Our Ailing Communities

Public-health advocate Richard Jackson argues that the way we build cities and neighborhoods is the source of many chronic diseases.

There are few things more delicious professionally than finding a well-­credentialed expert from another field—perhaps one that is better trusted than one’s own, such as medicine—who has dedicated his life’s work to proving everything you’ve been arguing for years. That’s why so many city planners are in love with Dr. Richard Joseph Jackson, whose latest book—Urban Sprawl and Public Health, coauthored with Howard Frumkin and Lawrence Frank—is being giddily passed around at conferences like a box of Teuscher chocolate truffles (you know, the dark ones with the powder coating).

The message of the book is simple: our car-dependent suburban environment is killing us. Planners, most notably the New Urbanists, have been saying this for decades, but Jackson’s got the statistics. And the charts. And the tables. In his book and in lectures nationwide, Jackson demonstrates—technically, like a doctor—how sprawl is at least partially responsible for a full range of American diseases, from asthma to diabetes, from hypertension to depression. The reason that we spend one dollar out of six on health care is very preventable, and yet we claim some of the worst health statistics in the developed world.

Trained as a pediatrician, Jackson has spent more than 25 years in public health, most notably as the director of the National Center for Environmental Health, at the Centers for Disease Control and Prevention, and recently as Governor Schwarzenegger’s state public health advisor. Jeff Speck, a city planner and the director of design at the National Endowment for the Arts, caught him at his desk at the University of California Berkeley to discuss our built environment.


Let me start with a quote from your book. You say, “The modern America of obesity, inactivity, depression, and loss of community has not ‘happened’ to us. We legislated, subsidized, and planned it this way.” When did you first start to make the connection between the design of our national landscape and the health of our citizens?
In July 1999 the head of the CDC invited his dozen directors to the central office to work on a paper about the ten leading diseases of the twenty-first century. I’m driving over there, and as always I’m thinking about pesticides, herbicides, cancer, and birth-defect clusters—you name it. I’m late, stuck in traffic on Buford Highway, voted one of the ten worst streets in North America. It’s a seven-lane road surrounded by garden apartments, mainly for poor immigrants, with no sidewalks and two miles between traffic lights. It’s 95 degrees out, 95 percent humidity. I see a woman on the right shoulder, struggling along, and she reminds me of my mother. She’s in her seventies, with reddish hair and bent over with osteoporosis. She has a shopping bag in each hand and is really struggling.

Carless in the car zone…
This woman stayed in my mind during the whole discussion we were having about the future of public health. Afterward I e-mailed Howie Frumkin and said, “If that poor woman had collapsed from heat stroke, we docs would have written the cause of death as heat stroke and not lack of trees and public transportation, poor urban form, and heat-island effects. If she had been killed by a truck going by, the cause of death would have been ‘motor-vehicle trauma,’ and not lack of sidewalks and transit, poor urban ­planning, and failed political leadership.” That was the “aha!” moment for me. Here I was focusing on remote disease risks when the biggest risks that people faced were coming from the built environment.

You’ve developed almost a cult following for your speeches. Who is your best audience?
Planners really get this, but so does the public-health community. I’m speaking to the UCSF medical center—“Grand Rounds,” it’s called. There will be 150 doctors young and old sitting there, and usually they hear about the latest drug or surgery. I’m going to start out by saying, “Here’s the patient you just saw today. He’s 40 years old, he’s 20 pounds overweight, his blood pressure is too high, his cholesterol is too high. He’s depressed and he has erectile dysfunction.” Then I’m going to say, “You’ve all taken care of this patient. Here are the seven drugs you use, and they cost $400 a month. Now I’m going to give you another way of treating your patient, which is that you, the doctor, need to be much more active politically and socially about creating communities that allow people to meet their life needs without sitting in a car three hours a day.”

A lot of your research is focused on children, who seem to suffer inordinately from sprawl. You mention that while 60 percent of children walked to school in 1973, now only 13 percent do.
It’s shocking. There is a big effort to turn that around. California—as strapped as we are for educational funds—is now spending more than a billion dollars a year on school buses to do what kids’ legs used to be able to do.

You discuss, in a very encouraging way, how walking is really the best exercise.
It’s the one exercise we can do at virtually every age. It breaks my heart when I see people pushing four-year-olds in those three-wheeled strollers. I know that parents want to get things done, but that child needs to walk. The same is true of the elderly.

It seems that what has been eliminated from our new suburban communities is the useful walk: the one that serves a purpose because it gets us somewhere we need to be. It’s only possible with mixed-use zoning.
When you’re getting things done, you don’t even notice that you’re walking. The other thing that I would emphasize alongside fitness is public safety. Bringing public safety into the tent is very important.

You are known for asking your audiences, “In what kind of community are you most likely to end up in a pool of blood?”—which compares statistics from the suburbs with the roughest inner city.
I was the guest editor for a built-environment issue of the American Journal of Public Health (September 2003). One of the articles asked who is more likely to die violently. Is it the commuter driving long distances from a pretty suburb or the person walking short distances in an urban area?

That study caused quite a stir in the planning community. If you add crime and car crashes together, you’re 20 percent more likely to die in the suburbs.
It has been asserted that I’m too negative when I describe this situation, and it’s true that we doctors tend to focus on pathology. But we know the treatment for these problems. We know how to build communities with central commons surrounded by civic buildings, with sidewalks, parks, and transport, with kids and old folks being able to get back and forth to their daily destinations. I think we are at the right moment to reinvent American communities back to what they were at their absolute best.

One of the things I most enjoy about your work is that it reintroduces to planning the original motivation of public health—which has largely been missing for a century—but it turns this impulse on its head. The very first city planners increased life spans through an act of separation, by moving households away from those dark satanic mills. Now you and your colleagues are saying that the greatest danger is not the factories but the separation itself.
It certainly is a good idea to not have our children living next to tanneries and slaughterhouses. That said, there is really no reason we shouldn’t be close to retail and accountants’ offices and all the rest. The fact is that we do know how to build healthy communities. We just have to make it happen.

And there’s the rub. Here at the Arts Endowment, we sponsor institutes for mayors and governors that promote good urban design and smart growth. The goal is to inspire top-down leadership on design issues.
That’s certainly needed. But speaking of art, we are really talking about a cultural shift, and it is art that is so important when you want to change a culture. We doctors can talk pathology and disease forever, but what really causes change is when art—the narrative, the music, and the things that add value and joy to our lives—is directed in a way that is congruent with what’s healthier for us. That’s where we need to be going.

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