Environments we build for ourselves influence our general satisfaction with all aspects of life, including recreation, culture, values, and, importantly, personal health. Healthy People 2010 points out that life expectancy in the United States has increased by approximately 30 years since 1900. It is estimated that only 7 of those years can be attributed to healthcare, the remaining increase in longevity is related to immunizations and to improved environmental conditions. Dr Richard Jackson, former director of the National Center for Environmental Health, and Chris Kochtitzky of the Centers for Disease Control and Prevention (CDC) summarized the point succinctly, "Public health professionals need to begin to see the built environment as having as much ability to influence public health as vaccines or water quality."1(p15)
In the last few years, the idea that we can build environments to promote human health and well-being has progressed from an interesting to an emerging to an important component of the national health agendas, such as CDC Healthy Places, Robert Wood Johnson Active Living, and Smart Growth initiatives. Local public health and planning professionals are encouraged to integrate comprehensive health considerations in land use planning, and many agencies have been responding. These local efforts are quite diverse with respect to the specific issues addressed and nature of their approach. In general, local initiatives that are most likely to be sustainable are those with strong leadership: a focus on community health, especially reduction in health inequities; broad-based partnerships; and meaningful community engagement (the article by Farhang et al in this issue is an example of a comprehensive local initiative).
The World Health Organization helped establish a vision for health in 1948-"Health is a state of complete physical, mental and social well being and not merely the absence of disease." Clearly, at the local level, it would be overwhelming to deal with all environmental, social, and behavioral impacts, collectively. Health impact assessment tools have been developed by national organizations, including the National Association of County and City Health Officials (NACCHO), American Planning Association (APA), and the CDC. Tools are tailored to local circumstances by local public health and planning practitioners. They are used to help communities identify high-priority projects for review and judge them as to their potential health effects. All this before the project or plan is implemented.
A wide variety of excellent health impact assessments is described in this issue and demonstrates that the built environment affects our lives at a number of points. Community design and development affect access to housing, food, and services, exposure to toxins, availability of suitable housing, risk of injury, personal safety, opportunities for physical activity, mental health promotion such as with greenspace and parks, friendliness to children and elderly, and social capital by providing opportunities for positive community engagement.
As communities propose changes for improvement, questions of cause-and-effect relationships are almost inevitable, especially when there are competing interests in use of the land involved. Some cause-and-effect relationships are relatively straightforward. The high number of pedestrian injuries in a populated area that does not have safe walking paths is an example. Findings of assessment processes are not necessarily binding; they can be used to inform the affected community and others who make the decisions. Even relatively simple, rapid health impact assessments can raise awareness and result in improvements that would not have been made without the assessment. An obvious point but worth saying is that the earlier the assessment takes place, the easier it is to make changes.
Sometimes cause and effect are not always clear and experts can disagree. The community voice is an essential part of the balance. People feel strongly about their environment. Results of population-based survey research in Michigan (see the article by Bassett and Glandon in this issue) showed that vast majority of people feel that their environment is very important to their overall health (physical and mental health). Environment ranked in importance on the order of family, work, and recreation. When respondents were asked, "What is 'environment' to you?" most reported "neighborhood." Sometimes, as healthcare professionals, we struggle to understand how significant the built environment is in our lives, but when we put on our community resident hats, few of us have much doubt.
Communities have a good idea of the kinds of things that are troubling them and tend to be realistic about considering alternatives. For example, they usually do not want to close down business. In general, communities can provide an important holistic perspective about impacts not typically possible with quantitative data alone.
When cause-and-effect relationships of a proposed project or plan have not been fully worked out, the precautionary principle can serve as a guide. My paraphrasing of the principle is: when an activity clearly threatens human health, but is not proven one way or the other, precautions should be taken to relieve the threat.
As we move toward the goal of overall community health improvement, it is crucial to remember that a measure of "average community health status" is not the level of health experienced by everyone in the community. Many community residents experience significantly poorer health and quality of life. Typically, people with poor health are residents with lower income, are elderly or disabled, or are of certain racial or ethnic background. Poor health is too common in unstable neighborhoods with poor air and water quality, higher exposure to environmental toxins, inadequate housing, and unsafe for physical activity or recreation. These health disparities are avoidable. They result in part from inattention and in part from elements of unfairness and injustice in our culture. An important objective of health impact assessment is to eliminate these health inequities to the greatest extent possible.
Many local agencies are concerned about having the resources needed to conduct health impact assessment. In 2005, the APA conducted a survey of 350 public health and 350 planning professionals, key partner agencies in any land use and health initiative. Respondents reported that the two disciplines routinely work on wastewater treatment and septic system regulations, two areas where they have long shared responsibility. But only a fraction, on average less than 10 percent, collaborated on emerging areas of built environment such as housing, pedestrian safety, air quality, walkability, and transportation. The biggest barrier reported was a lack of resources.
The perception of insufficient resources is not surprising. A separate survey conducted by NACCHO in 2005 gathered information from a large sample of the approximately 3000 local health departments in the United States. Results showed that many local public health agencies are small, about one third have fewer than 10 employees, and less than one fifth have more than 100 employees. The survey indicated that the nature of work carried out by these agencies has changed over the last 10 years. Over half of the agencies have completed a community health assessment (CHA). This is interesting because a CHA has several features in common with the kind of impact assessments discussed here, an important component being "community engagement." An ongoing CHA involves working with local communities to identify major health issues and develop improvement strategies. In 2005, more than 88 percent of local health departments have increased collaboration within their communities; the vast majority did more than simply exchanging information. Significantly, 62 percent are involved in community efforts to address root causes of health problems.
Community health assessment and improvement projects involve gathering quantitative and qualitative information. In short, CHA requires skills and techniques needed for assessing health impacts of projects and plans involving built changes in the environment. Both are local processes with a goal of community health improvement for all residents. Agencies involved in CHA may be able to build on their skills and established partnerships to make a transition to integrating public health considerations in local land use planning and community design processes.
It is clear that local agencies will continue to need help. NACCHO, in cooperation with national partners such as the APA and the CDC, assists local health departments and planners assess mitigate and prevent potential health risks associated with development projects or planning policies. NACCHO assists local health departments by
* providing training and technical assistance to planning and local public health agencies for collaboration and implementation of NACCHO/APA tools and resources;
* developing knowledge of healthy land use planning in local jurisdictions; and
* creating educational sessions with other national partners for legislators and policy makers regarding need for resources at the community level to better address the range of public heath and social justice issues resulting from decisions about the built environment.
Creating environments to promote healthy communities is a new vision. Public health and planning professionals across the country are working in concert with local communities, bringing insight and ingenuity into planning processes. With support, such efforts can expand and grow in number and help move this country closer to a state of complete physical, mental, and social well-being.
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