In what might be described as a call to arms, Bruce Bragg and colleagues have argued that "[i]t is important to re-engage public health professionals, after an absence of almost half a century in the issues of land development and community design."1(p78) Another writer recently observed, "Public health advocates have reconnected with the historic roots of zoning controls as a mechanism for promoting public health and welfare."2(p1405) These exhortations and others like them are the result of two ironic developments. On one hand, by the late 20th century, "the institutional voice of public health officials [had] largely disappeared from discussions about urban design and land use patterns."3(p558) On the other hand, it has become increasingly obvious that many public and individual health ills such as cancer, obesity, asthma, cardiovascular disease, mental health, substance abuse, and crime originate at least in part from the so-called "built environment," within which individuals conduct the activities of ordinary daily life.4 As a result, zoning and other land use controls are again recognized as potential instruments in the hands of public health authorities. Because zoning and other land use restrictions are inherently local and have a demonstrable impact on public health, local public health practitioners have both the opportunity and duty to not only monitor its conduct but also influence its outcome.

Then and Now

During the 19th and early 20th centuries, the goal and disciplines of urban planning and public health were not only "synergistic" but also virtually indistinguishable.3 Both shared the focus on separation of usages, creating a less-dense living space cordoned off from industrial activity.5 Public health advocates, at that time, of course were driven by the desire to remedy the ills resulting from unrestricted urban growth, including prevention of infectious diseases, supportable sewage and drinking water systems, and protection from the dangerous exposures of industry.6 The focus, then, was on the separation of living spaces from harmful industrial and urban activity. Public health advocates and their allies were strikingly successful, as many of the leading infectious disease and toxic substance threats were decreased by a combination of education and changed "lived environments."

Today, in contrast, the "new urbanism" and "smart growth" promote the notion that public health will often best be served when the places where people work, play, and live are the same. Overreliance on the automobile is deemphasized.5 Advocates incorporate public health assumptions in multiple-use land designs and "smart growth" practices such as the copious inclusion of sidewalks, open space, parks, and recreation areas. The reduction and limitation of dark/hidden spaces, fast-food restaurants, gun sales, adult stores, predatory advertising, large supermarkets, and alcohol can also contribute to a more salubrious environment. Obesity is often the specific focus of built environment causes and remedies.3,7-9 Urban and suburban sprawl is said to have contributed to the dependence on the automobile and the concomitant growth of the sedentary life style, as have the lack of sidewalks and the unavailability of "walkable" shopping and recreation areas. Housing near industry, waste facilities, and large highways expose residents to air pollution and irritants that can exacerbate asthma and other maladies.5 Large-volume highways and long driving distances pose dangers to both drivers and pedestrians, especially in areas that lack sufficient sidewalks and bike paths.3 Zoning has also been linked to a reduction in the sites and density of drug sales, prostitution, and other criminal behaviors.2,10 In these and many other ways, changes in the built environment may play an important role in maintaining and improving the public's health.

Opportunities & options

Public health professionals are well equipped and within their scope of authority and professional mandate to assist in land use design and zoning ordinance development to improve the health of the people they serve. Ideally, public health officials will play a vital role in providing information when community development plans are still in their nascent condition. In 2006, the National Association of Local Boards of Health developed a guide titled Land Use Planning for Public Health: The Role of Local Boards of Health in Community Design. The National Association of Local Boards of Health guide emphasizes the public health importance of "built environment" campaigns and calls for early and intimate involvement of local board of health members in land use planning decisions such as zoning.11 The core functions of assessment, policy development, and assurance lend significant value to the development and ongoing changes found in land use. The impact of land usage on air and water quality, traffic, and physical activity can have a tremendous effect on the quality of life for those in surrounding areas.12 Therefore, a good working relationship between public health professionals and those on local planning boards can have synergistic effects on health outcomes related to land use. These two disciplines already have a history of successful "crossover ideas" including the development of parks and recreation to improve physical activity and mental health, energy use, and greenhouse emission control to affect climate, emergency preparedness, and access to healthcare.6

Public health practitioners can attend zoning hearings offering formal or informal evidence relating to the zoning change under consideration. Public health professionals can provide relevant public health information and research data to planning boards and local government. They can help produce, analyze, and critique land use development plan impact statements.7 Public health practitioners can also help planners and government officials analyze the use of other means of improving the built environment including the use of special permits, environmental regulations, building and housing codes, tax incentives, environmental regulations, quotas, and spacing rules.

As "honest brokers," public health input into the debate at the local level can add a dimension to discussions frequently solely dominated by commercial interests and individual landowners. Public health professionals can collaborate with planners, governmental officials at every jurisdictional level, and other pertinent, interested agencies to adjust archaic codes and zoning designations. Public health practitioners can play an important role in protecting the interests of underrepresented/minorities, many of whom already experience health disparities in part attributable to previous land use decisions.9 A public health perspective can also help ensure equity in planning. The public health practitioner can serve as an unbiased representative able to evaluate proposals with the safety and well-being of the public in mind.

