‘Primum non nocere’: first, do no harm

‘Primum non nocere’: first, do no harm

Considering health and the environment in our work as transport planners

Figure 1 The Value of Place (courtesy of pps.org)

Planning, environmental considerations and health are historically linked. Modern urban planning practices as we know them came about in response to the spread of infectious diseases through poor air and water quality in the tenement buildings of developing industrial cities of the 19th and early 20th centuries. In response, policies and legislative acts were enacted to address the spread of diseases such as tuberculosis. Authorities had to plan for proper sanitation, the delivery of clean water, and introduce building codes to alleviate overcrowding and the likelihood of fire. A move to new lower density planned areas from the crammed of inner city tenements had a positive effect on population health in Dublin[1]. While this suburbanisation model proved it had many health benefits, recent research has shown us that its health impacts are not all positive. The relationship between the design of our neighbourhoods, road networks and transport systems and our health is complex. My pursuits as a multi-disciplinary researcher highlighted to me the extent to which we professionally exist within our silos. Therefore, in this article I hope to draw attention to some of the issues that deserve our consideration when approaching a project, or plan, to ensure a healthy population which is critical for sustainability[2]. In particular, I would like to address a common misconception among the transportation community that our role in improving population health solely lies in increasing the number of people walking and cycling!

Figure 2 Money-Fat / Fat-Money (courtesy of imgur.com)

The World Health Organisation (WHO, 1948) defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. Giving consideration for this definition of health we need to expand our understanding of the determinants of health which are influenced by our work practices. Smarter travel initiatives are undoubtedly of key importance – the health benefits of physical activity are well documented with irrefutable evidence of the effectiveness of regular physical activity in the prevention of several chronic diseases and premature death’[3]. These chronic diseases include cardiovascular disease, diabetes, cancer, hypertension, obesity, depression and osteoporosis. In 2011, 63% of Irish deaths were from cancers and circulatory diseases (CSO). It is estimated that 14.2% of all-cause mortality in Ireland is associated with physical inactivity[4]. Recent Irish study findings indicate that 53.8% of people aged 50 and over in Ireland are living with two or more chronic conditions, e.g. diabetes, stroke or coronary heart disease[5] which can be prevented, reduced or reversed by adopting a healthier lifestyle. While physical inactivity is one piece of the jigsaw, it is not the only health reducing behaviour influenced by planning practices contributing to ill health[6] in our population. Increased fuel usage results in greater transport related emissions, which can impact on the air quality and respiratory health of inhabitants[7].

Alongside physical health, social health and well-being are integral elements of our population’s health. Humans are social creatures with an inherent need to belong. Social isolation, environmental stressors such as busy roads and evidence of crime or social disorder, and decreased physical activity levels result in chronic stress and increased inflammatory markers which in-turn increase the likelihood of chronic diseases and depression[8]. Opportunities for neighbourhood walking can also improve social connections which improve psychological well-being[9]. Improved public health and well-being has implications beyond the demands on our increasingly expensive healthcare service. Our health is indeed our wealth; a productive workforce is a healthy one!

Figure 3 Example of a residential community designed cording to the keynote principles of segregated street networks (DMURS, Figure 2.4)

In recent years, as researchers have re-examined the linkages between the places we built and human health, they are finding that a lot of the neighbourhood or village structures which were developed in the past before the advent of the car would be of great value today. Researchers have shown a positive link between compact, mixed-use, well connected ‘traditional’ neighbourhoods and walking for transport and total physical activity compared to newer suburban neighbourhoods[10]. In Ireland we traditionally have a strong affinity to place and sense of community stemming from our traditional parish and village structures. Individuals who live in neighbourhoods with a variety of destinations (e.g. schools, recreational facilities, neighbourhood restaurants, places of worship, public spaces and shops) are more likely to experience higher levels of social cohesion and social capital which is also associated with positive emotional and improved physical well-being[11]. Historically, walking was the primary mode of transport for most humans, and most of the urban places we lived in accommodated walking and thus physical exercise. Unfortunately, a lot of contemporary suburban development models were developed with the assumption that residents would have access to a car to carry out their daily activities. This resulted in long segregated cul-de-sac developments with single access points onto wide, heavily trafficked distributer roads which deemphasize walking – the dendritic street layout. This hostile pedestrian environment is the antithesis of the sort of mixed use, human scale development that encourages walking (or cycling) to attain one’s daily needs. Additionally, increasing commute times in personal transport modes decrease time for social interaction. In contrast, access to nature through urban parks, seafronts and other green and blue spaces have a restorative effect[12]. A wealth of research investigating the relationship between urban planning and design and physical health can be found on the Robert Wood Johnson Foundation’s webpage http://www.activelivingresearch.org/.

