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Urban Transport and Health

Urban Transport and Health

Division 44 , Energy,

Urban Transport and Health Module 5g : A Sourcebook for Policy-makers in Developing Overview of the sourcebook S ustainable Transport: A Sourcebook for Policy-Makers in Developing Cities

What is the Sourcebook? How do I get a copy? ThisSourcebook on Sustainable Urban Transport Electronic versions (pdf) of the modules are addresses the key areas of a sustainable trans- available at http://www.sutp.org or http://www. port policy framework for a developing . The sutp.cn. Due to the updating of all modules Sourcebook consists of more than 31 modules print versions of the English language edition mentioned on the following pages. It is also com- are no longer available. A print version of the plemented by a series of training documents and first 20 modules in Chinese language is sold other material available from http://www.sutp.org throughout China by Communication Press (and http://www.sutp.cn for Chinese users). and a compilation of selected modules is being sold by McMillan, India, in South Asia. Any W ho is it for? questions regarding the use of the modules can The Sourcebook is intended for policy-makers be directed to [email protected] or [email protected]. in developing cities, and their advisors. This target audience is reflected in the content, which C omments or feedback? provides policy tools appropriate for application We would welcome any of your comments or in a range of developing cities. The academic suggestions, on any aspect of the Sourcebook, by sector (e.g. universities) has also benefited from e-mail to [email protected] and [email protected], or this material. by surface mail to: Manfred Breithaupt How is it supposed to be used? GIZ, Division 44 The Sourcebook can be used in a number of P. O. Box 5180 ways. If printed, it should be kept in one 65726 Eschborn, Germany location, and the different modules provided to officials involved in urban transport. The F urther modules and resources Sourcebook can be easily adapted to fit a formal Further modules are under preparation in the short course training event, or can serve as a areas of Energy Efficiency for Urban Transport guide for developing a curriculum or other and Integration. training program in the area of urban transport. Additional resources are being developed, and GIZ has and is still further elaborating training Urban Transport Photo CD-ROMs and DVD packages for selected modules, all available are available (some photos have been uploaded since October 2004 from http://www.sutp.org or in http://www.sutp.org – photo section). You http://www.sutp.cn. will also find relevant links, bibliographical references and more than 400 documents and W hat are some of the key features? presentations under http://www.sutp.org , ( http:// The key features of the Sourcebook include: www.sutp.cn for Chinese users). A practical orientation, focusing on best practices in planning and regulation and, where possible, successful experiences in developing cities. Contributors are leading experts in their fields. An attractive and easy-to-read, colour layout. Non-technical language (to the extent possible), with technical terms explained. Updates via the Internet. Modules and contributors (i) Sourcebook Overview and Cross-cutting Issues V ehicles and fuels of Urban Transport (GTZ) 4a. Cleaner Fuels and I nstitutional and policy orientation (Michael Walsh; Reinhard Kolke, Umweltbundesamt – UBA) 1a. The Role of Transport in Urban Development Policy (Enrique Peñalosa) 4b. Inspection & Maintenance and Roadworthiness (Reinhard Kolke, UBA) 1b. Urban Transport Institutions (Richard Meakin) 4c. Two- and Three-Wheelers(Jitendra Shah, World Bank; N.V. Iyer, Bajaj Auto) 1c. Private Sector Participation in Urban Transport Provision 4d. (MV V InnoTec) (Christopher Zegras, MIT) 4e. Intelligent Transport Systems 1d. Economic Instruments (Phil Sayeg, TRA; Phil Charles, (Manfred Breithaupt, GTZ) University of Queensland) 1e. Raising Public Awareness about Sustainable 4f. EcoDriving (VTL; Manfred Breithaupt, Urban Transport (Karl Fjellstrom, Carlos F. Oliver Eberz, GTZ) Pardo, GTZ) E nvironmental and health impacts 1f. Financing Sustainable Urban Transport 5a. Air Quality Management (Dietrich Schwela, (Ko Sakamoto, TRL) World Health Organization) 1g. Urban Freight in Developing Cities 5b. Urban Safety (Jacqueline Lacroix, (Bernhard O. Herzog) DVR; David Silcock, GRSP) planning and demand 5c. Noise and its Abatement management (Civic Exchange Hong Kong; GTZ; UBA) 2a. Land Use Planning and Urban Transport 5d. The CDM in the Transport Sector (Rudolf Petersen, Wuppertal Institute) (Jürg M. Grütter) 2b. Mobility Management (Todd Litman, VTPI) 5e. Transport and (Holger Dalk- mann; Charlotte Brannigan, C4S) 2c. Parking Management: A Contribution Towards Liveable Cities (Tom Rye) 5f. Adapting Urban Transport to Climate Change (Urda Eichhorst, Wuppertal Institute) Transit, and cycling 5g. Urban Transport and Health 3a. Mass Transit Options (Carlos Dora, Jamie Hosking, (Lloyd Wright, ITDP; Karl Fjellstrom, GTZ) Pierpaolo Mudu, Elaine Ruth Fletcher) 3b. R esources (Lloyd Wright, ITDP) 6. Resources for Policy-makers (GTZ) 3c. Bus Regulation & Planning (Richard Meakin) S ocial and cross-cutting issues on 3d. Preserving and Expanding the Role of Non- urban transport motorised Transport (Walter Hook, ITDP) 7a. Gender and Urban Transport: Smart and 3e. Car-Free Development Affordable (Lloyd Wright, ITDP) (Mika Kunieda; Aimée Gauthier)