To participate responsibly and meaningfully in zoning and other built environment discussions, public health practitioners should be sensitive to the legal and political limitations of the mechanism.

Zoning and the Law

"Public nuisance" law prevents an individual from using his or her property in a way that unreasonably interferes with the health, safety, or welfare of the public. Judges must decide on a case-by-case basis whether a particular activity meets the nuisance standard. In contrast, zoning controls the regulation of the use of property over potentially broad areas or zones. As a result, zoning offers a wide range of options for urban planners and public officials who wish to control and channel public life. Zoning can be used to segregate uses of property into categories, for example, commercial or residential. It can also be employed in more refined ways to restrict property use according to type of residential dwelling (single family or multiple unit), type of business (retail or industrial), building tolerances (eg, number of stories, required green space, set-backs). Zoning may be used to create density limitations applied to population, number and types of business, or other criteria. "Conditional" zoning allows a regulated activity to continue in the relevant zone as long as it conforms to the stated conditions. "Performance standards" allow an activity to continue but only under stipulated requirements.13 In these ways and others, local officials possess a number of techniques potentially at their disposal.

Zoning has been supported constitutionally as a legitimate use of the state's police power since the case of Village of Euclid v Ambler Realty Co (1926).14 Although some green space requirements might constitute "takings" and thus require compensation under the fifth amendment of the US Constitution and eminent domain theory, zoning actions are otherwise relatively easy to defend legally and constitutionally. If the zoning board or authority has followed its own standards and provided an appropriate opportunity for notice and open debate, then the zoning action need only bear a reasonable relation to public's health, safety, or welfare. This standard is highly deferential constitutionally and means that as a practical matter, most zoning actions will withstand constitutional scrutiny and litigation if they are not arbitrary, capricious, and have some minimal basis in fact. Zoning actions are on the strongest legal ground if their relationship to health, safety, and welfare is explicitly linked to the public's health, safety, and welfare through data, data that can be supplied in part by public health professionals. Zoning decisions are more viable against legal challenges when they are part of or the result of a "master plan" land use plan for the community. This reality underscores the importance of public health involvement before specific zoning decisions.15 Local guidance is usually available. For example, the North Carolina Institute of Government has produced a zoning roadmap titled Zoning Hearings: Knowing what Rules to Apply.16 Similarly, the California Department of Health Services has produced a comprehensive technical guide entitled General Plans and Zoning: A Toolkit on Land Use and Health which focuses on the practical aspects of developing a comprehensive built environment with public health in mind.17

Caveats and cautions

Zoning is, unavoidably, a political process in which multiple motivations are involved.18 Public health practitioners should ensure that they do not serve or appear to serve interests other than the public's health. Practitioners should also be sensitive to the reality that much of their other work, by necessity, depends on the good will and trust of the community. Thus, as a pragmatic matter, it is important that public health officials' activities in the zoning arena are not misconstrued as partisan interventions. Some proposed changes will test US citizen's willingness to live in communities in which commercial uses are intertwined with residential uses. Many or most changes will involve a reevaluation of the US citizenry's relationship with the automobile. Local public health officials cannot and should not expect to mandate, direct, or compel social change of this magnitude. The ultimate success of imposed environmental changes will ultimately rest in the court of public opinion, that is, if you build the environment, will they come? The public's affection for the freedom represented by the private automobile may cool attitudes toward mass transportation plans and the use of neighborhood walkways for shopping and other activities. Similarly, attempts to reduce or limit fast-food restaurants may meet public disdain and or even censure because much of society has come to rely on their convenience and reasonable price points. Large-lot, limited-use zoning, while an admitted source of urban sprawl, is embraced by many Americans and will be defended by those property owners who value suburban lifestyles.9 Educating the public to gain its support to overcome what are now ingrained behaviors will itself be a daunting, important challenge for public health professionals. Indeed, if such reeducation were practical and easy, then one might reasonably argue that many such environmental changes would be unnecessary and that public preference and the market would engender the necessary changes in the built environment.

Advocates of significant changes in the built environment through zoning and associated means should face their goal with historical modesty and their eyes fixed on the rule of unintended consequences. After all, it was well-meaning land use regulation and limited-use zoning that helped in part contribute to urban sprawl that is now playing a role in undermining public health. Zoning rules initially intended to enhance livability and safety have, in some instances, hastened the development of dangerous environments and thwarted their renovation. In some instances, land use restrictions have benefited, and harmed, various classes, races, and ethnic groups disproportionately.5 Restrictive building codes in some areas have discouraged renewal and led to further urban deterioration and promotion of urban sprawl.19,20 As a result, it is premature to assume that there will be automatic, deep, and broad-based public support and provisions for zoning as a means to assist in changing behavior.21 Behaviors and habits that have existed for such a long time are going to be hard to break. Enacting and gaining support for wise land use limitations and zoning changes will likely require the time and insight of diligent, thoughtful, and honest public health professionals.

REFERENCES