San Bernardino, Calif., the 100th largest city in the U.S., has several other distinctions: compared to the rest of the state, it has the worst food index (ratio of unhealthy to healthy food index), an average life expectancy that is eight years lower, a homicide rate that is 150% higher, the 2nd highest concentration of alcohol outlets and a 400-acre deficit of parks (two-thirds of residents don't live within a mile of parks or green spaces).

The county of San Bernardino doesn’t fare much better. In the 2011 County Health Rankings, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, San Bernardino ranks 50th out of 56 California counties in health factors and 55th out of 56 in physical environment factors such as access to healthy foods and air pollution days.

San Bernardino is in the midst of a public health crisis.

The Healthy Communities team at the Bernardino County Public Health Department set out to tackle that crisis—on a staff of three. “We knew partnerships would be critical,” said Evelyn Trevino, Program Coordinator for the program. Thus, the Healthy San Bernardino County Healthy Places Coalition was born.

One of the first steps was to conduct an environmental scan, the results of which provided many of the nuggets above, as well as information on parks and recreation space, the food environment, air and water quality and economic opportunities, said Mark Hoffman, Senior Planner for The Planning Center.

Peggi Hazlett, Assistant to the Mayor of the City of San Bernardino, lives and raises two children in the area, and has been committed to making it a healthier, happier place to live for her own family and future generations. It’s a constant struggle, though. The week of the conference, there were three homicides within a 20-block radius, including a stray bullet that slayed a 15-year-old. “Welcome to my world,” said Hazlett.

This weekend at the New Partners for Smart Growth Conference, NewPublicHealth attended a walkability audit of downtown San Diego with the inventor of the tool and "Johnny Appleseed of walkability," Dan Burden. In 2001, TIME magazine named Burden one of the world’s six most important civic innovators. He is currently a senior urban designer and executive director of the Walkable and Livable Communities Institute, and previously co-founded Walkable Communities, Inc., and the Bicycle Federation of America. Burden has worked in more than 3,000 communities and led more than 4,000 walking audits throughout North America.

Walking audits have been happening for about 25 years now, though they are a skill and a field now coming into their pinnacle—the first official course on walkability audits was taught recently in Tucson to a mix of health, planning and engineering professionals. “A very big part of the walkability audit is to start to break down the walls between disciplines. It really helps open people’s eyes. It’s been a very powerful tool.”

A walking audit is an assessment of the walkability or pedestrian access of the built environment in a community. Burden created this tool to help communities understand how their environment encourages or discourages its residents from walking.

“America became something different. We lost our focus. We stopped designing cities for people,” explained Burden.

Dan Burden began to run walking audits about 25 years ago during his tenure at the Florida Department of Transportation. He realized that the engineers never went out and walked the streets they’d designed. “As we went out, we realized more and more how wrong the designs were.”

In his presentation, Burden shows photos of places that make you want to stay inside your house (or get in a car) rather than walk anywhere—deteriorating or no sidewalks, dangerous intersections built for cars that leave scarcely enough time for a healthy person to cross, acres of asphalt littered with bottles and trash with no green space in sight, and unlit alleyways that seem built to shelter crime.

“Over 80 percent of Americans want to be able to seamlessly switch modes of transportation,” said Burden. “That’s not what we’re funding.” In fact, he said, less than 1 percent of federal transportation dollars go toward supporting walking and biking infrastructure, and even those scarce funds are under threat.

Burden typically takes anywhere from one to 100 people with him on his walkability audits (though he recommends a group of 30 for less seasoned walkability gurus), inviting city planners, elected leaders, citizens, advocates, police officers, persons with disabilities and public health officials—anyone with a vested interest in creating a better community.

Before he brings in the whole group, though, Burden tries whenever he can to take a first pass through a neighborhood on his own to connect with residents, kids and local retailers to get their take about what’s working and not working in the community. One six-year-old told him all she wanted to do was to walk to school and play with her friends, but she was afraid to be outside by herself. The goal of the walkability audit is to find out what steps the community needs to take to get it to be a place its residents can be proud of and happy to live in.