i About the authors Dr Jamie Hosking is a public health medicine specialist affiliated with the School of Popula- Dr Carlos Dora is an expert on transport, tion Health, University of Auckland, Auckland, health impact assessment and “health in other New Zealand. His particular interests include sectors” policies. He is coordinator of the World transport, climate change and health equity. Health Organization's Interventions for Healthy His recent work includes a systematic review Environments unit in the Department of Public of “Organizational plans for improving Health and Environment, Geneva Headquar- health” (Cochrane Collaboration, 2010) review- ters, and has led work on a WHO Health in the ing health outcomes related to work and school- Green Economy review of the health co-benefits based travel change interventions and review of of climate change mitigation in five economic health co-benefits of climate change mitigation sectors, including transport. policies in the transport sector in the context of Previously at the WHO European Centre for the WHO Health in the Green Economy series. Environment and Health, Dora was involved in He also has developed a framework for monitor- developing a European Charter on Transport, ing health disparities in transport systems at a Environment and Health and in establishing district level. the ongoing Pan-European Process (the PEP) Dr Pierpaolo Mudu is a geographer currently that provides technical support for harmonised working at the WHO-Environment and Health transport, health and environment policies in Office in Europe. He has previously worked in the European region. Dora has an MSc and a several universities in Italy, UK, USA, France PhD in epidemiology from the London School and South Korea. His interests include urban/ of Hygiene and Tropical Medicine. A medical population geography and transport and the doctor by training, he also practiced medicine impacts of industrial contamination. His articles and directed the organisation of health services have been published in several books (the most in Brazil and in the UK. He is the editor of recent one is “ Health in Areas with the book Transport, Environment and Health Local Industrial Contamination” with Bened- (WHO, 2000), and author of a book on etto Terracini and Marco Martuzzi) and jour- communication: Health hazards and public nals (e.g. Archives of Environmental and Occu- debate: lessons for risk communication from the pational Health, Pharmacoepidemiology and BSE/CJD saga (WHO, 2006). Drug Safety, International Journal of Health Email [email protected] Geographics and Journal of Risk Research). ii Elaine Ruth Fletcher is a senior editor in With contributions from: Interventions for Healthy Environments WHO's „„ Annette Prüss-Ustün is a Scientist with unit in the Department of Public Health and WHO's Department of Public Health and Environment and managing editor of the WHO Environment. She has been developing Health in the Green Economy series. Fletcher is methods and estimates of the global burden the author of “Healthy Transport in Develop- of disease from environmental , and is ing Cities” (WHO, 2009), undertaken as part the author of a range of related publications of the WHO/UNEP Health and Environment (http://www.who.int/quantifying_ehimpacts/en/ http://www.who.int/heli Linkages Initiative ( ). She index.html). She has also contributed to the is also the author of “Transport in the Middle development of the new WHO Urban Out- Earthscan Reader on World Trans- East” in the door Air Database, as well as recent port Policy and Practice (Whitelegg J. and Haq estimates from urban outdoor World G. Eds, 2003); a former guest editor of (WHO, 2011a; WHO, 2011b). Transport Policy and Practice (WTPP; Vol 5. No. „„ Claudia Adriazola, Director, Health & 4, 1999); and author/co-author of research on Road Safety Program, EMBARQ, the World mortality from vehicle-related particulate emis- Resources Institute Center for Sustainable sions (WTPP; 4:2 & 4:4; 1998) as well as trans- Transport, Washington DC. Adriazola, port, environment and social equity (WTPP; a lawyer by training, focuses on global Vol 5. No. 4, 1999). strategies for addressing the public health impacts of urban transportation and urban development. „„ Salvador Herrera, an urban planner and deputy director of the Center for Sustainable Transport (CTS) Mexico. Herrera also has served as an advisor in the USA, Spain and Mexico on development and urban planning. „„ Alejandra Acosta, a political scientist, has worked in the definition and implementation of public policies aimed at promoting local development, sustainability, and political responsiveness in Colombia, Mexico and the .

iii WHO Library Cataloguing-in-Publication Data The designations employed and the presentation of the material in this publication do not imply Urban transport and health. the expression of any opinion whatsoever on the part of GIZ or the World Health Organiza- “On behalf of Federal Ministry for Economic tion concerning the legal status of any country, Cooperation and Development (BMZ)” territory, city or area or of its authorities, or (Sustainable transport: sourcebook for policy concerning the delimitation of its frontiers or makers in developing cities, module 5g) boundaries. Dotted lines on maps represent approximate border lines for which there may 1.Transportation - economics. 2.Social planning. not yet be full agreement. 3.Risk assessment. 4.Motor vehicles - statistics. The mention of specific or of certain 5.Public policy. 6.Policy making. 7.Decision manufacturers’ products does not imply that making. I.Deutsche Gesellschaft für Inter- they are endorsed or recommended by GIZ nationale Zusammenarbeit. II.World Health or the World Health Organization in prefer- Organization. III.Series. ence to others of a similar nature that are not ISBN 978 92 4 150244 3 mentioned. Errors and omissions excepted, the (NLM classification: WA 275) names of proprietary products are distinguished by initial capital letters. © Deutsche Gesellschaft für Internationale All reasonable precautions have been taken by Zusammenarbeit (GIZ) GmbH GIZ and the World Health Organization to and verify the information contained in this publi- World Health Organization 2011 cation. However, the published material is being distributed without warranty of any kind, either All rights reserved. Publications are available for expressed or implied. Findings, interpretations free PDF download from the websites of GIZ/ and conclusions expressed in this document are SUTP (http://www.sutp.org) or WHO (http:// based on information gathered by GIZ, WHO www.who.int). Requests for permission to repro- and its consultants, partners and contributors duce or translate this publication – whether for from reliable sources. GIZ/WHO do not, how- sale or for noncommercial distribution – may be ever, guarantee the accuracy or completeness addressed to Manfred Breithaupt GIZ, Division of information in this document, and cannot 44, P. O. Box 5180, 65726 Eschborn, Germany be held responsible for any errors, omissions or (email: [email protected]) or to WHO Press losses which emerge from its use. The responsi- through the WHO web site (http://www.who.int/ bility for the interpretation and use of the mate- about/licensing/copyright_form/en/index.html). rial lies with the reader. In no event shall GIZ or the World Health Organization be liable for damages arising from its use. iv Module 5g Urban Transport and Health

