Health at the University of California, Los Angeles. While serving as director of the National Center for Environmental Health at the Centers for Disease Control and Prevention in the 1990s, he began understanding and exploring the growing and sometimes fatal connections between the built environment and human health. He then served as state health officer for California and during that time co-authored the book Urban Sprawl and Public Health.
A pediatrician and long-time member of APHA, Jackson embarked four years ago on a project as narrator and host of “Designing Healthy Communities,” a provocative four-hour series that is airing on PBS stations across the country and looks at the impact of the built environment on key public health indices: obesity, diabetes, heart disease, asthma, cancer and depression. A companion book by the same name is also available from APHA Press.
Q: Congratulations on the PBS series and your new book. What was your “aha” moment when you realized community design was adversely affecting human health?
The first of my “aha” moments occurred when I was at the CDC as the director for the National Center for Environmental Health. In that job I confronted threats of the environment to human health ranging from the microscopic — bacteria, toxic elements — to macroscopic — for example, climate change and disasters. I was driving to the CDC director’s office one day for a big meeting on the 21st century health threats, and I saw a woman struggling, walking alongside Buford Highway in 95 degree heat. She was elderly, bent over carrying shopping bags, and she looked like my mother. I wanted to stop and give her a ride. I didn’t, but she weighed on my mind for days after.
I tell that story for a reason. If she had collapsed and died from exhaustion, the cause of death would likely have been heat stroke. It wouldn’t have been an absence of trees or an absence of public transportation. And if she had been killed by a truck going by, the cause of death would have been motor vehicle trauma, not absence of sidewalks, no public transportation or poor urban planning. That story is a very simple way of explaining that public health is about the causes of the causes of death, and how we intervene with these causes.
But it also struck me that we have forgotten that much of our health is dictated by where we live, what surrounds us all the time: the physical, the social, the cultural, the nutritional environments that we’re in. A hundred years ago, people understood full well that you can’t be healthy in unhealthy buildings, tenements, without sunlight, fresh air or adequate sanitation. And yet we assumed starting in the 1920s forward that if everyone drove away from the cities in a car, they’d all be perfectly fine. Lo and behold, the cars and roads created new kinds of air pollution, more water runoff and pollution, and a higher prevalence of chronic diseases because we were sitting too much and walking too little.
Q: Why do you think it’s taken us so long to begin to connect the dots?
Using 20th century thinking we solved many of our problems by being deeply reductionist, so the sciences became further and further refined. All of our knowledge becomes ever more specialized, which is fine if we are looking for treatment of a unique cancer, but by endlessly fractionating our challenges, we fail to confront the big ones. Ultimately, we must think about solutions that cross multiple domains. As my friend Larry Cohen at the Prevention Institute says, “A good solution solves multiple problems.” In the 21st century, we must confront environmental challenges, we must face social and health problems, and we must be much better at fixing unemployment and a sick economy. We end up deeply frustrated because we can’t move the interconnected network of challenges. The only way to move a spider web is to move its frame, and I assert that the frame we need is one where our built environments are healthier, more sustainable, and job- and good food-creating than what we’ve built over the last 70 years.
Q: Can you give us two or three examples of communities that are getting it right? How so?
In the series, we visited a number of cities. One is “the healthiest city in the healthiest state” — Boulder, Colo. Boulder has the advantage of a strong economic base with the university and lots of young, well-educated people. But the other advantage it had was the sons of Fredrick Olmsted, founder of landscape architecture. They visited Boulder years ago and looked at the creeks and the streams from the Flatiron mountains and said we need to put walking and carriage trails, parks and respite areas along those water features. Pretty quickly, people were able to go about their business east to west in Boulder. Then, 20 or 30 years later, they said we ought to have the same routes going north and south and began to knit the community together with these walking and bicycle routes. When you see people on them today, it seems like they are all smiling. People go to work without dealing with a traffic light. They don’t need to go to the gym for exercise; they’ve got it built into the utilitarian activities that they pursue during the day. And they save money.
But what’s happened in addition to this activity is a normative change. It’s kind of normal, it’s expected to bike to the meeting with the mayor. And no one asked, “Where is your three-piece suit? Why are you in a bicycle outfit?” I hope someday when someone drives a short distance by car for a meeting or errand, that it will be seen as unhealthful and foolish as smoking in a restaurant or schoolroom.
I think the city that really has confronted some of the most difficult problems is Detroit. Motown, the motor city that drove 25 percent of the entire U.S. economy in the 20th century, was based upon motor vehicles. With that industry’s abandonment of Detroit, the city fell into deep decay. Until a few months ago, the entire city of Detroit did not have a single supermarket. Little businesses, mom-and-pop barber shops, hanging on for dear life, not even able to get insurance because the buildings all around them had been abandoned.