The components of a walkability audit get very nitty gritty: the exact width of the “walk-and-talk zone” of a sidewalk (ideally four feet, leaving another two to four feet on either side as a buffer and a place for sidewalk “furniture” such as benches, bus stops and street lamps), the number and width of lanes for cars, the average speed of cars and average traffic volume on each block, and more. But what’s most critical is not the sidewalks or traffic patterns—it’s how the land is used, how connected are the hubs of activity, and how much open space there is. While sidewalks are important, they’re useless if they don’t lead somewhere people want to go, said Burden.

While the walkability audit of San Diego at the Smart Growth conference was quite literally, at times, a walk in the park on a beautiful, sunny day, that’s not always typical. Burden’s longest audit spanned 16 miles on a day when the temperature peaked at 120 degrees. Another audit could only be conducted 10 minutes at a time because the temperature dipped below a frigid –54 degrees. Yet on the 16-mile, 120-degree day, a woman in a wheelchair stuck it out for the entire audit to help show her community the challenges she faced daily in navigating a city that simply was not built for her.

What makes a community work? Five key aspects, said Burden:

1. Security
2. Convenience
3. Efficiency
4. Comfort
5. Welcome

There’s both an art and a science to walkability. The science involves a set of measures and ratings, described in detail in the Environmental Protection Agency’s Walking Audit tool, co-designed by Burden (and admittedly still “in beta”—more will likely be added to the tool as it is continually tested and refined).

Though health is not the primary goal of a walking audit, it is a critical outcome of a walkable community.

>>Read more NewPublicHealth coverage from the New Partners for Smart Growth Conference.

The great thing about the New Partners for Smart Growth Conference is the wide variety of different sectors, fields and perspectives represented. Each brings a different set of ideas, challenges and solutions to the discussion, from housing to transportation to urban planning.

As we look beyond the public health sector to understand how to create healthier communities, we also look beyond NewPublicHealth to some of our fellow bloggers at the conference.

The Initiative for a Competitive Inner City (ICIC) is a nonprofit research and strategy organization and the leading authority on U.S. inner city economies and the businesses that thrive there.

ICIC featured a recap of day one of the New Partners for Smart Growth Conference on their blog. The post was penned by Alex Abboud, a blogger and non-profit professional who writes about ideas, cities and sports at alexabboud.com and works on promoting housing and ending homelessness in his community. His recap of the second day of the conference can be found here. Some highlights from both posts:

• A boarding school for foster teens built on an organic farm, where the students participate in tending to the farm
• A method of getting the public engaged in community planning—online
• New tools to measure the need for use of cars in a community

We've got our ear to the ground for new and varied perspectives on creating healthier communities. Keep the ideas coming!

Also follow our coverage of the conference, which will continue into next week, including Q&As with conference presenters and smart growth leaders as well as perspectives from attendees.

For lunch today, the New Partners for Smart Growth Conference set up a mini-farmers' market to give attendees access to healthy, sustainable, local and affordable food options. Among the most popular: fish tacos, hummus and curry and fresh fruits and vegetables from a local farm.

In the past year, 1,000 new farmers' markets opened in the United States.

California boasts the most farmers' markets in the U.S., with over 700, so it may be easier to create a "pop-up" market here at the Smart Growth Conference in San Diego.

Even if you can't share in the healthy, sustainable food here at the conference, follow our Smart Growth coverage to learn more about how new growth can support better health in your community.

The National Prevention and Health Promotion Strategy provides a new, health-in-all policies approach to prevention, requiring the efforts of many federal agencies (17 to be exact) and other stakeholders. Good community design, with sidewalks, adequate lighting and traffic-slowing devices, improves the walkability of communities and promotes physical activity. Increasing access to healthy, affordable food options provides people with the opportunity to make healthy choices about what they eat.

The Strategy launched in June 2010, as a product of the National Prevention Council, a body of 17 federal departments that for the first time have been mandated to find opportunities for collaboration and coordination around prevention, health and wellness.