Findings, interpretations and conclusions expressed in this document are based on infor- mation gathered by GIZ and its consultants, partners and contributors from reliable sources. GIZ does not, however, guarantee the accuracy or completeness of information in this document, and cannot be held responsible for any errors, omissions or losses which emerge from its use.

Authors: Carlos Dora, Jamie Hosking, Pierpaolo Mudu, Elaine Ruth Fletcher

Editor: Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH P. O. Box 5180 65726 Eschborn, Germany http://www.giz.de

Division 44 – Water, Energy, Transport Sector Project “Transport Policy Advisory Services”

On behalf of Federal Ministry for Economic Cooperation and Development (BMZ) Division 313 – Water, Energy, Urban Development P. O. Box 12 03 22 53045 Bonn, Germany

Friedrich-Ebert-Allee 40 53113 Bonn, Germany http://www.bmz.de

Manager: Manfred Breithaupt

Editing: Dominik Schmid

Cover photo: Andrea Broaddus, Gothenburg, Sweden, 2007

Layout: Klaus Neumann, SDS, G.C.

Eschborn, September 2011

v Contents

1. Introduction 1

2. Health: challenges for the transport sector 1 2.1 Health impacts of transport 1 2.1.1 Air pollution exposures 2 2.1.2 Road traffic injuries 5 2.1.3 Lack of physical activity, obesity and non-communicable diseases 7 2.1.4 Noise 9 2.1.5 Climate change, transport and health 10 2.1.6 Land use, access, social well-being and other factors 12 2.2 Groups at higher risk of health impacts from transport 13 2.3 Regional overview of health impacts from transport 14 2.3.1 Organisation of Economic Co-operation and Development (OECD) countries 14 2.3.2 Developing countries 16

3. Instruments: tackling the problem 17 3.1 Policies for healthy transport 17 3.1.1 Improving land use planning 17 3.1.2 Facilitating healthy transport modes 18 3.1.3 Improving vehicles and fuels 19 3.1.4 Comparison of policy options 20 3.2 Tools for assessing the health impacts of transport systems 21 3.2.1 Introduction 21 3.2.2 Types of assessment tools 21 3.2.3 Applying qualitative and quantitative tools – case studies and examples 26 3.2.4 Modelling greenhouse gas emissions and health 30 3.3 Economic mechanisms 31 3.3.1 Health in the economic evaluation of transport systems 31 3.3.2 Transport pricing measures 33 3.3.3 International financial mechanisms 34 3.4 Governance frameworks and mechanisms for transport, environment … 35

4. Good practices 37 4.1 Principles of healthy transport 37 4.2 Co-benefits of healthy transport systems 40 4.3 Barriers to progress on healthy transport 40

5. Summary 42

R eferences 43

vi Module 5g: Urban Transport and Health

1. Introduction 2. Health: challenges for the

Transport has a powerful impact on health – transport sector and that influence on health is growing globally 2.1 Health impacts of transport along with increased mobility. The transport sector also offers major potential for reducing Transport has a major impact on health, and greenhouse gas emissions, making transport a transport system's development may either policies an important area of attention in the enhance health or, conversely, increase health climate change field. This module aims to risks. The most familiar health risks of trans- describe the health risks and benefits that arise port include exposure to air pollutants, noise from transport, and to identify transport sys- emissions from motorised vehicles, and risks of tems that protect and promote people's health road traffic injury. Less well known, but equally both in the short-term, e.g. reducing immediate important, are the health benefits that can be risks from air pollution and injuries, as well as realised if travel involves a certain amount of over time by supporting the development of physical activity such as cycling to work or healthier and more sustainable cities. walking briskly (e.g. 15–20 minutes daily) to a transit stop. The module starts by providing an overview of the key pathways by which transport can influ- Along with the journey itself, transport impacts ence health, and the scale of transport-related health by providing access to employment, health risks in OECD and developing coun- education, health services and recreational tries. It then discusses instruments that are opportunities – all of which influence health available to assess and counter transport-related status and health equity. However, policies and health risks. It offers some principles that can infrastructure that improve access for one type be used to guide the development of healthy of travel, particularly motor vehicle traffic, may transport systems, and concludes with some also create barriers for those travelling by other case studies illustrating good practice in diverse modes, e.g. , bus, or on foot. That, cities of the world. in turn, can lead to severe inequities in access to health services, education, employment, food choices, and restrictions in mobility for many groups – all of which impact health. Significant health and health equity impacts from transport may also occur more indirectly – in terms of the ways that shape the design and character of neighbourhoods and cities. For instance, heavily trafficked roads that cut through neighbourhoods can limit activity and constrain social interactions that strengthen social networks and communities. When expansion of road and parking space in cities takes place at the expense of potential walking and green corridors, opportunities for healthy mobility may be lost to everyone – impacting children, women and the elderly most severely. And when cities develop around road-oriented patterns of low-density sprawl, this in turn, over time, may create a vicious cycle of increased dependency on motor vehi- cles for essential travel, increasing even more direct health impacts from pollution and injury as well as the more indirect health impacts

