Location is everything in real estate. It drives both mortgage rates and rent prices.
Research is showing that location can have a significant impact on health outcomes.
It is well-known that air and water pollution can lead to poor health outcomes. Furthermore, it shouldn’t surprise that people living near health services can have an effect on the quality and quantity of their care.
However, new studies that examine the effects of geographic-specific features on health reveal the importance of built environments, housing policies, and the impact they have on health disparities across the United States.
This attention is becoming more mainstream. There are increasing numbers of partnerships being formed between public health experts and city planners. However, the consequences of systems in place decades ago are now becoming evident. It is possible to fix past harms with preventive measures that are taken today.
Walking as a Social Determinant for Health
In North America, urban design practices began in the 1950s. They led to the development and maintenance of car-oriented suburban areas. These areas were characterised by low population density (or “urban sprawl”), the separation of residential developments from commercial and retail areas, and street designs lacking pedestrian infrastructure. Review.1
These postwar built environments (e.g. Levittown in Pennsylvania or New York) made biking and walking dangerous and impractical primary modes. Research shows that these decisions eventually had downstream health consequences, as demonstrated by metabolic health assessments in individuals who live near high walking areas compared to those who live in areas with lower walkability.
Walkability refers to the amount of walking that a neighborhood encourages or supports as a mode of transportation. Residents living in suburbs may not have access to amenities within walking distance of the house and may need to drive to get to the pharmacy or grocery store.
Data showed that people who live in walkable neighborhoods are more active and have lower body weights in general than those who live in less walkable areas.
Research concluded that dense, walkable urban environments were associated with better metabolic health in comparison to regions that were more car-oriented and less walkable. It is possible that policies aimed at increasing walking could result in tangible health benefits.
One AnalysisThe review found that in Ontario, Canada, a higher level of neighborhood walkability was associated both with a stable prevalence and decreasing incidence of diabetes. All three rates were significantly lower than those in less walkable areas, which saw an increase in obesity.2
However, this association is not solely due to geographic and population density. Destinations also have an impact on neighborhood walkability, stated Gillian Booth, MD. MSc of the Department of Medicine at University of Toronto, in an interview. The American Journal of Managed Care (AJMC).
Booth is a scientist at MAP Centre for Urban Health Solutions of St. Michaels Hospitalin Toronto and coauthor of the aforementioned research.
Factors outside of design, density, and destinations affect neighborhood-specific health outcomes, and can even negate the benefits of living in highly walkable areas, she stressed.
Booth and his colleagues found that those who live in areas of low traffic-related pollution had greater benefits from walking. This was true for diabetes risk as well as hypertension.
But, if there [were]High levels of air pollution can cause walking difficulties. This is because the air pollution itself is a risk factor in diabetes. It is not enough to build. [environments] right.
Other than pollution, other factors can have an impact on how people use walkability and the neighborhood’s ability to make environmental improvements. Safety, sidewalk conditions and crime rates, as well as transportation options, all have an impact on whether or not walking is encouraged or discouraged, regardless of the space’s design.
Booth stated that we always need to consider where people live, the neighborhood as a whole, and what makes a neighborhood healthy. There is a lot of interest in how to make healthier designs and how to make more equitable investments.
Housing Discrimination and Redlining
More than 40% are obese in America and 37 million Americans have diabetes. Not only are these crises self-perpetuatingobesity is a key risk factor for diabetesbut stark racial and economic disparities exist within these figures.
The incidence of diabetes in America has increased substantially over the past 20 years.77% higherHispanics have 66% higher rates of African Americans than White Americans.
A higher percentage of poverty has been associated with higher levels of poverty. obesityRates are influenced by factors like low individual income or food insecurity.
Although there is evidence that structural racism, including discriminatory housing policies, has been a contributing factor to diabetes disparities throughout the 20th Century, there is a dearth of research that examines discriminations shaping resource distribution and opportunities between neighborhoods and their impact on cardiovascular disease. PNAS.3
Redlining was a practice that was institutionalized by the federal government. Security maps of Home Owners Loan Corporation HOLCMahasin Mujahid MS, FAHA, associate professor of epidemiology, UC Berkeley School of Public Health.
The color codes were based upon high concentrations of Black, immigrant or working-class residents. They were then considered dangerous and too risky to invest in.
Researchers explained that the grades were a barrier to residents of these unfavorable neighborhoods, especially Black residents, from obtaining mortgage financing and home ownership. This led to years and years of systematic investment and contributed to inequities in quality of the physical, social, and environmental environments in which historically marginalized communities reside in greater amounts.
These predominantly Black neighborhoods were more vulnerable to the negative effects of programs like urban renewal or deindustrialization. This resulted in low home ownership, uneven economic growth, displacement of residents and community disintegration.
Mujahid and his colleagues compared the modern-day cardiovascular health of residents in historically redlined areas to those in wealthier, non-redlined areas using data from Multi-Ethnic Study of Atherosclerosis.
The analysis included 4779 participants from six sites in the United States. 26.7% of these were Black, 23.9% Hispanic, 13.3% Chinese, and 35.1% White. 18.9% of the participants lived in historically redlined/hazardous places (based on HOLC scores), 44.2% in declining neighborhoods, 36.9% in so-called “desirable neighborhoods”.
Researchers found that CVH scores in historically redlined areas were not always the lowest.
- Hispanic (23.8%), Black (22.9%), and Chinese (26.0%) participants were more likely to have lived in historically redlined locations than White participants (10.4%).
- Ideal CVH and CVH behaviors were higher in Chinese participants than in Black and Hispanic participants.
