Putting the "health" in "healthy" cities

In 2003, developers asked the San Francisco Planning Commission for a rezoning to allow them to build four mixed-use high-rise towers including 1,600 residential units. The developers argued that the project would meet the city's housing needs as well as its "smart growth" objectives.

And who showed up to comment on the project, but the Health Department? Why the Health Department - at a zoning hearing?

While the Health Department supported the project and its objective to increase residential density in the downtown business district, it pointed out that the housing would be unaffordable to 93% of area households. Many low- and moderate-income workers were already moving significant distances from San Francisco for affordable homes, and mismatch between housing costs and income meant that few downtown workers could afford these new homes. The proposal missed out on an important opportunity to address the regional health consequences of lengthening commutes, including asthma, vehicle injuries, noise-related stress, and physical inactivity.

Furthermore, San Francisco Planning law required 12% of the developed units to be affordable to moderate-income households, but some developers did not want to integrate the affordable units into the new project. Instead they proposed to build them in Bayview-Hunter's Point, a lower-income neighborhood to the south. The health review pointed out that this might have the effect of reinforcing residential segregation. From a public-health perspective, reinforcing segregation meant perpetuating inequality in key resources necessary for good health, such as the availability of fresh produce, public safety, and employment networks. Health Department research had documented that residents of neighborhoods like Bayview suffer a disproportionate burden of environmental exposures from power generation, industry, and busy roadways. Research also showed that residents of San Francisco's segregated low-income neighborhoods live fewer years, sustain more injuries, and suffer more preventable hospitalizations from chronic diseases such as asthma and diabetes.

Finally, the health review questioned the project's lack of planning for a school. The review argued that neighborhood schools could further reduce traffic and air pollution, promote physical activity, and support children's development and educational success.

The Planning Commission approved the project despite these criticisms, but community organizations later appealed this decision to the Board of Supervisors, and Supervisor Chris Daly negotiated an agreement with the developers calling for a higher proportion of affordable units. Ultimately, zoning rules for the Rincon Hill Planning Area approved in 2005 required all below-market-rate units to be constructed within the South of Market Planning District and included impact fees on developers for street improvements, parks, community centers, affordable housing, economic development, and community cohesion in surrounding neighborhoods. Some community stakeholders used data and evidence from the health review in arguing for these changes.

Health Impact Assessment

The Health Department's intervention in this project was one of the first examples in the U.S. of a Health Impact Assessment (HIA). HIA aims to inform decision-makers comprehensively how public policy can affect the underlying causes of a healthy population. It also aims to increase the involvement of affected people in decision-making. For decades federal and state laws have required environmental-impact analyses. The idea behind HIA is similar: policy-makers should also ask: how might our decision affect people's health?

Australia, Canada, Germany, New Zealand, Sweden, Thailand, and the United Kingdom are some of the many countries that already use HIA to advise policy-makers on health considerations. In the U.S., environmental-impact assessment has historically included some but not all issues relevant to public health.

According to the Institute of Medicine, improving health in the 21st century will require new approaches to environmental health, including strategies for waste, unhealthy buildings, urban congestion, suburban sprawl, poor housing, poor nutrition, and environmentally related stress. Increasingly, the public-health and urban-planning communities understand that the design of neighborhoods critically impacts public safety and human health. For example, San Francisco's downtown neighborhoods experience a disproportionate share of the city's vehicle trips and consequently a disproportionate share of its 800 annual pedestrian injuries. High levels of traffic-related noise in these areas can adversely affect sleep, school and work performance, and temperament; and can cause hearing impairment and high blood pressure. Further, air pollution from vehicles concentrates around busy roadways and increases respiratory illnesses.

Adequate transportation is also necessary for human health. For example, a recent study of 15 low-income neighborhoods in the Bay Area demonstrated that 66% of residents had no transit access to hospitals, and 48% didn't have walking access to a supermarket. For the elderly and disabled, limited access to public transit creates barriers to participation in community and civic life, leading to depression and alienation.

Society can prevent illness and promote health through integrating these health concerns into land-use and transportation decisions; U.S. public-health institutions, however, have focused primarily on disease surveillance, behavior change, and preventative screening, largely ignoring health's social and environmental determinants. Planning departments lack the resources, expertise, and experience to assess health impacts. It is new for health officials to try systematically to translate the health effects of land-use decisions to the public and to city leaders with the goal of literally healthier land use.

A more ambitious effort

Today the Department of Public Health is preparing a much more ambitious HIA. The Eastern Neighborhoods Community Health Impact Assessment (ENCHIA) aims to analyze how rezoning and community-development plans for the Mission, SoMa, and Potrero Hill/Showplace Square neighborhoods might promote and protect both community and individual health.

For more information on the ENCHIA visit www.sfdph.org/phes/enchia.htm

The ongoing ENCHIA process has examined many of the same factors as other community-planning processes, but through the lens of protecting and promoting human health and with full involvement of health professionals and diverse community stakeholders. This assessment looks at the needs for housing, nutritious foods, accessible parks and public spaces, safe pedestrian and bicycle environments, air quality, neighborhood public schools, physical safety, employment, goods and services, and civic participation. The assessment is designed to inform zoning as well as land use.

The anticipated benefits of conducting this HIA include:

• prevention of chronic diseases including asthma, obesity, and diabetes;
• prevention of both unintentional and violent injuries;
• improvement of childhood physical and cognitive development;
• improved neighborhood quality of life and property values;
• responsiveness to community demands for health, social, and neighborhood-impact analysis;
• proactive resolution of future land-use and environmental conflicts.

Ultimately, tools like HIA may encourage society to consider a more holistic definition of health, enabling public-health practitioners to improve human well-being in ways beyond simply treating and preventing disease and illness. Then we all may be able to speak with clarity of healthy cities.

by Rajiv Bhatia, M.D., M.P.H., director, occupational and environmental health, San Francisco Department of Public Health. Dr. Bhatia is part of a new wave of public-health professionals who focus on the connection between health and the built environment.