1 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

related to access, physical activity patterns and of health-damaging air pollutants (see Section social interaction. 2.3). However, serious and quantifiable health The following sections provide more informa- damage occurs at the levels of air pollution typi- tion on the key transport-related health impacts cally found today in both developed and devel- that are most relevant to developing cities. More oping countries. The higher air pollution levels, extensive reviews of individual impacts are the worse the associated health problems. noted in the Reference section. Health impacts of air pollution 2.1.1 Air pollution exposures Fuel combustion produces a number of air pol- The transport sector is responsible for a large lutants substances that have been linked to ill and growing proportion of urban air pollutants health and premature mortality. The evidence that impact health. The sector also is responsible regarding their health impacts is summarised for a significant proportion of global emissions below, and described in more detail in the

of CO2 and other global warming pollutants WHO air quality guidelines (WHO 2006a). that contribute to climate change, and its Transport-related air pollutants that affect long term health impacts. This latter issue is health include: particulate matter, oxides of discussed in a separate section of this report. nitrogen, , carbon monoxide and benzene. Air pollution concentrations are, on average, They increase the risk of a number of impor- particularly high in developing cities, where tant health problems, including cardiovascular transport has become one of the major sources and respiratory disease, cancer and adverse birth outcomes, and are associated with higher death rates in populations exposed (Table 1) (Krzyzanowski et al., 2005). Exposure to heavy traffice.g. ( living near a major road) is itself associated with poorer child and adult health and increased death rates (Brugge et al., 2007, Health Effects Institute 2010b). Children’s health and development is particularly at risk from ambient air pollution (WHO 2005). In many developing countries, old and poorly-per- forming diesel vehicles often are responsible for the greatest proportion of small particle emis- sions from vehicles, and visual assessments of “black smoke” emissions from and can be a rapid and inexpensive “proxy” indicator of excessive tailpipe particle emissions (Krzyza- nowski et al., 2005).

F igure 1 Table 1: Health outcomes associated with transport-related air pollutants Rapid motorisation in developing cities Outcome Associated transport-related pollutants contributes to high Mortality Black smoke, ozone, PM2.5 levels of air pollution. Respiratory disease (non-allergic) Black smoke, ozone, nitrogen dioxide, VOCs, CAPs, Photo by Jinca, Nanjing, PR China, 2010 Respiratory disease (allergic) Ozone, nitrogen dioxide, PM, VOCs, CAPs, diesel exhaust Cardiovascular diseases Black smoke, CAPs Cancer Nitrogen dioxide, diesel exhaust Adverse reproductive outcomes Diesel exhaust; also equivocal evidence for nitrogen dioxide, carbon monoxide, sulphur dioxide, total suspended particles

PM: particulate matter; PM2.5: PM < 2.5µm in diameter; VOCs: Volatile Organic Compounds (including benzene); CAPs: Concentrated Ambient Particles

Source: adapted from Krzyzanowski et al., 2005

2 Module 5g: Urban Transport and Health

Key health-harming air pollutants from In developing as well as developed cities, short- transport term exposures to increased fine particulate Small particles of less than 10 microns in diam- concentrations have also been studied, and eter (PM10) and fine particles of less than 2.5 associated with increased rates of daily mortal- microns in diameter (PM2.5) are linked most ity and hospital admissions, mostly as a result closely to impacts on public health. Such par- of chronic respiratory and cardiovascular con- ticles bypass the body's usual defences against ditions (WHO – Regional Office for Europe dust, penetrating and lodging deep in the res- 2004). piratory system. Small particles emitted by road Fuel combustion particles may contain or carry vehicles may be comprised of elemental carbon more toxic compounds (e.g. metals) than par- or carbon compounds, heavy metals and sul- ticles from natural sources such as dust storms. phurs, and also carcinogens, e.g. benzene deriva- But at present, total PM10 or PM2.5 mass con- tives. Such pollution is measured in terms of centrations per volume of ambient air are con- the mass concentration of particles smaller than sidered to be the best indicators of potentially PM10 or PM2.5 per cubic meter of air, e.g. micro- health-damaging exposures for risk reduction grams per cubic meter (µg/m3). purposes (WHO – Regional Office for Europe Health effects from fine have been 2000 and 2004). observed at all ranges of observed annual aver- age concentration levels – from average annual Global burden of disease from air 3 pollution concentrations of 8 µg/m for PM2.5 and 15 µg/ 3 m for PM106. New WHO Air Quality Guide- Urban outdoor air pollution from small parti- lines, issued in 2006, set guideline values of 10 cles is estimated by WHO to cause about 1.3 3 µg/m for PM2.5 (annual average concentrations) million deaths globally per year (WHO 2011a). 3 and 20 µg/m for PM10 (WHO 2006a). A reduction in average particulate concentra- 3 Cumulative, long-term exposure to elevated tions from 75 µg/m for PM10 (a level common levels of small and fine particulates is associ- ated with reduced lung function, increased frequency of respiratory disease and reduced life expectancy. Most of the long-term studies of such health impacts in large urban populations, to date, have been conducted in the United States and Europe (WHO – Regional Office for Europe 2000, 2002 and 2004).

