| What Olmsted Knew
Richard Joseph Jackson, MD, MPH
Director, National Center for Environmental Health
Centers for Disease Control and Prevention
Atlanta, Georgia
February 2001
Medicine alone will be inadequate to deal with the health challenges
of the 21st century, even with the help of the sequenced genome and advances
in robotic surgery. Despite the United States’ expenditure of more
than one of every seven dollars on medical care, the prevalence of chronic
diseases, and the costs for their care in an aging population, will continue
to increase. Of the strategies to limit these burdens, none will be as
cost effective and improve the quality of life more than giving much more
attention to how we plan and design our living environments. Healthy living
environments include not just a clean and heated kitchen, bath or bedroom,
but also the structures and landscape around us. Health for all, especially
for the young, the aging, the poor, and the disabled, requires that we
design health-fullness into our environments as well. During the nineteenth
century life of Frederick Law Olmsted, the nation’s greatest landscape
architect, the average American’s life span was less than 40 years.
Today, it is 80. Surprisingly, only seven of the added years are the result
of better disease care. The rest comes from efforts that Olmsted would
have understood perfectly: broader immunity to disease combined with higher
living standards and a healthful environment, including clean water and
food, and better and safer housing.
Of the many challenges of the 21st century, the major one for planners
and designers will be good design for density. As we look around the nation
today, we are staggered by population spread. We can drive the megalopolis
from Norfolk, Virginia to Portland, Maine and scarcely see an open field
(unless it has been protected as public land). Yet, the Census Bureau
estimates that the US will double its population again in this century—a
whole new nation added --600 million people! Designers and architects
will be required to design for quality density.
This population increase brings new challenges for those in public health
who work to make the nation healthier. The health challenges of the 21st
century include assuring a healthy aging population, protecting mental
health, thwarting environmental threats, preventing and controlling chronic
diseases such as diabetes and obesity, and eliminating disparities such
as diminished health among the poor. To address these challenges, we will
need to be much smarter about how we use the land and design our housing
and landscape.
This is particularly true as we work to end the disparities in health
and survival between the rich and the poor. Economic favor is reflected
most in the overall quality of our environments. For example, in Los Angeles
housing cost is highest in areas of the city where air quality is best.
It is not just a social equity goal, but also a health goal, to have communities
where rich and poor can live where there is good public transportation,
accessible parks, sidewalks, and public areas.
As an epidemiologist who has investigated disease outbreaks of all kinds,
I have seen the links between how we design our living environments or
use our land and the origin and magnification of disease events. For example,
water treatment alone will not fully prevent transmission of diseases
in drinking water. Rather, protection of the sources of drinking water--
the rivers, lakes and groundwater--will also be essential. Thus, land
and water protection is therefore health protection, now and for the future.
The same is true for air quality: ozone alerts, heat island effects, particulate
air pollution cannot be solved by mere “Ride-Share” programs.
Focusing on how we build, insulate, and cool our homes, and how efficiently
and cleanly we can be transported to home, work, and school, will determine
whether air quality is fit enough to go for a walk or a run.
An example of a disease problem epidemic that is exacerbated by bad environmental
designs is that of the epidemic of obesity in the US. Twelve per cent
of the U.S. population was obese in 1991; 18% was in 1998. Obesity is
unhealthy, it raises risks of heart disease, high blood pressure, diabetes,
stroke, and diminishes vitality. For diabetes, from 1980 to 1994 the prevalence
in the population increased by 2.2 million cases, an increase of 39%,
and diabetes is the 7th leading cause of death in the US. Type 2 diabetes
(formerly only associated with older and often obese adults) has increased
in every age group in the population. Lack of exercise, or any physical
activity, contributes to obesity and diabetes epidemic. Despite common
knowledge that exercise is healthful, fewer than 40% of adults are regularly
active, and 25% do no physical activity at all. The way we design our
communities makes us increasingly dependent on automobiles for the shortest
trip, and recreation has become not physical but observational. There
is increasing evidence (though much more research is needed) that contributing
to the obesity epidemic is the lack of safe and healthy places to pursue
even the most basic physical exercise, walking. Walking does not require
steel, gasoline, or a catalytic converter. It is a socializing and safe
exercise for everyone, and the prime exercise for the elderly.
Changing the environment can change health, profoundly for good or ill.
In the 1970s the heavy metal lead had thoroughly contaminated our environment,
and our own developing brains, and its removal seemed an insurmountable
task. Fifteen years ago, as a representative for the American Academy
of Pediatrics in Congressional testimony, I asserted that lead poisoning
was “the number one environmental health risk to children in America”.
Changing the environment, removing lead from gasoline, paint, food containers
and other sources, has been astonishingly successful in lowering the lead
levels in all Americans, most importantly in the developing brains of
children. But not all children have benefited equally. Today, the children
with high lead levels are ones who are poor, often malnourished, and live
in deteriorated lead-painted houses. These same homes are risky for reasons
other than old lead paint: they often have insect and rodent infestations
that contribute to lung and other disease. Wiring, plumbing, insulation
are usually dangerous or inadequate and contribute to fires and injuries.
The healthier community designs of the future will need healthier homes
as well.