At this week’s New Partners for Smart Growth Conference, Corinne Graffunder, Director of the National Prevention and Health Promotion Strategy at the Centers for Disease Control and Prevention, along with colleagues from the U.S. Department of Agriculture (USDA), Environmental Protection Agency (EPA) and the Department of Housing and Urban Development (HUD)participated in a panel to discuss their respective roles in the National Prevention Strategy – and how the Strategy intersects with smart growth principles.

>>Follow our coverage of the New Partners for Smart Growth Conference, from a public health perspective, here.

“This is meant to be more than just a document,” said Graffunder. “The Council is an ongoing leadership body that will continue to figure out how to make this work.”

Graffunder also emphasized that it is the National Prevention Strategy—not a federal strategy. That means it recognizes the critical role of partners beyond the government, from the business, non-profit and state and local government sectors.

Town and city streets are an important part of the livability of communities, says Barbara McCann, Executive Director of the National Complete Streets Coalition and a presenter and moderator at this week’s New Partners for Smart Growth conference in San Diego. McCann says streets ought to be for everyone, whether young or old, motorist or bicyclist, walker or wheelchair user, bus rider or shopkeeper. “But too many of our streets are designed only for speeding cars, or worse, creeping traffic jams.”

But in communities across the country, a movement is growing to complete the streets and these communities are asking planners and engineers to build road networks that are safer, more livable, and welcoming to everyone.

Instituting a complete streets policy, according to McCann, ensures that transportation planners and engineers consistently design and operate the entire roadway with all users in mind. NewPublicHealth caught up with McCann in advance of this week’s conference.

NewPublicHealth: What is the scope of Complete Streets?

Barbara McCann: Complete Streets is about getting communities around the country to adopt policies to ensure that streets work for all users, and we have focused quite a lot on policy adoption. We’re seeing success in more half of the states and in about 300 local communities. And now we’re turning our attention towards implementation. What do communities need to do once they have a policy in order to actually make changes on the ground that creates a safer environment for walking and bicycling and taking the bus and other really active transportation?

NPH: How quickly have you seen changes recently?

Barbara McCann: Well, certainly in policy adoption it’s been going great guns. We’ve pretty much doubled the number of policies adopted every year for the past three years, from close to zero where we started this in 2006. So the policies are really, really spreading. Implementation of actually seeing change on the ground is a long haul process in most places because Complete Streets policy must make sure that every future project is done differently, and so that means that you’re not going to see an overnight change in your community, but it does mean that as investments move forward, every transportation investment will start to make a difference.

There are communities that have been doing this for a number of years and we do see improvements in facilities, we see public support or some of the innovations that are happening on the roadways really rising. We see safety improving and we see an increase in biking and walking in some of the places that have taken this approach.

NPH: What community would you hold up as a model for Complete Streets?

The eleventh annual New Partners for Smart Growth Conference begins tomorrow in San Diego. The conference is a national, multi-disciplinary smart growth gathering presented by the Local Government Commission. The conference draws experts including local elected officials, city and county staff, developers and builders, planners, transportation professionals, public health professionals, architects, bankers, realtors, urban designers, parks and recreation professionals, advocates for social and environmental equity, school superintendents, board members and facilities staff, advocates for older adults and youth, bicycle and pedestrian advocates, environmentalists, crime prevention professionals and many others committed to building safer, healthier and more livable communities everywhere.

In advance of the conference, NewPublicHealth spoke with several presenters about the conference and the growing efforts to use smart growth to help improve the lives of all Americans.

Geoffrey Anderson is the President and CEO of Smart Growth America and previously ran the Smart Growth Program at the U.S. Environmental Protection Agency. At the Smart Growth conference, he will be presenting in the training session, "Achieving the Prosperity Benefits of Transit and Smart Growth."

NewPublicHealth: What does smart growth mean and what are the strategies for making it happen?

Geoffrey Anderson: It really means building urban, rural and suburban communities with transportation and housing choices near jobs, shops and schools. So it’s about building complete neighborhoods so that you can get most of what you need to do on a day-to-day basis done nearby and have a high quality of life.

NPH: What is it that’s kept that from happening?

