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Reducing the Burden of Poor Health and Health Inequities Through Transportation and Land-Use Policies
Policy Date: 10/28/2008
Policy Number: LB-08-03
Reducing the Burden of Poor Health and Health Inequities Through Transportation and Land-Use Policies
The World Health Organization’s Commission on Social Determinants of Health has declared that the design of communities affects both health and health equity.1 Improving two key elements of community design—transportation and land-use patterns—through effective policies and practice can prevent the onset of many costly medical conditions. This resolution updates the evidence base from American Public Health Association (APHA) policy 2004-04, “Creating Policies on Land Use and Transportation Systems that Promote Public Health” linking transportation and land-use patterns to several health impacts.2 With national health care expenditures surpassing $2 trillion annually in 2006 [approximately 16% gross domestic product (GDP)] and projected to constitute 17% of GDP by 2011,3 effective transportation and land-use strategies can not only improve the health and well-being of Americans but also decrease demand on an already overextended health care system.
This resolution delineates the improvements in health and the financial savings possible through transportation and land-use policies and practice that prevent trauma and death caused by traffic incidents, chronic diseases associated with physical inactivity and obesity, respiratory illnesses from poor air quality, and health inequities.
The Effect of Transportation and Land-Use Patterns on Unintentional Injuries and Fatalities
Traffic injuries and fatalities are an enormous public health and health care problem, accounting for more than 41,000 deaths annually,4 2.5 million nonfatal injuries,5 and more than $200 billion in annual expenditures.6 More Americans younger than the 34 years die from traffic crashes than from any other cause of death7; more Americans of all ages die from traffic crashes than any other type of injury-related death.8
However, traffic injuries and fatalities can be prevented through effective traffic safety policies and practices.9 In 1966, the US government demonstrated a national commitment to reducing injuries and fatalities on the nation’s highways by passing the Highway Safety Act, which authorized the National Highway Safety Bureau, now the National Highway Traffic Safety Administration (NHTSA), to set vehicle safety standards and to fund research and programs that promote safety on US roads.10 NHTSA, in collaboration with the Centers for Disease Control and Prevention, has fostered traffic safety innovations, including vehicle safety (e.g., bumpers and airbags), occupant safety (e.g., seat belt laws and child safety seats), and changes to the design of roads and community environments (e.g., sidewalks, lane widths, and well-marked intersections).11 It is projected that between 1966 and 1990, nearly 250,000 lives were saved as a result of federal highway, traffic, and motor vehicle safety innovations.12
Strong evidence indicates that traffic safety legislation has been effective and largely responsible for increasing people’s use of passenger and occupant safety features.13,14 In addition to the enactment of traffic safety legislation, enforcement of stricter laws and public education have contributed to individuals’ making personal choices that favor safety (e.g., avoiding impaired driving, reducing speed, wearing helmets, and using child safety seats and safety belts).15 However, despite the significant progress that has been made in reducing traffic injuries and fatalities, the absolute toll on US lives (41,059 people killed in traffic crashes in 2007) remains unacceptable, and there are still important opportunities for future gains.
Effect of Transportation and Land-Use Patterns on Physical Activity
According to the US Surgeon General, 60% of US adults do not meet recommended levels of physical activity, and 25% are completely sedentary.16 The causal link between physical activity and health is well established, with sedentary lifestyles estimated to contribute to as many as 255,000 preventable deaths per year and physical inactivity being a major contributor to the rising rates of a number of chronic illnesses such as obesity, type II diabetes, and heart disease.17 The World Health Organization as well as APHA policy 2005-8, “Supporting the WHO Global Strategy on Diet, Physical Activity and Health,”18 recognize the role of transportation and land-use patterns in promoting physical activity and ensuring access to healthy foods. An emerging body of evidence shows that particular transportation and land-use patterns can influence people’s decision to be physically active or not, making transportation and land-use decisions an opportunity to increase levels of physical activity.19–20
Transportation and land-use elements that increase the likelihood of individuals choosing to travel by bicycle, foot, or public transit, can increase levels of physical activity and decrease dependence on vehicles.24,25 The specific land-use characteristics that have been associated with higher levels of physical activity include high-density and mixed use development, good public transportation, and proximity to destinations.26,27 Characteristics such as bicycle and pedestrian facilities, good street connectivity, presence of parks and open space, and residents’ perceived safety have also been shown to enhance physical activity in some communities.28–31 Because walking and bicycling remain more dangerous than motorized travel, per trip and per mile,32 improving the safety of bicyclists and pedestrians must have high priority. Ensuring that public fears regarding violence and overall safety are fully addressed may also increase levels of physical activity.33,34
Impact of Transportation and Land-Use Patterns on Air Quality
Research indicates that living, working, playing, or going to school near major roadways increases the risk of a variety of adverse health impacts. Particulate matter and other pollution are often present at high concentrations along traffic-heavy roads,35 especially when a large fraction of this traffic uses diesel fuel.36 According to the U.S. Environmental Protection Agency, 35 million people are exposed to air toxins emitted from road traffic.37 Related to APHA policy 2000-12, “Reducing the Rising Rates of Asthma,”38 transportation patterns have an important role in reducing the burden of asthma. Several studies have documented that children going to school near major roadways have higher rates of respiratory symptoms,39 asthma diagnoses, and allergic sensitization,40,41 and children living near major roadways are more likely to suffer from asthma.42–48 Adults living or working near roadways are also more likely to suffer from asthma,49–51 and other respiratory diseases,52–56 as well as atherosclerosis and other cardiovascular problems.57,58 Other health effects associated with roadway exposure include cancer,57–63 adverse reproductive outcomes,64 and impaired neurocognitive performance in children.65