B ox 1: CO and NOX Two other important health-harming pollutants from transport are carbon monoxide (CO) and

oxides of nitrogen (NOX). CO in ambient air F igure 2 forms a bond with haemoglobin and impairs The number of cities in the oxygen-carrying capacity of blood. Health developing countries impacts from short-term exposure to the levels with air quality of CO typically found in ambient air pollution monitoring systems may include cardiovascular effects, such as is increasing rapidly: the aggravation of angina symptoms during An information , and impaired exercise performance board displaying (UNEP, ILO and WHO 1999). Health impacts of concentrations of exposure to NOX include reduced lung function PM10, O2, CO, SO2 and increased probability of respiratory symp- and NO in Bangkok. toms (WHO – Regional Office for Europe 2000). 2 Photo by Dominik Schmid, Bangkok, Thailand, 2010

3 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

3 in many cities) to 20 µg/m for PM10 (the WHO and weak public transport systems that often guidelines) would be expected to lead to a characterise developing city environments. reduction in mortality of 15 %. is estimated to contribute up to 30 % of PM in European cities (Krzyzanowski Burden of disease from air pollution in 2.5 et al., 2005), while experimental monitoring developing cities of PM2.5 concentrations in major developing Average concentrations of health-harming air cities has yielded contributions ranging between pollutants in major developing cities are esti- 12 % and 69 % (UNEP/WHO 2009). In many mated to far exceed those in developed cities of urban settings, transport is also a leading source comparable size (Figure 3). The worst levels of of other air pollutants, including: carbon mon- air pollution today are found in cities in Asia, oxide (CO), oxides of nitrogen, and benzene, as Africa and the Middle East. Air quality moni- well as contributing to the formation of ground- toring systems to measure air pollution expo- level ozone (Krzyzanowski et al., 2005). sures in developing cities are often still limited, and need to be improved to allow better analy- In Asian cities, transport has been estimated sis of local sources of air pollution, its impacts to contribute 40–98 % of total CO emissions on health, and scenario planning. and 32–85 % of total NOX emissions (Zhongan et al., 2002, IGES 2006, Haq 2002, Kebin Urban air pollution attributable to et al., 1996, Suksod 2001, ADB 2002a and transport 2002b, Benkhelifa et al., 2002). In Mexico City There has been no global systematic review of and São Paulo, mobile sources were estimated Figure 3 transport's contribution to urban air pollution. to comprise 97–98 % of CO emissions and 55–97 % of total NO emissions (Vincente de Average annual PM10 However, available data suggests that in devel- X concentrations in oping cities transport is a significant and grow- Assuncão 2002, Landa 2001). In Europe, vehi- urban areas between ing contributor to urban air pollution – often cles are the main contributors to NOX (Krzyz- 2003 and 2009: anowski et al., 2005). Micrograms/m3 (µg/m3) more so than in certain developed cities. This is in relation to WHO due to factors such as the age and composition Until recently, transport was a major con- recommended levels. of the vehicle fleet, poorer maintenance/regula- tributor to environmental lead exposure, a Source: WHO 2011a tory environments, as well as rapid motorisation highly toxic substance to , particularly

250

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4 Module 5g: Urban Transport and Health

children. While most countries have now 2.1.2 Road traffic injuries eliminated leaded gasoline, lead remains an Road traffic injuries cause 1.3 million deaths important transport-related hazard in countries per year globally (WHO 2008c), with up to 50 where it is still used. million people injured (Peden et al., 2004). The In many developing cities, a sizable proportion of burden of road traffic injuries is growing along transport-related air pollution emissions is from with increased motorisation. It is projected that – which may comprise up to 80 % by 2030 road traffic will account for nearly 5 % of the vehicle fleet e.g.( in the so-called “motor- of global disease burden, and rank as third- cycle cities” of Asia). Two stroke engine motor- highest cause of death overall (WHO 2008c). cycles emit particularly large proportions of CO, Around 90 % of road traffic injury disease burden occurs in low- and middle-income coun- NOX and PM per person-kilometre of travel. tries, which tend to have more hazardous travel Legislation replacing two-stroke engines with environments. Road traffic injury affects espe- four-stroke engine motorcywcles, as well as reg- cially young people, and it is the second highest ulations requiring regular engine maintenance, cause of death between ages 5 and 29 years. has, in some settings, significantly reduced pollution. However, the rapidly The correlation between vehicle kilometres trav- increasing volume of motorcycle and motor elled (VKT) and road safety is so strong (Figure vehicle traffic tends to outpace the impacts of 4) that VKT has even been proposed as a proxy such technological improvements, so that the indicator for road safety, particularly since traf- net gain in ambient air pollution reductions is fic injury statistics are often incomplete (Love- somewhat less. grove et al., 2007).

