Winter 2006 Newsletter

Well-Designed Learning Centers Offer Immense Health Benefits for Families & Children

Neal KaufmanNeal Kaufman, MD, MPH  is a professor of pediatrics and public health at the UCLA School of Medicine and co-director of the UCLA Center for Healthier Children, Families and Communities, which is dedicated to improving society’s ability to provide children with the best opportunities for health and well-being, and the chance to assume productive roles within families and communities. Dr. Kaufman is also vice-chair of the First 5 LA Board of Commissioners.

The L.A. metro area, as well as much of urban California, is involved in making substantial urban neighborhood investments (tens of billions) in public facilities–mostly schools, parks, police stations, daycare centers, and adult education.  Many in public health have long asserted that healthy place-making ought to be on the agenda and part of the design considerations when such facility investments are sited and planned.  Explain how you would define “healthy place-making.” 

Healthy place-making revolves around the idea that the places where people live, work, learn, and play can have a profound impact on the individual’s well-being.  Not only do places have to be free of toxins and have clean air and water, but they also have to be where human relationships are nurtured and where individuals can get enough physical activity and exercise as part of their everyday activities.  They’re places where individuals have access to appropriate fruits and vegetable, and where people have the opportunity to just run into their friends and make social connections and have a sense of place.  And the way that you design and site buildings and organize the activities in those buildings either inhibits those things from happening or enhances them.  When it’s done right, you have a place that promotes health. 

The mission of First 5 L.A., on which you serve as a commissioner, includes promoting the quality of life and health of children, pre-natal to 5 years old, and their families.  First 5 LA has now spawned another organization, LAUP, which focuses on providing universal, voluntary access to pre-K education in LA County.  Their missions involved facilities and place-making.  Elaborate on the nexus between healthy place-making and the missions of LAUP and First 5 L.A.? 

First 5 L.A. and LAUP are not just about the creation of physical spaces or even the services that happen within them.  They’re both trying to improve outcomes for young children, and to produce a good outcome for children, they need to not only have a good physical place in which to live, a good school or good childcare center.  They need to offer services that meet the needs of those families.  They need families that are educated and know how to take care of their kids and address their needs.  So, in addition to appropriate educational experiences in a preschool, it’s also very important for that preschool to be part of the community and the neighborhood.  The relationships between that preschool and the other services in the community have to be strong for the families to meet children’s’ needs.

You bring a perspective, as a pediatrician, to this subject and interview.  Comment, if you could, on how health care is increasingly becoming involved with the built environment? 

If you think about what’s happened in the country over the last 100 years, in the 1850s, we improved the health of the public by linking public health with the built environment.  Cities were unhealthy places.  There was poor sanitation, polluted air, limited physical activity; people were dying from communicable diseases, waterborne diseases, injuries, and healthy place-making – with open spaces, proper sanitation, safe food – resulted in healthier people.  For instance, they moved the cemeteries away from the people; they had safe building conditions.  All of that led to a marked increase in the health and welfare of the population. 

But after the Second World War the paradigm of improving people’s health was based on what most people call a medical model.  The idea was that people had an illness, you would diagnose that illness as accurately as possible and then identify the treatment, whether it be surgical, medicinal, or high-tech.  That treatment was facilitated by building up an extensive network of hospitals and physicians, and health insurance programs, and research into the biological basis of disease, and medications that would treat it.  That became increasingly sophisticated, with ever more fancy pharmaceuticals and the like, and it made major progress in the treatment of diseases.  But, still, the vast majority of improvement in life expectancy derived not from medicine but from public heath. 
As we go into the 21st century, we face a very different issue.  Individuals’ life spans are increasing, but their performance spans are not.  They’re living to their 80s and 90s, but they’re becoming increasingly debilitated or infirm as they age.  And if you think about health as a “resource for living,” as Dr. Lester Breslow describes it, you think about how to help the individual become able to do the things that they want to do.  The best example would be to think about what we call “lifestyle diseases” – lifestyle choices colliding with genetics in a toxic environment, and they can be improved by modifying lifestyles, by healthy place-making, and by quality medical care. 

Elaborate both on the health challenges of LA’s families and children,  and  on how healthy place-making might be a significant contributor to better health.  

We have an epidemic of individuals who, by lifestyle choices – the main ones being sedentary activities; consuming too much fat, sugar, and salt; and smoking, alcohol, and drugs – have so damaged their bodies that they’re not able to maintain a healthy performance as they get older.  Obesity may be the best example: We evolved to minimize the amount of activity it took to get us enough calories and to eat everything that was in our presence, because we might not have enough food the next day, and to hold on to every ounce of fat, sugar, and salt.  It turns out that some people are more capable of holding on to every ounce of fat, sugar, and salt, because their ancestors died when everyone else lived through the famine or other evolutionary struggle, such as the Middle Passage for African-Americans. 

