Health by Design: the Crusade for Healthier Cities in the Sacramento Valley

July 12, 2006

From The Next American City, May 2006

PLANNING: Health by Design: the Crusade for Healthier Cities in the Sacramento Valley

by Eric Amster

ALONG INTERSTATE 80 IN CALIFORNIA'S Sacramento Valley, sprawling suburbs spring from the fertile agricultural land that has long been the economic and cultural center of the region. New developments of track homes and super-stores are named for the crops they supplanted: Walnut Grove, Wheatland, and Orangevale. Signs lining the freeway from San Francisco advertise spacious homes from the low-$300,000s and, as one billboard puts it, a “better, easier life.” As Bay Area residents flee San Francisco’s disappearing jobs and soaring housing prices, Sacramento, lying just seventy miles to the east, braces for unprecedented growth. More than a million additional housing units will be needed in the six-county, 10,000-square-mile Sacramento Valley region to accommodate the 70% population growth expected over the next twenty years. Growing pains are inevitable.

The usual cast of builders, city planners, advocates, and homeowners are the loudest voices in the disputes about development in the Sacramento Valley. But a new voice has been vying for recognition: the voice of the public health and medical community. Health experts argue that city planning and development is integrally related to many of the most pervasive health epidemics in our country, including asthma, obesity, and diabetes. These experts are particularly worried that the Sacramento area—which claims some of the worst air in the nation and a prevalence of obesity and diabetes above statewide averages—stands at a crossroads of unprecedented growth and public health crisis. The role that urban development plays in shaping the health of the community is beginning to infiltrate planning discussions, but the question remains: is there room for a public health perspective on the future growth of the Sacramento Valley?

Public Health
and the Built Environment

The idea that certain cities breed healthier citizens is not a new one. For decades, sociologists and planners have investigated how housing density and land use might connect to sanitation and mental health. As far back as 1926, in Village of Euclid v. Ambler Realty, the U.S. Supreme Court cited public health protection as one of the basic responsibilities of local governments when it came to issues concerning land use and zoning.

It is fairly intuitive that what we do with the land, water, and air around us has health implications. It was not until the relatively recent epidemic of childhood obesity, however, that a small group of academics and public health officers began to take a scientific look at the relationship between city planning and human health. They found that traditional risk factors, such as poor diet and lack of exercise, were only part of what was causing the 74 percent increase in obesity nationwide over the past ten years. Housing characteristics, land-use patterns, and transportation choices were also found to be influential when it came to what many have called the “fattening of America.”

The links between land use and health were further explored and legitimized by a 2001 article published in the esteemed Journal of the American Medical Association. This article looked at the effect that decreased auto traffic during the 1996 Atlanta Olympic Games had on ozone levels and asthma attacks. The study demonstrated that a 22 percent decrease in auto traffic (in part resulting from improved public transit during the Atlanta games) resulted in a 41 percent drop in emergency room visits due to asthma attacks. Over the past few years, entire issues of the American Journal of Public Health and the Journal of Urban Health have been dedicated to discussing and documenting the growing body of evidence linking the built environment and human health. Once indices measuring sprawl were shown to correlate with the prevalence of obesity and asthma, the public health community started to expand their definition of ‘risk factor’. The built environment—the space, buildings, roads, parks, and infrastructure we interact with—has now become a variable in many major medical studies.

A “Junk Science”

In his Sacramento office directly across from the lush lawns of the state capitol, Dr. Richard Jackson, California’s Chief Health Officer, reflects on the field he helped to create. During his tenure as one of the directors of the Centers for Disease Control, Dr. Jackson, a pediatrician by training, developed much of the initial research linking the built environment and human health. “The first article I wrote [on the relationship between health and the built environment] was lambasted. I was attacked for espousing junk science.” Since then, developers and politicians have continued to attack him for his “junk science.”

Jackson sees California, and the Sacramento Valley in particular, as “a laboratory for looking at health and the environment.” He intends, however, to go beyond just looking to doing something notoriously rare in public health circles: turning research into practice. His first and most ambitious goal has been to facilitate dialogue and cooperation between public health officials and planners.

Getting the two groups to talk to one another, it turns out, is easier said than done. Dr. Glennah Trochet, Sacramento’s Public Health Officer, believes that the sprawling growth in her county will create more auto traffic, thereby worsening air quality in a valley that, according to the American Lung Association, already has the seventh worst air in the country. However, she has done little to coordinate her worries with other county officials because, she says, “The county public health officers can’t talk to the planners.” She says she cannot even set up a meeting with a planner in her county because she “wouldn’t even know what to talk about. You can’t have a dialogue without the same language.”

Dr. Jackson is trying to move beyond such barriers. In his first year on the job, he has encouraged county and local health officers to train staff in issues of the built environment, and his office is planning a seminar for city planners and public health officials to network and coordinate planning efforts in the region.

One group more than willing to talk with public health officials is the advocacy community. For years, advocating for smart growth and sustainable development seemed an uphill battle to many in the Sacramento Valley. The election of Gov. Arnold Schwarzenegger, known to enjoy big houses and big cars—he is often called the Hummer Governor, owning seven in total—only increased fears that high-density, mixed-use developments and improved bike and pedestrian infrastructure would be even harder to accomplish in Sacramento.