In addition, technological improvements do 16 not address the other health risks of motorcy- cles – traffic injury, noise emissions, and bar- 14 Rural riers motorcycles pose to healthier cycling and Urban walking. Strategies to reduce the dependence 12 on motorcycle transport in developing cities are therefore required alongside measures to 10 improve vehicle and fuel quality. Land use plans and traffic planning can make cycling 8 and walking alternatives more efficient and safe, and avoid the encroachment of vehicles into 6 spaced used by non-motorised transport modes. Additionally, policies encouraging development 4 R2 = 0.862 and use of electric bicycle technologies can be explored. Electric bicycle technologies combine Traf c Fatalities Per 100 000 Population 2 some of the advantages of motorcycle travel 0 (greater range and speed) with those of a bicycle 0 10 000 20 000 30 000 40 000 50 000 60 000 (clean fuel source and opportunities for moder- ate physical activity). All in all, an emphasis on Per Capital Annual Vehicle Mileage multi-modal transport development in cities is integral to air pollution mitigation strategies as well as to traffic demand management more Speed is a major risk factor for road traffic F igure 4 generally. injury – insofar as kinetic energy is a causative Vehicle miles agent of injury (Peden et al., 2004). Kinetic travelled and SUTP Air Quality Management Module ll energy is a function of mass and velocity, both road traffic injury Further information on how to tackle air pol- of which are usually higher in the case of motor mortality (USA), lution issues can be found in SUTP Module vehicles than for walkers and cyclists. The risk 1993–2002. Source: Litman and Fitzroy 2011 5a (Air Quality Management), available for of death for a struck in a 50 km/h download at http://www.sutp.org. collision is about eight times higher than that of

5 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

a pedestrian in a 30 km/h collision (Dora and higher (Elvik and Mysen 1999). Road traffic Phillips 2000). injuries are also caused by factors such as the Walkers and cyclists are more likely than motor use of alcohol, medicinal or recreational drugs, vehicle occupants to be injured if a crash occurs, the use of hand held mobile phones, or the dis- and are typically described as “vulnerable road regard for personal protective equipment like users”. Other vulnerable road users include chil- helmets (for cyclists) or seat belts. Other factors dren, the elderly and motorcyclists (Peden et al., affecting road traffic injuries include design of 2004). Higher traffic volumes are a particularly the street environment, pedestrian and cycling strong risk factor for child pedestrian injury, spaces and facilities, as well as enforcement of and falls in traffic volumes have previously legislation. been accompanied by falling child pedestrian Despite the scale of the problem, road traffic deaths (Peden et al., 2004). Motorcycles are a injury is largely predictable and preventable particularly important factor in injuries in low- (Peden et al., 2004). However, effective meas- income cities, where they may be the dominant ures to address risks cannot rely solely upon mode of motorised transport. In Delhi, 75 % of modifying individual behaviour alone. Rather, road traffic injury deaths have been estimated the traffic system needs to be designed in a to involve , cyclists and users of way that helps users to cope with increasingly demanding conditions. The vulnerability of the human body should be a limiting design param- eter for the traffic system. Traffic calming interventions that reduce speed, including 20 mph urban residential zones, physical barriers and pavement design, have also been shown to significantly reduce injury rates (Bunn et al., 2003, Grundy et al., 2009). Traffic interventions that reduce speed can also remove safety barriers to active travel – thus helping reduce car use, and further reducing both inju- ries and emissions. Figure 5a/b Additionally, greater emphasis on public trans- Motorised two- port can help improve the safety of the trans- wheelers have a high port system. In comparison to private vehicles, modal share in many developing cities, and are frequently used to transport numerous family members, including children, without proper safety measures such as helmets. Photos by Santosh Kodukula, Delhi, India, 2008

motorised two- and three-wheelers (UNEP/ WHO 2009). Globally, a WHO survey found that these vul- nerable road users accounted for 46 % of road traffic deaths (WHO 2009b). However, crashes F igure 6 involving pedestrians or cyclists are poorly Elderly people are among the reported in official road traffic injury statistics, most vulnerable groups. so actual injuries in these groups may be even Photo by Carlos F. Pardo, Pereira, Brazil, 2007

6 Module 5g: Urban Transport and Health

rail and bus transport are often the safest mode Figure 7 of travel per kilometre. The risk of Speed limits injury for bus users in the United States, for and dedicated instance, is much lower than the risk to car infrastructure for non- users (Beck et al., 2007). motorised transport modes help to reduce Poor road safety tends to perpetuate a “vicious risks for pedestrians cycle” which deters many pedestrians and and cyclists. cyclists while improving road safety can encour- Photo by Jeroen Buis, Rio age a “virtuous cycle” that encourages more de Janeiro, Brazil, 2007 walking and cycling. Traffic calming measures that slow motor vehicle speeds, for instance, are associated with increased walking and cycling (Cervero et al., 2009, Centers for Disease Con- trol and Prevention 2000). Improving road safety by reducing traffic volumes and speeds are thus important ways to both help prevent injury and also to encourage healthy physical activity. Increased numbers of walkers and cyclists may also lead to a “safety in numbers” effect, since reduce road traffic injury risk, but also fuel con- higher walking and cycling rates are associated sumption and thus GHG emissions (Kahn et al., with lower per capita injury risks for walkers 2007). Enforcement of a speed limit reduction and cyclists (Jacobsen 2003, Robinson 2005). from 100 km/h to 80 km/h in the Netherlands However, this association could also plausibly lowered PM10 emissions by 5–25 % and NOX be due to environmental improvements in the emissions by 5–30 % (Keuken et al., 2010), system. In addition, while more walking or while air quality monitoring showed reductions cycling may be associated with a lower risk per in PM10 and PM1 concentrations (Dijkema et al., walker or cyclist, the total number of injuries 2008). may still increase due to the larger volume of SUTP Road Safety Module walkers and cyclists, who remain at a higher ll injury risk than car drivers (Bhatia and Wier Revised in early 2011, the SUTP Sourcebook 2011, Elvik 2009). This underlines the need to Module 5b (Urban Road Safety) presents ensure that measures increasing walking and up-to-date figures on the challenge of cycling are accompanied by strong environmen- road safety in developing cities, and out- lines measures to address the problem. To tal measures (such as reducing motor vehicle find out more, download the document at speeds and volumes) to prevent injury among http://www.sutp.org. these vulnerable road users. Overall, strategies that reduce the need for pri- 2.1.3 Lack of physical activity, vate motor vehicles improve public transport obesity and non-communicable services and encourage walking and cycling, diseases are recommended as key road safety actions for Lack of physical activity is responsible for over . “Smart growth” land use policies three million deaths per year globally (WHO that support compact, mixed use, urban devel- 2009a). It is a leading risk factor for poor health, opment also helps to reduce the need to travel and is one of the factors global increases longer distances; this in turn may also reduce in major causes of death and illness such as car- the extent to which people are exposed to the diovascular disease, type II diabetes and some risk of road traffic injury (Peden et al., 2004). types of cancer. These non-communicable dis- Many recommended strategies to prevent road eases (NCD) are no longer just major contribu- traffic injury also have the potential to reduce tors to disease burden in developed countries. In greenhouse gas emissions (GHGs). For instance, fact, most deaths from non-communicable dis- speed reductions on motorways can not only eases now occur in developing countries (WHO

