Cover StoryCuring Our IllsCan architects and urban planners, builders and landscapers help solve some of our most pressing 21st-century health problems? Yes, says Dr. Richard Jackson—but only if a systems approach to healthcare is implemented rather than one dictated by individual medical strategies. By Penny BondaThe drive from my office to my suburban Atlanta home is all too familiar: it begins with a scary seven-lane thoroughfare, infamous for its strip malls, lack of sidewalks and high pedestrian fatality rates; progresses to a jumble of connecting interstate highways packed with rush-hour traffic despite 12 or more roadway lanes; and ends with clusters of new, low-density, single-family residential developments lacking public parks, playgrounds, libraries, nearby stores or cafés, sidewalks, bicycle trails and public transit. Adults and children in my neighborhood travel by private automobile to virtually all of their destinations because they have no practical transportation alternatives."This daily routine will sound regrettably similar to many suburbanites, but for the senior advisor to the director of the Centers for Disease Control and Prevention (CDC) it's particularly painful. Dr. Richard Jackson readily admits that he lives in Atlanta's suburbs because of the city's high crime rates and failing schools. However, unlike most who have simply resigned themselves to accepting life as it comes, his life's work is, in his words, "to better understand the broad impact of our built environment on health and then to build future communities that promote physical and mental health."Jackson has devoted his career to matters of public health: in India where he worked on smallpox eradication, in California studying farm worker health and pesticide issues as well as infectious disease control programs and, finally, at the CDC where he ran the environmental health center for the last nine years. He currently works in the office of the director, Dr. Julie Gerberding, where he's leading the strategic planning process. Jackson recently sat down with us to talk about the impact of the built environment on human health.What prompted you and other public health officials to begin connecting some of our most pressing health problems such as the rise of obesity and diabetes with the ways in which we design and build our environments?
JACKSON:The connection between the physical environment that we live in and our health was perfectly evident to Frederick Law Olmsted and to basically all the pioneers in urban design and urban planning throughout the 19th century. In fact, at one time in the 1850s, my home town in New Jersey was the unhealthiest city in America. Many of the sanitary reforms that were put in place were led by docs working with business people and designers. It was perfectly obvious that sanitation influences people's health. Even before they knew about the germ theory, they knew that people needed sunshine and fresh, clean water. Western science has been brilliant in terms of breaking apart problems to grapple with the challenges that we face. Over time, we have become so reductionist that urban planners aren't talking to architects who aren't talking to health officials who aren't talking to bankers, etc. The problem is that many of the problems with the 21st century are systems problems. They are not isolated, and pure reductionism impedes our ability to deal with them.
When did you begin to look at these issues?JACKSON: I've studied environmental epidemiology for 25 years, investigating cancer and birth defect clusters, water contamination with pesticides and other chemicals, air pollution studies and on and on. When I became head of the Center for Environmental Health nine years ago we pushed very hard for bio-monitoring, which is the measurement of chemical body burdens in people. About five years ago—and this is a true story—I was driving from my office to the CDC headquarters and I saw a woman who reminded me of my mom. She was thin, elderly, stooped over a bit, walking along in 100° heat next to Buford Highway, which is a street that's seven lanes wide with no sidewalks. The poor woman had a plastic shopping bag in each hand. I wanted to stop, but I was late and she'd probably think I was a pervert if I offered a ride. But I got to thinking that I'm spending all my time worrying about parts per million and parts per billion and here is the most obvious health and environmental threat. We in healthcare have really not paid enough attention to the design of the environment. If that woman had collapsed from heat exhaustion, the cause of death would have been heat exhaustion. It wouldn't have been lack of trees or the lack of sidewalks. If she was killed by a truck, it would be a motor vehicle trauma. It wouldn't be blamed on bad urban design or negligent city management.I began to work closely with a colleague of mine, Howard Frumkin, a professor of occupational and environmental health at Emory University. We started a livability work group at CDC and began working with the people in the injury center who were very interested in studying how to design environments that would be safer and healthier. We also began working with the folks in the obesity and nutrition program who were very concerned that we'd engineered physical activity out of our environment. For example, only seven percent of our kids walk to school today versus 50 percent when I was a child. Across the CDC, we discovered a great deal of interest in this that hadn't been crystallized. Are you attributing the growing rate of obesity in the U.S. to poor urban and suburban design?