Walt Seifert, executive director of the Sacramento Area Bicycle Advocates, has noticed over the past few years that an increasing number of public health officials are attending conferences and seminars, educating advocates on the links between the built environment and health. As a result, his organization, which sits on a number of city and regional planning committees, has attempted to use public health arguments in advocating smart growth policies: “Any scientific argument I can use, especially a strong public health argument, is welcomed.” Mr. Seifert, however, is skeptical of the influence this has had on city planning. He worries that the city council and board of supervisors don’t see public health as their job. “I think they recognize the problem,” says Mr. Seifert, “but they don’t see themselves as a part of the solution.”

Meeting Demand?

When it comes to building healthy cities, where does the responsibility lie? Do developers have an obligation to build cities that are, according to epidemiologists, healthier? Many developers in the Sacramento Area feel that they are simply meeting public demand. After all, if the market rewards the development of large, single-family housing, it is difficult to blame developers. And if people end up living a ten-minute drive from the nearest shopping center, as is the case in the Sacramento exurb of Roseville, it is typically the result of zoning ordinances and not developer preference.

It is hard to get anyone from the major building corporations in Sacramento to talk about the human health implications of the developments they construct. Either they simply are not aware of the implications, or they do not believe it is their job to know. One developer (who spoke under the condition of anonymity) believes there are only a few factors that truly influence what developers end up developing: city officials, housing prices, and lawsuits. When it comes to building cities, he stated, “We need to get the elected officials to stop telling the developers to do the wrong thing.”

As for housing prices, current zoning ordinances make it hard to build neighborhoods that are healthy by design, thus meaning that supply is far below demand. Neighborhoods like Sacramento’s midtown—where storefronts are filled with shops and markets and every street has a tree-lined bike path and light-rail station—are the most expensive in the region. “You can’t have equity, you can’t have prosperity without affordable housing,” the developer says.

And what about lawsuits? Many developers already over-engineer their projects to protect themselves from liability. Safety is one factor that litigation has forced developers to consider, but those safety concerns have traditionally been limited to issues like whether or not a building will fall over, or whether the building was erected on top of a retired toxic waste dump. Perhaps developers in Sacramento won’t become proactive about building healthier cities until an obese resident, blaming sprawl for his infirmity, brings suit. Unless that hypothetical becomes reality, the impetus for change must come from either the pocketbooks of homeowners or the laws of their elected officials.

MPO to the Rescue

Fortunately for Sacramento, the city has an award-winning metropolitan planning organization (MPO) to sort out its growing pains. This past year, the Association of Metropolitan Planning Organizations named the Sacramento Area Council of Governments (better known as SACOG) the best large MPO in the United States, and the Federal Highway Administration presented SACOG with a Transportation Planning Excellence Award. SACOG’s primary job is to manage the Metropolitan Transportation Plan (MTP), which outlines the spending of $22.5 billion in federal funds for the 6 counties and 22 incorporated cities of the Sacramento Valley. With the blessing of nearly all city and county governments in the region, they have expanded their role to develop a comprehensive blueprint for growth in the region.

As MPOs go, SACOG is unabashedly proactive in envisioning growth that works. Their blueprint for the region includes high-density, multi-use housing, centered on mass transit hubs, bike lanes, and safer pedestrian infrastructure, and improved parks and recreational facilities. Former SACOG Chair and West Sacramento Mayor Chris Cabaldon said, “We’ve decided to take control of our future, rather than watch from the sidelines as traffic increases, air quality worsens, and open space disappears.”

Although many public health officials and advocates would have liked to see human health concerns assume a more prominent role in SACOG’s plan, this organization has gone a step further than most MPOs in viewing urban development as public health work. They have a committee focusing specifically on air quality issues. And SACOG is planning a symposium with the University of California at Davis Medical Center that will bring together public health officials, architects, planners, and builders to discuss the impact of land use, planning, and transportation on human health.

This increased interest in health may come partly from strong concern expressed in a recent series of public meetings held as part of developing the metropolitan plan.

Over 1,500 people in Sacramento attended 38 community workshops organized by SACOG, during which neighbors sat over coffee, cookies, and satellite maps and highlighted certain parts of the city with multi-colored pens. At the conclusion of the public comment period, air quality was one of the most commonly raised issues.

Making Healthy Living Easy

Still, those involved with the meetings represent only a small fraction of the total populace. Most people living in Sacramento are painfully aware of the worsening air quality in the region, but few recognize that the way their area is growing will contribute to the problem. Demand for single-family homes in sprawling communities is high, and for good reason. When compared to the city center, housing prices in the new suburbs are considerably lower, the homes are newer, and there is a feeling of freedom and space. Ideally new smart growth developments should be made more affordable and appealing so that such developments can meet market demand. But doing so will require changes in zoning to entice builders to construct such developments—which in turn requires public support. Such support may be more forthcoming if the public better understands the link between worsening air quality and choices made about development.

In essence, public health is about making healthy living easy. Prevention, the heart of public health, is best accomplished when it is passive. For example, fluoridation of the water supply as a method of preventing cavities is a public health intervention built into the infrastructure of our daily lives. It requires almost no public effort or education and thereby makes being healthy easy. Developing cities that are by design healthier could be a similarly important public health development. By designing cities that are walkable, with safe pedestrian corridors and centralized multi-use developments, we design cities that promote resident activity and thus lead to less obesity. By designing cities with better mass transit and bicycle lanes, we design cities with less air pollution and incidence of asthma.

According to Dr. Jackson, “every planner, developer, and architect needs to see that they have a critical role in public health.” In the Sacramento Valley, city officials, planners, and developers are beginning to see their actions as such. There’s still a long way to go, but at least it’s a start.

Link: PLANNING: Health by Design: the Crusade for Healthier Cities in the Sacramento Valley