"Designing Healthy Communities,” a four-part series funded in part by the Robert Wood Johnson Foundation, debuts this month and next on many Public Broadcasting stations. The program looks at the impact the built environment has on key public health problems such as obesity, diabetes, heart disease, asthma, cancer and depression. In the series, host Richard Jackson, MD, MPH, professor and chair of environmental health science at the UCLA School of Public Health, connects bad community design with burgeoning health costs, then analyzes and illustrates what citizens are doing about this crisis by looking upstream for innovative solutions.

NewPublicHealth recently caught up with Dr. Jackson, who will also be a featured speaker at the New Partners for Smart Growth Conference in San Diego next week, leading a session on “Health as a Messaging Tool.” Dr. Jackson received the New Partners for Smart Growth Lifetime Achievement Award in 2008.

Follow NewPublicHealth coverage on-site at the Smart Growth conference here and on twitter @RWJF_PubHealth.

NewPublicHealth: What prompted the "Designing Healthy Communities" series?

Dr. Jackson: My background is that I’ve worked in environmental health in one form or another for over 30 years. I started out as a pediatrician and have become more and more focused on the whole mix of environment and health and the outcomes and the impacts on our population, acute impacts such as asthma, car injuries, all the way through to chronic diseases, cancer and birth defects, and I’ve investigated all of them. And then beyond chronic diseases, long-term health impacts such as endocrine disrupters in the environment and health effects of global climate change.

I spent nine years as the Director for the National Center for Environmental Health and I was State Health Officer for California for a year and a half, and I’ve become increasingly convinced that I’m sitting at the end of the disease pipeline waiting for somebody to come in the door with obesity-related diabetes, with injuries related to a bad urban design or for that matter a lack of adequate crosswalks. Asthma and even heart disease are related to very poor air quality. That it is not feasible for the future of our country. When I was a young doctor, seven percent of all the money in the United States that was going to medical care. It’s now more than 17 percent, and the U.S. is still ranked about number 50 in life expectancies worldwide.

So, we’re not doing something right, and I would assert that what we’re not doing right is we’re failing to really operate in the realm of prevention. We’re not going far enough upstream in thinking about what things are affecting our health. What I would assert is a big driver that’s affecting our health but it’s also affecting our happiness, our prosperity, and our future is how we have built America. We have built it for the needs of cars and other short-term needs, maximizing sale of commodity foods of various kinds and we have not built it with an eye towards people and an eye towards future generations.

I co-wrote a book ten years ago called “Urban Sprawl and Public Health,” and then became much more focused on these issues of built environment and co-wrote a textbook, where we very deeply document the impact of the built environment on everything that you would imagine, but also further upstream to obesity and lack of fitness, and even further upstream to unhappiness, to depression, and we began to think that just as this damaged environment can have multiple negative health outcomes, creating health environments should have positive health outcomes. And that’s why the television series is called “Designing Healthy Communities."

Ten years ago there really was very little recognition of this issue, but that’s changing. There were almost 300 sessions that either had the words “built environment” or “land use” at the last American Public Health Association National Meeting in early November in Washington, DC.

NPH: What’s driving that increasing interest?

Tomorrow, Leadership for Healthy Communities will be hosting a webinar called Making the Connection: Linking Economic Growth to Policies to Prevent Childhood Obesity. The webinar will highlight the important links between economic growth and public health, and look at ways to implement policies that improve both. In advance of the webinar, NewPublicHealth spoke with Harriet Tregoning, Director of the Washington D.C. Office of City Planning , about efforts to make the district "a walkable, bikeable, eminently livable, globally competitive and sustainable city."

NewPublicHealth: How did city planners come to view health as part of their mission, and why is that important?

Harriet Tregoning: City planners increasingly take a broad view of their purview. So it’s not just the physical layout of the city, but also what kind of results for cities and their residents do plans produce. It’s clear that obesity is a growing epidemic, and for municipalities, in most cases, one of the most quickly rising costs is health care. So figuring out how to plan cities for the best health outcomes is on the agenda of most city planners.

NPH: What city planning activities are now underway in Washington, D.C., that address childhood obesity prevention?