What’s happening now is that young people are moving in and there seems to be a good working relationship between the African American population that has stayed and these young, urban, creative people who are happy to buy a house for a few thousand dollars and not have to be hostage to their mortgages. Restaurants are springing up, artistic places, and music. A lot is going on, including development of urban farms. Admittedly, they can’t produce all their winter food, but they are producing a lot of food. It’s meaningful work for people who are there, it cools the environment, it creates social networks and social structures. The Eastern Market, which had been an original transit spot for food coming into the city by train, has now become a huge farmer’s market filled with lots of different kinds of locally grown as well as other food. It’s become a magnet for people to go and get what they want, and to socialize. You walk through there and there are flowers and neighbors smiling, and people feel quite safe. There is a musician playing, and it gives a heart back to a city that has been disheartened for a long time. To have that coming back, in a way I think, is a metaphor for the U.S.
We have got to put a heart back into so many of our disheartened but also heartless communities. I could blindfold you and take you to any one of a hundred thousand street corners in the U.S., and you’d see the same big box stores and gas stations and no sidewalks and no trees, and you wouldn’t know whether you were in the state of Maine or Florida or the West Coast. It all looks alike. To recreate America with that mix of good nutrition, good opportunities for physical activity, good community and good culture, and frankly, maybe some vitality in the economic scene, that’s really what we ought to be doing in the 21st century.
Q; What role should public health professionals and organizations be playing to be part of the solution?
One of the core things of public health is what is in front of you. Just don’t look at that, but look at what are all the things behind it that created this situation, this problem that you are confronting. And as a public health professional, yes, it’s fine for the environmental health people to inspect the restaurant and the pool, but if they’re building a school without adequate sidewalks for kids to get there and we look at 30 percent traffic increase around the schools every morning with a social milieu that makes riding to school acceptable, we need to consider the consequences. We are looking at an inactivity and obesity epidemic in our kids. We need to think of public health in a much broader and systemic way, and this is the way that public health is going. We need health in our school, transportation, food and other policies. Health is where and how we live, not a doctor’s office.
The purpose of public health, and this is from the Institute of Medicine definition, is to “assure the conditions where people can be healthy.” Let’s think of this in a bigger way. Speak up to the planning agencies, speak up to the tax policy people. Be involved as they rewrite the master plan, the overall “constitution for growth” for that city or county. Be involved with that, get some training.
The second big thing is that health impact assessment is here to stay. Old-fashioned environmental impact assessments, where you looked, again very narrowly, at only environmental aspects of plans or projects that are proposed are a “fail” as the kids put it. In the 21st century, we should not accept impact assessments that just give a hand wave to health concerns.
You know, 10 years ago, I did a search for the terms “land use” and “built environment” at the Annual Meeting of APHA, and there was not a single session several years running. I looked at the 2011 program and came up with about a 180 sessions for one and about 140 for the other. So there is a huge outpouring of interest among researchers, which is always helpful. But I think in some ways, the 21st century people of the future are looking at the problems that we are confronting and are looking for organic solutions. And by organic I mean that an organic plant is one that “fits,” it belongs where it is and it doesn’t need a lot of external inputs. It’s appropriate to the setting that it’s in. And we need to have solutions that are organic as we go forward, and they need to solve across multiple domains.
There were no programs jointly between, for example, urban planning and public health, at the various schools of public health across the country 10 years ago. I would say there are at least 10 now. We just started one at UCLA. There is one at Berkeley. There are other institutions where this has taken off. And I will tell you, the students love this. I have to cap my classes because they find this issue so captivating and interesting. And I hope that with the PBS series, a whole lot more will.
Q: Have you met much resistance as you’ve championed this issue, or do people seem to get it?
Well, early on among the housing developers. They did a survey of the 50 richest people in Sacramento a few years ago and 37 of them were builders and developers. They saw this as a threat to their livelihood. And their livelihood was to take a $25,000 quarter acre and put a $100,000 house on it, turn it around and sell it for $400,000.That model of converting land into subdivisions was very lucrative until very recently.
I say recently for a variety of reasons. For reasons of the environment, at least in California, we have a “sustainable communities” statute that requires developers to be responsible for the carbon footprint of communities and neighborhoods that they put up. For reasons of population pressure and the rise of consumerism in developing countries, materials have and will continue to become more expensive. And with the weak economy, housing is and will be depressed for a long time. And for reasons of demand, 54 percent of potential home buyers in the U.S. are looking for a home in a walkable neighborhood with public transit access to where they work. And this is not surprising because young professionals and people coming into the job market want to live in a place that’s attractive and fun. And the baby boomers don’t want to mow the lawn any more. Both ends of career life are looking for the same type of setting. So there is a lot of demand for smarter environments and the old vision of a city being dirty, crowded and dangerous is not what’s happening. We are seeing more and more cities that are lively throughout the day and the night, and when you have good policing and good sanitation, they are pleasant places to be. But buildings need to be well built, they have to be energy efficient, they also need to be well sound insulated, they need to have the amenities that make it fun to live there.
The series “Designing Healthy Communities,” hosted and narrated by Dick Jackson, is airing on PBS stations across the country. Visit the website to learn when it airs in your community.