But if you look at Los Angeles, with an increasing proportion of ethnic minorities, of individuals whose ancestors were far superior at surviving famine, they then collide with an environment in which the average person gets almost no physical activity.  They drive to work long distances, they sit at their desk, they come home exhausted after commuting, and they end up either working or falling asleep in front of the television, without expending calories.  And getting food also takes no calories.  In addition, their food is laden with hidden sugar, fat, and salt.  So genetics and lifestyle choices collide with a toxic environment that makes it hard to be active and get the food that’s right for you. 

You make a compelling case for the nexus between the environment, health and the choices we make.  Yet in the public policy arena, that nexus thesis has not won the day.  As you say, we have significant epidemics among our young people, with diabetes, obesity, etc., and yet the choices about the siting and design of pre-K through 12 schools don’t seem to take into account criteria that could positively affect the community’s health.  What explains this failure? 

It was only 50 years ago when Lester Breslow first demonstrated that your lifestyle may impact your chances of getting heart disease.  People didn’t understand or believe it then, and I think we’re in a similar denial now.People are so fixated on the notion that people simply choose their lifestyles. As if they choose to live in a neighborhood without any parks; as if they choose to live in a neighborhood where they can’t get fresh fruits and vegetables; as if, after watching years of TV advertising high-sugar and high-fat foods, that they simply choose to eat them; as if they’re making a personal choice not to be active and to eat too much.  That’s simply not the case.

Certainly there is some degree of freedom, and, of course, individuals make choices.  But they make those choices in the context and limitations of their environment, and it’s very difficult to convince people of that.  But, I think the tide is turning.  We have seen, with the epidemic of obesity, diabetes, cardiovascular disease, an increasing recognition, for example, that the health environment of a school has an impact.  The banning of sodas in LAUSD was critical.  The legislation in the state of California to get rid of junk foods and sodas was important. I don’t know if people have gotten quite to the point that they understand the built environment component. 

This idea of health impact analysis around the built environment has begun to take root around the country and here in Los Angeles.  Elaborate on that methodology and its promise for creating an accepted nexus between the built environment and health-promotion behavior. 

Health impact assessment is a methodology with a 25-year history in Europe, Australia, New Zealand, and Canada that helps decision-makers identify unintended health consequence from the way they build the building and get information in time to modify their plans.  So, for example, if the stairs in a building meet the code for fire escapes but are unavailable for individuals to use them, individuals in that building will be less likely to walk the stairs.  Now, you might say that walking the stairs is not big deal, but if you walk two or three flights every day, you actually burn a significant number of calories over time. 

So you could have regulations that encourage accessible stairs.  You could have sidewalks that encourage walking.  You could have streets that discourage automobiles and encourage walking.  By building the buildings and co-locating schools and parks and libraries, it increases the chances that children and the neighborhood will use those facilities and become healthier.  So it offers a systematic, scientific way of analyzing the negative impact of a particular choice and trying to come up with a feasible method to improve people’s health. 

What are the kinds of innovative approaches to the design of the built environment that offer promise, both for building out preschool seats as well as primary and elementary school seats in L.A. County?

Any school or preschool, first and foremost, has to be a site where children feel comfortable and can get a good education. But if you think about that school a being part of a neighborhood, where that school is sited is critical.  So, siting a school in a place where, for example, the parents of a preschooler walk their child to school, they not only get physical activity but also get to know their neighborhood. The size of that school makes a huge difference also.  It has to be big enough so that it’s cost-effective, but it also has to be small enough so that the student feels comfortable and understands the environment around them. 

The actual architecture or style of that school makes a difference.  Schools that have both indoor and outdoor components allow students to recognize nature even when they’re in class.  Exposure to sunlight bouncing off leaves stimulates children’s’ brains and actually helps brain development more than flat light going off a wall. 

Having the school provide services that bring other people from the neighborhood to the school enhances that school’s sustainability and also makes that school helpful to the rest of the neighborhood.  So, for example, a preschool with a drop-in center for parents of children under four is more likely to be able to support that neighborhood.  The school that links itself to its surroundings, both architecturally as well as programmatically – where the students go out into the community to learn about their neighborhood – increases the diversity of the children’s’ experience and is much more likely to help them grow.  And, finally, if that school is the center of the neighborhood, the neighborhood cohesion will maintain that school’s function for much longer.