7 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

2004). Rising rates of overweight and obesity in respiratory rate and travel times. This expo- are one consequence of inactivity, but physical sure is likely to be dependent on route taken (e.g. activity has health benefits regardless of whether bike paths through parks) as well as on local or not a person is obese (Hu et al., 2005). traffic conditions, weather and emissions. Active transportation (e.g. walking and cycling Likewise, risk of traffic injury is a problem for to work or daily destinations) is an important pedestrians and cyclists in most settings, as they means of incorporating more physical activity lack the protective shield of an automobile. Yet into people’s lives (WHO 2006b, Branca et al., overall, in cities and settings where air pollution 2007, Cavill et al., 2006, Boone–Heinonen et rates are comparatively lower and well-defined al., 2009). In fact, a recent WHO systematic pedestrian/cycle paths, and pedestrian/ review of health literature found that one of the cycle right-of-ways exist, the evidence shows most effective means of encouraging physical that health benefits from walking and cycling activity generally was through transport and far outweigh its risks (WHO 2008b, de Hartog urban planning policies (WHO 2009c). et al., 2010, Andersen LB et al., 2000, Mat- thews et al., 2007). For example, estimates for There is also a growing body of scientific the population identified research which has found that people commut- 20 fold larger health benefits from increasing ing by bicycle live longer lives and have less car- cycling for transport, after considering the phys- diovascular diseases than people who commute ical activity benefits and the risks from injuries by motor vehicles (WHO 2004). Two long- and air pollution (Rutter 2006, Hillman et al., term studies, for instance, in Copenhagen and 1990). In car-oriented developed cities and in Shanghai, found that the annual mortality rates developing cities with heavy mixed traffic vol- of cyclist commuters were 30 % lower, on aver- umes, aggressive air pollution and traffic injury age, than commuters who did not travel actively mitigation measures are particularly important or exercise regularly (Andersen et al., 2000, to minimise the risks of active travel. Matthews et al., 2007). Evidence from system- Countries with a higher proportion of trips atic review has also shown that walking reduces made by walking, cycling or public trans- et al., cardiovascular disease (Boone–Heinonen port also have lower obesity rates on average, 2009), and that physical activity more gener- although such studies do not demonstrate cau- ally also improves many other facets of health sality (Bassett et al., 2008). A very wide range (Table 2). of confounding variables must also be con- Along with the positive aspects of active trans- sidered in terms of diet, culture, development, port, there may be drawbacks. For instance, etc. Outdoor physical activity, such as walking people walking or cycling in polluted urban and cycling, may be particularly important, as areas may experience higher air pollution expo- sunlight exposure can increase people’s vitamin sures as compared with car users due to changes D levels, which is associated with reduced risks

Table 2: Health effects associated with physical activity Lower all-cause mortality** Less coronary heart disease** Less high blood ** Less stroke** Less type 2 diabetes** Less metabolic syndrome** Less colon cancer** Less breast cancer** Less depression** Better fitness** Better body mass index and body composition** More favourable biomarker profile for preventing cardiovascular disease, type 2 diabetes and bone health** Better functional health in older adults** Better quality sleep* Less risk of falls in older adults** Better health-related quality of life* Better cognitive function** Key: **: strong evidence; *: modest evidence. Source: U.S. Department of Health and Human Services (2008)

8 Module 5g: Urban Transport and Health

of cardiovascular disease, type 2 diabetes and Figure 8a/b5 some cancers (Pearce and Cheetham 2010). As Transport infrastructure occupies an increasing share of urban space, while high sun exposure also increases risks to health recreational facilities are hard to find in many developing cities: Urban from ultraviolet radiation (such as skin cancers) highways (above) and the popular Lumpini park (below) in Bangkok. a balanced approach is needed. Overall, access Photos by Dominik Schmid, Bangkok, Thailand, 2010 to outdoor activities and urban green spaces can F igure 96 thus help to maintain both physical activity and vitamin D levels for urban residents. Compared Traffic is the most serious source of with motorised transport, walking and cycling noise in many developing cities. Photo by Andreas Rau, Beijing, PRC, 2009 improve health both through reduced air pollu- tion emissions and through physical activity.