JACKSON: I think good physical environments probably could reduce our obesity rates by five or 10 percent. I'm oftentimes accused, by homebuilders for example, of junk science when we argue that sprawl is a health issue. I am not saying that how we build our environments causes obesity and other health problems, but even if it contributes only a small percentage it represents a huge number of overweight people. My point is, we need a systems approach to this rather than an individual medical approach.
How do we educate design professionals so that we can begin to make some changes?
JACKSON: When I started talking about this four or five years ago, people thought I had lost my marbles because I didn't know anything about urban planning and architecture. But I did know that people spend 95 percent of their time indoors—virtually all of that time in environments that have been designed and constructed by someone else. We can't deal with the resulting health problems without reaching out and embracing these other professions. I've spoken with AIA, the American Planning Association, landscape architects and a string of others and I will tell you that this message has been enormously resonant with them. They love being told that they are public health authorities, that they really are making a difference in people's well-being. I think a lot of them went into their professions because they wanted to make a contribution and improve people's lives and they intuitively understood this already.But aren't these the very people who are developing suburban sprawl?
JACKSON: Right, but there are multiple issues at work here. One is financing. At many banks there is a specialist for retail, another for residential and a specialist for commercial, etc. Smart growth really requires that the financing community finds a home for multi-use development. Also, developers legitimately claim that their problem is building codes. We've been working with a number of groups, including Georgia Tech and Emory University, to make recommendations for re-writing building and planning codes that would reflect some of our concerns. The American dream is centered around single-family homes in suburbia that are separated from each other. People believe that the more land they have, the more successful they are and the happier they are going to be. This has led to sprawl because we keep going farther and farther out and we build more and more highways to get there. How do we convince people that this is not a good way to live?
JACKSON: About 20 to 25 percent of adults in America still smoke. My point is that people will do what they want to do. On the other hand, in a free society, people are also going to have what they want to have. I do think that providing children a place where they can walk and bicycle and be connected to their community resonates. When you talk to people that have moved into smart growth developments, they always say that they don't know how they ever lived anywhere else.Lousy density is what we all hate—the types of places where you can hear your neighbors through the wall, where you don't feel safe and the schools are dreadful. That's why most people move out of cities. There's nothing wrong with density, but it has to be accompanied by smart growth. Sooner or later, people are going to decide they don't want to spend 58 hours a year stopped in traffic. These folks are commuting an hour and a half each way to a 10-hour-a-day job and they're wondering why they don't know who their kids are. I'm an advocate of communities that allow people to exercise, allow them to connect with each other and that use minimal amounts of environmental resources, including land.
What are the biggest obstacles that we're facing, in terms of turning this around—going from sprawl to smart growth? JACKSON: I think it's a mindset—people's own perceptions that urban life or greater density is bad and unless we can create quality density that people want to be in, we're never going to turn it around. We need leadership from the building design communities but, as I said earlier, a percentage of people are still going to want their isolated one-acre houses and all that goes with it.Do you think sprawl is strictly an American problem or is it occurring in other parts of the world?
JACKSON: America has perfected it, but I am told that the same thing is going on now in Chile and parts of Latin America. I was invited by the World Health Organization to give a talk at their environmental headquarters in Germany and they are finding that the American dream of a car and a house and all the rest is going on in the French countryside, the German countryside and many other places as well. As a result, they're beginning to show the signs of an obesity epidemic, though it's nowhere near as marked in Europe as it is here. It's always fascinating to see how the world wants to imitate us.What other health problems are you studying?JACKSON: One-third of Americans born in the year 2000 will be diabetic by age 40, with an overall reduction in life span of 15 years and quality of life reduction of about 20 years. We're on the threshold of just horrific health problems. We actually don't know why we're looking at an asthma epidemic. There are schools now where one-third of the kids have inhalers. It probably has something to do with the design of our homes. We spend 90 percent or plus of our time indoors so it's got to be somehow related to indoor air quality. For example, we're covering most of our floors with wall-to-wall carpet and the allergen load in a carpet is far greater than it is on a bare floor. We've done studies of the health effects of mold, radon and volatile organic chemicals and the fix for all of these is the same. If a house is badly designed, badly ventilated, you're going to see these problems.It only costs one or two percent more to build a home that is well ventilated, well insulated, keeps moisture and pests out and all the rest, as long as it's done upfront. Trying to retrofit is often very, very difficult and very expensive, and that's where a lot of the opposition comes from. Consumers need to demand these smart homes and contractors will build them.
Are you optimistic about the future?