- The Ideal CVH factors summary score was highest for White participants and lowest for Black participants
- Hispanic participants (mean = 0.688) and Black participants (mean=1.02) had the lowest scores in social environment.
- The best social environments were found in historically A: Best Neighborhoods, which was home to both Chinese (mean = 1.111) and White participants.
- HOLC grades were found to be associated with all 3 CVH summary measurements: overall CVH, health variables, and health behavior, as well with 2 individual indicators CVH (blood pressure & body mass index), among Black participants. However, there was no association with Hispanic, Chinese, and White participants.
Mujahid, in an email, stated that the research revealed a correlation between living in a historically disadvantaged neighborhood and current-day CVH for Black residents. AJMC.
Black Americans have the highest mortality rate from cardiovascular disease in the country. This is higher than any other racial/ethnic group. Living in an area that has been historically redlined could expose residents to more stressors. These can manifest biologically as cortisol and increasing body mass index. Cumulative stress exposure can also cause physiological wear and tear (ie. weathering) that can lead to hypertension.
Mujahid pointed out that because of the disinvestment in redlined neighbourhoods, there are fewer sidewalks, parks, and places for people to safely exercise, play, or gather.
We also know that majority-minority areas are more frequently stopped and screened by police than most neighborhoods of majority White residents. This could be another way that racial residential separation prevents people who live in redlined areas from being able to safely spend time outside and get exercise, she said.
Planning Plus Public Health
These investigations highlight a fact that many urban planners have been advocating for for years: Improving social determinants and health cannot be done in a silo.
It is difficult to achieve the ideal neighborhood balance. This may require both monetary investments and intervention from the federal and local governments. Mujahid stressed that it is important to be aware of the negative effects of gentrification and suggested that intentional investments are necessary to ensure that residents are able to access new resources and opportunities for long-term, socially vulnerable residents.
In November 2021 the US Senate passed the bipartisan legislation Infrastructure Investment and Jobs Act (IIJA).A $1 trillion bill that aims to rebuild the roads of the nation, fund new climate resilience initiatives, address past decisions that contribute to health disparities, and address, in part, past mistakes.
Leigh Ann Von Hagen, AICP (PP), a planning practitioner, adjunct professor and managing director with the Alan M. Voorhees Transportation Center and a founder and leader of the Planning Healthy Communities InitiativeRutgers University Edward J. Bloustein School of Planning and Public Policy
One aspect of the IIJA is a census tract mapping component, which planners can use to apply for a Rebuilding American Infrastructure with Sustainability and Equity grant (RAISE).RAISEThis grant would highlight areas of persistent poverty or historically disadvantaged communities.
The US Department of Transportation and Federal Highway Administration provide the mapping tool that allows you to identify these areas. Von Hagen explained this in an interview with AJMC.
Many times, planning decisions are made without regard to public health but address those issues in the end. She said that transportation improvement is one example. Walking or bicycling is active transportation. This means that you are achieving healthier outcomes if you do it safely.
Despite the potential impact of the IIJA, many hurdles remain to implement improvements at the local level. These include the time and bureaucratic barriers that separate states from counties from cities.
Even if the top applications are granted federal funds, local governments may not have enough staff to oversee project implementation from beginning to finish. Communities that are underserved may not have the resources or the staff to apply for grants.
On the other hand, wealthy communities have more resources and can hire staff to write grants or outsource the task.
Von Hagen stated that the key to successful implementation is oversight capacity, resident buy in, expendable resource, and time.
Von Hagen cited the example of safety improvements along school routes and said that even though there is a comprehensive public involvement process, the years between implementation and implementation can be burdensome. Parents who contribute initially may see their children move on to other projects.
She stated that efficiency improvements, steady funding streams, the inclusion of public health officials in decision-making, and ensuring that a point-person is available for projects in underserved communities could all be helpful in expediting interventions in built environments. This could also improve health outcomes.
Looking long-term
Like many other fields of expertise, the COVID-19 Pandemic has strained partnerships between planning experts, public health, and other professionals. The latter has been stretched thin to cope with the ongoing public-health emergency.
Von Hagen insists on the importance of addressing social determinants in health. He asked if the country has learned its lesson and if better funding and staffing is required for public health.
COVID-19 actually showed us that there were more cracks than ever because of transportation issues and housing issues. Planners need to be reminded of the importance this topic by their public health partners.
Sometimes, direct integration of health data into decision-making is possible through the use CDC Health Impact Assessments (or initiatives like Health in All Policies), which allow for both the economic and humanistic impact of proposed legislation or projects to be included in the conversation.
Von Hagen said that professionals who are not in the health industry do not need to weigh the impact of new initiatives on their health. She added that the DOT is now considering equity in its decision-making.
Booth stated that although it is important to address obesity and diabetes once they have developed, individual patient interventions will not be enough to prevent long-term complications.
It must be tackled at every stage. [Diabetes]She said that the largest driver of health care costs in any country is their built environment. It takes time to change the built environment and implement policy, but I believe we must make those changes since what we have been doing is perpetuating this problem.
References
1. Booth GL, Howell NA. The weight of places: how the built environment correlates to obesity and diabetes. Endocr Rev. Published online February 24, 2022. doi:10.1210/endrev/bnac005
2. Creatore MI, Glazier RH, Moineddin R, et al. Association of neighborhood walkability and change in overweight, obesity, or diabetes JAMA. 2016;315(20):2211-2220. doi:10.1001/jama.2016.5898
3. Mujahid MS., Gao X., Tabb LP., and Lewis TT. Historical redlining and cardiovascular disease: A multi-ethnic study into atherosclerosis. Proc Natl Acad Sci USA. Published online December 13, 2021. doi:10.1073/pnas.2110986118
