What Makes a Community Healthy? Q&A with Howard Frumkin
Defining and measuring what makes a community healthy is a key component of the County Health Rankings & Roadmaps program, which helps create solutions that make it easier for people to be healthy in their own communities, focusing on specific factors that we know affect health, such as education and income. The 2012 Rankings were released last month, and this year includes the Roadmaps to Health Prize for communities working at the forefront of population health improvement.
Creating healthier places is a conversation every town, city and state is having now. To help advance that conversation, NewPublicHealth spoke with Howard Frumkin, MD, MPH, PhD, dean of the School of Public Health at the University of Washington, and a former member of the County Health Rankings Metrics Committee.
NPH: What does a healthy community look like? Are we getting there?
Dr. Frumkin: There ought to be places where the inhabitants of a community can thrive and do well. That’s your metric of success. People need certain things in order to thrive. They need some privacy, but they also need contact with other people. They need clean air, clean water and healthy, uncontaminated food. They need contact with nature, and they need beauty and inspiration. We could go on and on, but most of us would probably agree with what that core list of needs looks like. And then you can work with the community members to ask whether their community provides those needs for people, and we haven’t been doing that well over the last 50 years.
NPH: Why haven’t we been doing that well?
Dr. Frumkin: Well, I think that communities have been designed and built without necessarily a lot of designers’ strategic thinking, without placing the health and well-being of the people who live there at the top of the criteria for what makes it a good design.
So, for example, American cities sprawled outward in the post-World War II years. During that trend, when cities were suburbanizing, you had the expansion of cities over large land areas, you had to switch to lower-density land use. You had a separation of different land uses so that residential, commercial, recreational and employment were all in different places. All of that required a lot of travel. That meant that we moved toward a very automobile-dependent system. With low-density and long distances to travel, you can’t really implement alternatives like walking or biking or transit because they just don’t work.
So, here you engineered routine physical activity out of people’s daily lives, and that turned out to be a bad thing, contributing to what we now recognize as the obesity epidemic, the epidemic of sedentary lifestyles. So for lots of reasons we moved as a nation towards sprawl and ended up with a habitat that isn’t necessarily the optimal one for people.
NPH: What are some of the benefits of healthy, walkable communities?
Dr. Frumkin: There’s been a lot of research over the last decade or two that has led to an appreciation now based on evidence of how more walkable, mixed-use neighborhoods promote physical activity.
It also turns out that doing that yields a whole range of co-benefits. Motor vehicle crashes are the major cause of death among young people in this country, and reducing our time spent in cars is a great primary prevention strategy to reduce those fatalities.
And, if you reduce the amount of motor vehicle traffic, you reduce air pollution levels. That in turn is a great promoter of cardiovascular and respiratory health. Finally, if you get people out of cars and get them walking on sidewalks, then the social capital that results is substantial. We’re seeing the combination of environmental goals and lifestyle goals converging on better community design.
NPH: How well are we doing in getting the critical stakeholders to agree and to see change?
Dr. Frumkin: Well, this is a hard time to judge because we’ve had this economic slowdown since 2008 that’s resulted in a real sluggishness in the housing market. But that said, a lot of the signs are very positive. We’re seeing a migration back into cities by young people. There’s a very strong market demand for walkable, mixed use, vibrant, exciting neighborhoods in cities, something that in 1950s and ‘60s wasn’t really evident. We’re seeing a lot of developers and builders getting into this space because they’re responding to market demands. There’s a whole green building movement that turns out to dovetail perfectly with this healthy community design impulse.
NPH: Communities that have these livability qualities are generally more expensive. Are lower-income individuals able to benefit as much from these city-based initiatives?
Dr. Frumkin: That’s a great question. There is a real danger that as cities becomes more attractive and people move into them, then scarcity sets in, the prices rise, and people at the lower end of the socioeconomic ladder are priced out of cities. The market will never solve that problem. That has to be a solution that comes from deliberate social policy. So, when cities grant zoning variances or building permits to developers of large mixed-use developments, they can, and in many cases have, required that the developers set aside a certain proportion of the housing for affordable housing. Urban social systems do better when we mix it up rather than move into segregated, gated communities. It’s not just a matter of social justice and fairness, it’s not just a matter of accommodating the people who have lived in urban communities for a long time and shouldn’t be pushed out. It’s also a matter of creating vibrant cities that reflect the diversity and excitement of this country.
NPH: What’s your next project?
Dr. Frumkin: The one that I’m excited about is a proposal that we just put out from the University of Washington called the Sustainability Research Network. This is a National Science Foundation proposal. It brings together our College of Built Environments, our College of the Environment and our School of Public Health, and the idea will be to design healthy and sustainable communities and to do the science that we need to define in very empirical terms what makes places sustainable and healthy. We’re going to marry those two concepts together based on the notion that they really have developed independently of each other for the most part. We’re going to look for ways that research can advance the design of human habitats so that we can end up with habitats that are both environmentally sustainable and also great places for people to live and thrive.
NPH: What additional evidence is needed?
Dr. Frumkin: Well, one example of a domain about which we need to know much more is nature contact. We know that people seem to like being around nature. We know that plants and offices make people happy and productive; we know that natural daylight in offices does the same. There’s an emerging body of evidence that shows empirical demonstrably benefits. Post-surgical patients recover more quickly when they can see trees out the window of their hospital room; elders live longer and have less illness when they’re in green neighborhoods compared to more barren neighborhoods; and children gain weight less quickly in green neighborhoods. There is lots of evidence that contact with nature through various pathways improves health.
But that said, can I prescribe to you a dose of nature contact with the same level of precision and certainty that I can prescribe an antihypertensive? No, I can’t. Do you need trees or would shrubs do the trick? If trees, do the leaves have to be on the trees or do they work just as well when the leaves are off the trees? Do you need an hour a day or two hours a day? How long does the effect last? I can go on and on, but we don’t have the more granular design guidelines that you would ideally like to have to generate health-based recommendations.
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