As acknowledged in APHA policy 2007-8, “Addressing the Urgent Threat of Global Climate Change to Public Health and the Environment,”67 the transportation sector is a significant source of harmful air pollutants, including greenhouse gases. Motorized vehicles typically account for more than three fourths of the annual carbon monoxide emissions in the United States, more than half of the emissions of nitrogen oxides, and more than one quarter of fine soot particulate emissions67; together, the health costs of these elements of transportation-related air pollution were estimated to be $40 to $65 billion in 2000.68 Mobile sources emit more than half of the nation’s benzene, toluene, and acetaldehyde, the air toxics of greatest public health concern, as well as approximately 91 additional air toxics that are known carcinogens or have toxicity reference concentrations in the US EPA’s main risk assessment database, the Integrated Risk Information System.69 The US transportation sector emits approximately 10% of all energy-related greenhouse gas emissions worldwide and more than one third of all transportation emissions worldwide. Over the next 50 years, greenhouse gas emissions from the US transportation sector is poised to grow another 80% above current levels.70
Equity in Transportation and Land-Use Patterns
As acknowledged by APHA policy number 2007-3, “Environmental Injustices: Research and Action to Reduce Obesity Disparities,”71 barriers to necessary community resources such as healthy food and physically activity opportunities do not affect all Americans equally and have disproportionately contributed to poor health among particular populations in the United States.72 Executive Order 12898, Federal Actions to Address Environmental Justice in Minority Populations and Low-Income Populations, brought federal attention to the environmental conditions that have had disproportionately adverse health effects on low-income and minority communities.73 The US Department of Transportation and the Federal Highway Administration subsequently implemented requirements to incorporate environmental justice principles into all programs, policies, and activities.74
Low-income communities have the lowest rates of car ownership, making residents in these communities twice as likely to walk compared with people in households with higher incomes75 and more likely to rely on public transportation.76 Because low income and lack of access to a car are associated with higher risk of injury as a pedestrian,77 these populations are at greater risk for unintentional traffic injuries. Furthermore, public transit systems often do not provide convenient and practical access to key destinations in low income communities, and there is often less investment in public transit systems in low-income communities compared with moderate and high income communities.78
Traffic safety concerns among transportation disadvantaged populations create additional barriers to travel. Traffic danger inhibits approximately 40% of children from walking or bicycling to school.79 Seniors make just 8% of their trips by foot or bike, largely because of safety concerns, compared with 35% in some European countries.80 As the US demographic is projected to shift to include more seniors, with 1 in 5 US residents projected to be older than 65 by 2030,81 mobility for seniors will be an important transportation concern in the coming years. Although it is not clear exactly to what extent safety concerns because of violence affects levels of physical activity, research shows that violence or fear of violence is associated with lower activity levels, especially among children and youth, women of color, and seniors.82,83
Policy and funding practices at the federal, state, and local levels largely determine transportation and land-use patterns within communities. Public health should continue to advance policies and support for solutions that have a record of success while building momentum to increase health leadership on additional, promising transportation, and land-use issues.
Therefore APHA resolves that—
1. Transportation and land-use policies need to include consideration of the impacts on social determinants of health and equity such as access to health services, healthy food, safe physical activity resources, education, and employment.
2. Transportation and land-use policies and programs should consider and address disproportionate impacts on vulnerable populations.
3. Urban, suburban, and rural needs should be addressed in local and regional transportation and land-use decisionmaking by engaging public participation in the process.
4. Public health students and professionals, including local, state, and federal public health officials, should be trained on the links between transportation and land-use systems and policies and their relation to public health. Similarly, a public health component should be added to urban planning, architecture, and transportation design curricula. Public health should develop multidisciplinary partnerships with transportation and land-use agencies and organizations to enhance competencies and collaboration across disciplines and to provide training to land-use planners, engineers, and elected and appointed officials.
5. Federal, state, and local policymakers make public health protection and promotion one of the core principles of transportation policy and legislation. Public health professionals and agencies should engage in legislative and regulatory transportation and land-use initiatives that promote health and oppose those that potentially threaten health. Transportation planning and policy should include measures to require an assessment of the impact on health and safety.
6. Federal incentives, mandates, and regulations promote state expansion of programs that have been proven to improve traffic injury prevention. Although states have primary responsibility for traffic injury prevention, funding and an overarching emphasis at the federal level should be aligned with state and local activity.
7. Funding and guidance are needed by states, metropolitan planning organizations, and localities to improve facilities and safety for bicyclists and pedestrians and to expand public transit services. Federal, state, and local transportation agencies should improve and expand data collection on the availability, use, and users of nonmotorized modes of travel and public transit.
8. Additional research initiatives should be funded to document the adverse as well as beneficial health impacts and the costs of these impacts to society, especially on vulnerable populations, of various elements of the built environment related to transportation and land-use patterns.
References
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