Figure 4 Key Principles of Placemaking (courtesy of pps.org)

So what does this research really mean for our work practices? To start, we need to think beyond the provision of footpaths and cycle paths. Routes for walking and cycling need to be comfortable with opportunities to rest if necessary, overlooked and perceptually safe, enjoyable, and should provide a continuous permeable route without physical or perceptual barriers. These routes need to reflect desire lines and prioritise pedestrians, cyclists, public transport users and drivers in that order. To enhance wellbeing, a sense of belonging or attachment to place is a key factor in an individual’s perception of their neighbourhood or surroundings. Care needs to be taken that no scheme, plan or measure has a negative impact on opportunities for social interaction within communities and neighbourhoods. Wide roads which are difficult to cross and thus sever communities, the N11 in Donnybrook or Clanbrassil Street are prime examples. The emphasis on a balance between movement and place in the recent Design Manual for Urban Roads and Streets (DMURS) is a positive step towards creation of healthy places. While design teams and local authorities will undoubtedly experience challenges in implementing DMURS, it is a policy worth fighting for. Greater facilitation of multi-disciplinary teams is necessary for effective execution. Team members with an understanding of environmental psychology, such as urban designers, and behaviour science are of the utmost importance if we are to truly fulfil our role in enhancing people’s experiences of streets, villages, towns and cities. Positive experiences of these places will encourage more sustainable mobility behaviours, a greater sense of place and community and hence public health.

[1] It is important to note that there are many concepts of health and this positive effect, a reduction of disease and illness and therefore mortality rates, is positive with respect to the western scientific medical model definition of health: the absence of illness or disease.

[2] The three pillars of sustainability; society, environment and economy depend on healthy populations, workforces, communities and eco-systems.

[3] Warburton, D. E. R., Nicol, C. W., & Bredin, S. S. D. (2006). Health benefits of physical activity: the evidence. Canadian Medical Association Journal, 174(6), 801–809, p. 801

[4] Lee, I.-M., Shiroma, E. J., Lobelo, F., Puska, P., Blair, S. N., & Katzmarzyk, P. T. (2012). Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet, 380(9838), 219–29

[5] http://www.publichealth.ie/news/press-release/iph-press-release-conference-hears-more-half-our-over-50s-are-living-two-or-more

[6] The terms disease, illness and ill health are often used interchangeably although they have very different meanings. Disease is the existence of some pathology or abnormality of the body which is capable of detection. Illness is the subjective experience of loss of health, feeling ill, unwell or sick. Illness and disease are not the same although there is a large degree of coexistence. Someone could be diagnosed with cancer through screening when there have been no reported symptoms and alternatively someone can report symptoms without having a pathogenically detectible disease. Ill health is an umbrella term used to describe the experience of disease plus illness (Naidoo, J., & Wills, J. (2009). Foundations of Health Promotion (3rd Editio.). Edinburgh: Bailliere Tindall Elsevier, p.5).

[7] Younger, M., Morrow-Almeida, H. R., Vindigni, S. M., & Dannenberg, A. L. (2008). The built environment, climate change, and health: opportunities for co-benefits. American Journal of Preventive Medicine, 35(5), 517–26.

[8] Song, Y., Gee, G. C., Fan, Y., & Takeuchi, D. T. (2007). Do physical neighborhood characteristics matter in predicting traffic stress and health outcomes? Transportation Research Part F: Traffic Psychology and Behaviour, 10(2), 164–176.

[9] Forsyth, A., Oakes, J. M., Schmitz, K. H., & Hearst, M. (2007). Does Residential Density Increase Walking and Other Physical Activity? Urban Studies, 44(4), 679–697 & Frank, L. D., Sallis, J. F., Conway, T. L., Chapman, J. E., Saelens, B. E., & Bachman, W. (2006). Many Pathways from Land Use to Health: Associations between Neighborhood Walkability and Active Transportation, Body Mass Index, and Air Quality. Journal of the American Planning Association, 72(1), 75–87 & Saelens, B. E., & Handy, S. L. (2008). Built environment correlates of walking: a review. Medicine and Science in Sports and Exercise, 40(7 Suppl), S550–66.

[10] Leyden, K. M. (2003). Social capital and the built environment: the importance of walkable neighborhoods. American journal of public health, 93(9), 1546–51.

[11] King, A. C., Stokols, D., Talen, E., Brassington, G. S., & Killingsworth, R. (2002). Theoritical Approaches to the Promotion of Physical Activity Forging a Transdisciplinary Paradigm. American Journal of Preventive Medicine, 23(2S), 15–25

[12] Ibid.

Article Author: Dr. Lorraine D’Arcy, Senior Consultant, Transport Insights
Email: [email protected]
Phone: +353 1 685 2279