JACKSON: After all is said and done, we don't have any choice. We cannot have one-third of our adults diabetic. We cannot continue to be, on average, 20, 30, 40 pounds overweight with increased cancer, heart disease, blood pressure risks and all the rest. We live in a toxic environment in the sense that you turn on the TV and your kids are watching a thousand calories of food ads an hour, and they go to school and junk food is being shoveled at them. The environment is toxic from a nutritional standpoint, in terms of exercise and in terms of mental health. I mean, who feels good when they're in environments that are lacking in green space? The financial part of the healthcare system will collapse at the rate we are going. We're not going to spend 80 percent of the gross domestic product on healthcare. We have to turn it around. As Winston Churchill said, "Always count on Americans to do the right thing, after they've tried everything else." Eventually we'll get it right, because we don't have any choice.
Dr. Richard Jackson
Senior Advisor
Centers for Disease Control and Prevention (CDC)
1600 Clifton Rd.
Atlanta, GA 30333,
Public Inquiries: (404) 639-3534 or (800) 311-3435
www.cdc.gov
JACKSON:The connection between the physical environment that we live in and our health was perfectly evident to Frederick Law Olmsted and to basically all the pioneers in urban design and urban planning throughout the 19th century. In fact, at one time in the 1850s, my home town in New Jersey was the unhealthiest city in America. Many of the sanitary reforms that were put in place were led by docs working with business people and designers. It was perfectly obvious that sanitation influences people's health. Even before they knew about the germ theory, they knew that people needed sunshine and fresh, clean water. Western science has been brilliant in terms of breaking apart problems to grapple with the challenges that we face. Over time, we have become so reductionist that urban planners aren't talking to architects who aren't talking to health officials who aren't talking to bankers, etc. The problem is that many of the problems with the 21st century are systems problems. They are not isolated, and pure reductionism impedes our ability to deal with them.
When did you begin to look at these issues?JACKSON: I've studied environmental epidemiology for 25 years, investigating cancer and birth defect clusters, water contamination with pesticides and other chemicals, air pollution studies and on and on. When I became head of the Center for Environmental Health nine years ago we pushed very hard for bio-monitoring, which is the measurement of chemical body burdens in people. About five years ago—and this is a true story—I was driving from my office to the CDC headquarters and I saw a woman who reminded me of my mom. She was thin, elderly, stooped over a bit, walking along in 100° heat next to Buford Highway, which is a street that's seven lanes wide with no sidewalks. The poor woman had a plastic shopping bag in each hand. I wanted to stop, but I was late and she'd probably think I was a pervert if I offered a ride. But I got to thinking that I'm spending all my time worrying about parts per million and parts per billion and here is the most obvious health and environmental threat. We in healthcare have really not paid enough attention to the design of the environment. If that woman had collapsed from heat exhaustion, the cause of death would have been heat exhaustion. It wouldn't have been lack of trees or the lack of sidewalks. If she was killed by a truck, it would be a motor vehicle trauma. It wouldn't be blamed on bad urban design or negligent city management.I began to work closely with a colleague of mine, Howard Frumkin, a professor of occupational and environmental health at Emory University. We started a livability work group at CDC and began working with the people in the injury center who were very interested in studying how to design environments that would be safer and healthier. We also began working with the folks in the obesity and nutrition program who were very concerned that we'd engineered physical activity out of our environment. For example, only seven percent of our kids walk to school today versus 50 percent when I was a child. Across the CDC, we discovered a great deal of interest in this that hadn't been crystallized. Are you attributing the growing rate of obesity in the U.S. to poor urban and suburban design?
JACKSON: I think good physical environments probably could reduce our obesity rates by five or 10 percent. I'm oftentimes accused, by homebuilders for example, of junk science when we argue that sprawl is a health issue. I am not saying that how we build our environments causes obesity and other health problems, but even if it contributes only a small percentage it represents a huge number of overweight people. My point is, we need a systems approach to this rather than an individual medical approach.
How do we educate design professionals so that we can begin to make some changes?
JACKSON: When I started talking about this four or five years ago, people thought I had lost my marbles because I didn't know anything about urban planning and architecture. But I did know that people spend 95 percent of their time indoors—virtually all of that time in environments that have been designed and constructed by someone else. We can't deal with the resulting health problems without reaching out and embracing these other professions. I've spoken with AIA, the American Planning Association, landscape architects and a string of others and I will tell you that this message has been enormously resonant with them. They love being told that they are public health authorities, that they really are making a difference in people's well-being. I think a lot of them went into their professions because they wanted to make a contribution and improve people's lives and they intuitively understood this already.But aren't these the very people who are developing suburban sprawl?