As we look at respiratory risks to our children, asthma looms large. In
some schools as many as 30% of children carry inhalers and are said to
have asthma. Despite genuine advances in medical care and drug therapy
for asthma over the last 20 years, there has been a stairstep climb in
asthma cases nationally, with deaths increasing as well. The causes for
these increases are not known for sure, but indoor allergens and outdoor
air pollution do raise risks for both developing the disease, and for
setting off asthma attacks requiring and hospital visits. Every asthma
specialist recommends lowering dust and allergen loads in the home, followed
by removing pets, carpeting, curtains; by covering mattresses and pillows,
and by changing or improving air filters. Clearly good indoor air quality
is a problem that designers, architects, and builders can solve. There
are reliable and effective systems for replacing bad indoor air with heat-exchanged
filtered outside air in a well-sealed building – and not by pulling
air into the house from moldy areas like crawl spaces and. Such measures
usually reduce home radon levels as well.
While outdoor air is nearly always cleaner than indoor air, outdoor air
pollution is associated with asthma attacks. In Atlanta following Ozone
Alert days, emergency room visits increase by 30 to 40%. The largest contributors
to outdoor ozone production are pollutants coming from vehicles and power
plants, particularly on hot days. Cooler landscapes with light colored
paving and roofs, with more shading and trees, can reduce ground level
ozone effects and electrical power demand. This coupled with better housing
design and insulation would generate less power plant emissions. At the
same time commuters are not going to reduce their automobile use until
they have access to sidewalks, bicycle routes, and reliable and safe mass
transit systems. The tree shaded streets and neighborhoods that Olmsted
demanded, are the same streets our power demands require.
Mental distress, particularly depression, is epidemic in modern American
society. Prescriptions for SSRI antidepressants have climbed each of the
last 15 years since they were first marketed. Depression is associated
with lowered levels of the hormone serotonin in the brain, and exercise
can increase these levels. Some research is showing exercise to be as
effective as SSRI’s in raising serotonin levels. There is also some
research showing more rapid recovery of ill persons in the presence of
green landscape, though more research is needed. Human beings need to
walk and “re-create” themselves in safe and refreshing environments,
Olmsted knew this. As a man coping with his own tendency to depression,
he spent two trips to Europe studying landscapes that attracted and revitalized
people, and was himself revitalized.
Tasks that in other cultures were refreshing, socializing and enjoyable
have become in America burdensome and stressful. At the same time that
children’s days are being filled with increasingly more programmed
activities—school or day care, dance and music classes, library
work or sports practices— their parents transport them by car. These
children are being cheated of unsupervised but essential socializing with
peers on the way to school. Many children also see too little of their
loved ones. Because of parents’ long commutes to work, many pre-schoolers
never see their parents during daylight hours on workdays. These demands,
combined with long commutes, lack of reliable mass transit, and inevitable
traffic tie-ups are a recipe for stress. “Road rage” is not
imaginary; every commuter can describe an unpleasant and disturbing encounter
in the past year. Mental stress, with outcomes ranging from sleeplessness
to outright violence, is a serious health hazard. Better public transport
and putting density in our housing, with humane live-work-play community
designs, that put people on their feet rather than on their seats, might
help reduce aggressive driving which causes in 1500 fatalities each year.
Urban design that offers the benefits of more walking, more social contact,
surroundings that include water and vegetation, can offer healthful physical
exercise and psychic respite. Look at a child who gets up from video activities,
often they are aggressive and provocative. Contrast this with the same
child after a bicycle ride: they are usually smiling.
Columbia University Psychiatrist, Dr. Mindy Fullilove, studies the effects
of disordered physical environments on mental and physical health. She
has asserted from her studies throughout the United States: “disordered
environments make people crazy”. Physical environments can either
leave people feeling vulnerable and anxious, or in re-vitalized contact
with others and the world. Dr Fullilove has found that Harlem residents
re-occupying apartment buildings that were clean, orderly and “defensible”
showed improved physical and emotional health, including benefits like
lower blood pressure.
Frederick Law Olmsted was not a trained specialist in landscape, public
health, agriculture, or social reporting, although he excelled in each.
Perhaps, because Olmsted was not blinkered by over-specialization, he
could more readily see the connections between health and human circumstance.
As head of the US Sanitary Commission early in the Civil War, Olmsted
demonstrated the benefits of disease prevention as a social and practical
good. Military physicians at first thought him a meddler when he demanded
and provided clean water and safe food for wounded soldiers. It was not
until he demonstrated better survival and more rapid return of the injured
to service that the Army adopted his “radical” hygienic methods.
Olmsted profoundly understood that the parks and campuses he and colleagues
designed were for human well-being: cultural, physical and social. He
instinctively knew that the architect and the landscape designer, the
road builder and the house builder, were contributing as much as any physician—perhaps
more--to the health of all.
A Clearing in the Distance: Frederick Law Olmsted and America in the
Nineteenth Century.
Witold Rybczynski, Scribner, New York 1999
Rebuilding the Unity of Health and Environment: a new Vision of Environmental
Health for the 21st Century: Institute of Medicine. National Academy Press.
Washington, DC 2001
Obesity Reference: http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm
Physical activity reference: http://www.cdc.gov/nccdphp/sgr/summ.htm
Diabetes Reference: http://www.cdc.gov/diabetes/statistics/survl97/html/surveill.htm#Preval
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