JACKSON: Right, but there are multiple issues at work here. One is financing. At many banks there is a specialist for retail, another for residential and a specialist for commercial, etc. Smart growth really requires that the financing community finds a home for multi-use development. Also, developers legitimately claim that their problem is building codes. We've been working with a number of groups, including Georgia Tech and Emory University, to make recommendations for re-writing building and planning codes that would reflect some of our concerns. The American dream is centered around single-family homes in suburbia that are separated from each other. People believe that the more land they have, the more successful they are and the happier they are going to be. This has led to sprawl because we keep going farther and farther out and we build more and more highways to get there. How do we convince people that this is not a good way to live?
JACKSON: About 20 to 25 percent of adults in America still smoke. My point is that people will do what they want to do. On the other hand, in a free society, people are also going to have what they want to have. I do think that providing children a place where they can walk and bicycle and be connected to their community resonates. When you talk to people that have moved into smart growth developments, they always say that they don't know how they ever lived anywhere else.Lousy density is what we all hate—the types of places where you can hear your neighbors through the wall, where you don't feel safe and the schools are dreadful. That's why most people move out of cities. There's nothing wrong with density, but it has to be accompanied by smart growth. Sooner or later, people are going to decide they don't want to spend 58 hours a year stopped in traffic. These folks are commuting an hour and a half each way to a 10-hour-a-day job and they're wondering why they don't know who their kids are. I'm an advocate of communities that allow people to exercise, allow them to connect with each other and that use minimal amounts of environmental resources, including land.
What are the biggest obstacles that we're facing, in terms of turning this around—going from sprawl to smart growth? JACKSON: I think it's a mindset—people's own perceptions that urban life or greater density is bad and unless we can create quality density that people want to be in, we're never going to turn it around. We need leadership from the building design communities but, as I said earlier, a percentage of people are still going to want their isolated one-acre houses and all that goes with it.Do you think sprawl is strictly an American problem or is it occurring in other parts of the world?
JACKSON: America has perfected it, but I am told that the same thing is going on now in Chile and parts of Latin America. I was invited by the World Health Organization to give a talk at their environmental headquarters in Germany and they are finding that the American dream of a car and a house and all the rest is going on in the French countryside, the German countryside and many other places as well. As a result, they're beginning to show the signs of an obesity epidemic, though it's nowhere near as marked in Europe as it is here. It's always fascinating to see how the world wants to imitate us.What other health problems are you studying?JACKSON: One-third of Americans born in the year 2000 will be diabetic by age 40, with an overall reduction in life span of 15 years and quality of life reduction of about 20 years. We're on the threshold of just horrific health problems. We actually don't know why we're looking at an asthma epidemic. There are schools now where one-third of the kids have inhalers. It probably has something to do with the design of our homes. We spend 90 percent or plus of our time indoors so it's got to be somehow related to indoor air quality. For example, we're covering most of our floors with wall-to-wall carpet and the allergen load in a carpet is far greater than it is on a bare floor. We've done studies of the health effects of mold, radon and volatile organic chemicals and the fix for all of these is the same. If a house is badly designed, badly ventilated, you're going to see these problems.It only costs one or two percent more to build a home that is well ventilated, well insulated, keeps moisture and pests out and all the rest, as long as it's done upfront. Trying to retrofit is often very, very difficult and very expensive, and that's where a lot of the opposition comes from. Consumers need to demand these smart homes and contractors will build them.
Are you optimistic about the future?
JACKSON: After all is said and done, we don't have any choice. We cannot have one-third of our adults diabetic. We cannot continue to be, on average, 20, 30, 40 pounds overweight with increased cancer, heart disease, blood pressure risks and all the rest. We live in a toxic environment in the sense that you turn on the TV and your kids are watching a thousand calories of food ads an hour, and they go to school and junk food is being shoveled at them. The environment is toxic from a nutritional standpoint, in terms of exercise and in terms of mental health. I mean, who feels good when they're in environments that are lacking in green space? The financial part of the healthcare system will collapse at the rate we are going. We're not going to spend 80 percent of the gross domestic product on healthcare. We have to turn it around. As Winston Churchill said, "Always count on Americans to do the right thing, after they've tried everything else." Eventually we'll get it right, because we don't have any choice.
Dr. Richard Jackson
Senior Advisor
Centers for Disease Control and Prevention (CDC)
1600 Clifton Rd.
Atlanta, GA 30333,
Public Inquiries: (404) 639-3534 or (800) 311-3435
www.cdc.gov