2.1.4 Noise Road traffic is the biggest cause of community noise in most cities. Noise levels are increased by both higher traffic volumes and higher traffic speeds, with the level of human exposure also determined by other factors such as the proxim- ity of the source of noise (Berglund et al., 2004). Community noise exposure has a range of health effects. As well as more general effects such as causing annoyance, noise is linked to stress levels and increased blood pressure. There is increasing evidence that noise-induced stress raises the risk of cardiovascular disease, and noise may also have negative effects on mental health (Berglund et al., 2004, Moudon 2009, Babisch W. 2008). It also leads to annoyance

9 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

and sleep disturbance. Children living in areas Some strategies to reduce noise exposure can of high aircraft noise have been shown to have reduce both health impacts and emissions, such delayed reading age, poor attention levels and as reducing traffic volumes. Other measures to high stress levels (Haines et al., 2001), and high reduce community noise levels, such as lowering levels of road traffic noise have been associated traffic speeds and diverting traffic away from with impaired reading and mathematics perfor- residential streets, can help remove safety bar- mance (Ljung et al., 2009). riers to active transport in neighbourhoods, so An assessment of the burden of disease from may indirectly reduce emissions by promoting environmental noise concluded that traffic- mode shift towards walking and cycling. related noise accounts for over 1 million healthy SUTP Noise Module years of life lost annually to ill health, disability ll Figure 10a/b or early death in the Western Europe countries. In-depth information on policies to reduce This burden was due to annoyance and sleep traffic noise are outlined in SUTP Module Transport-related disturbance but also to heart attacks, learning 5c (Noise and its Abatement), which will be well-to- disabilities and tinnitus (WHO – Regional available at http://www.sutp.org in revised CO2 emissions by form by the end of 2011. mode (above) and Office for Europe 2011). region (below). Source: WBCSD 2004 2.1.5 Climate change, transport and health Climate change poses major risks to health Gigatonnes CO2-Equivalent GHG Emissions/Year through a range of pathways. Extreme weather 15 Total events, such as heat waves, floods, droughts Two- + Three-Wheelers and storms are becoming more frequent and 12 Buses intense (Costello et al., 2009). Some infections, Freight + Passenger Rail especially vector-borne diseases carried by mos- Water 9 quitoes, other insects and snails (e.g. schistoso- Air miasis), are changing their geographical distri- Freight Trucks bution in response to changing temperature and 6 Light Duty Vehicles climate zones. Climate-induced water and food shortages resulting from reduced agricultural 3 production in drought-prone areas of Africa and elsewhere may, in turn, precipitate population 0 displacement and conflict (WHO 2009d). 2000 2010 2020 2030 2040 2050 Transport is a leading contributor to greenhouse gas emissions. As well as accounting for 24 % of global energy-related emissions, growth in Gigatonnes CO2-Equivalent GHG Emissions/Year energy use is higher for the transport sector

15 Total than any other end-use sector. About 80 % of Eastern Europe transport energy use is due to land transport,

12 Middle East with most of this attributable to light-duty vehi- Africa cles (LDVs) including cars, followed by freight Former Soviet Union 9 transport (Kahn et al., 2007). As land transport OECD Paci c leads to more health impacts than shipping and India , and also accounts for the majority of 6 Latin America emissions, this report focuses on land transport. Other Asia

3 OECD Europe The potential for present-day emission reduc- China tions is highest in high-income countries, which OECD North America 0 have the highest per-capita transport emis- 2000 2010 2020 2030 2040 2050 sions. However, many developing countries are undergoing rapid motorisation (Figure 10a/b),

10 Module 5g: Urban Transport and Health

making mitigation strate- Table 3: GHG emissions from vehicles and transport modes in developing countries gies increasingly important in developing countries for Load factor CO2-eq emissions per passenger-km limiting future emissions. In (average occupancy) (full energy cycle) many developing countries, Car (gasoline) 2.5 130 – 170 however, even preserving the Car (diesel) 2.5 85 – 120 current mode share of walking, Car (natural gas) 2.5 100 – 135 cycling and public transport Car (electric)a 2.0 30 – 100 is likely to require substantial Scooter (two-stroke) 1.5 60 – 90 efforts. An important underly- Scooter (four-stroke) 1.5 40 – 60 ing principle, however, is that Minibus (gasoline) 12.0 50 – 70 potential health co-benefits of well-designed transport miti- Minibus (diesel) 12.0 40 – 60 gation strategies are as impor- Bus (diesel) 40.0 20 – 30 tant in developing countries as Bus (natural gas) 40.0 25 – 35 in developed countries, along Bus (hydrogen fuel cell)b 40.0 15 – 25 with their potential to reduce Rail transitc 75 % full 20 – 50 emissions or prevent future Note: All numbers in this table are estimates and approximations and are best treated as illustrative. emissions increases. a) Ranges are due largely to varying mixes of carbon and non-carbon energy sources (ranging from about 20–80 % coal), and also to the assumption that battery electric vehicles tend to be smaller than Some indicative ranges of conventional cars. CO2-eq emissions by travel b) Hydrogen is assumed to be made from natural gas. mode in developing countries c) Assumes heavy urban rail (“metro”) powered by electricity generated from a mix of coal, are noted in Table 3. Actual natural gas and hydropower, with high passenger use (75 % of seats filled on average). emissions per passenger kilo- Source: Kahn et al., 2007, Table 5.4. metre are strongly influenced by the age and type of vehicle, by urban and rural driving conditions, and by type and qual- ity of fuel used. Actual emissions also are highly dependent on occupancy rates and, in the case of electric or rail, electricity generation methods. However, the table illustrates that, when operating at full or near-full capacity, rail and bus modes typically emit less greenhouse gasses as well as other types of local emissions (per passenger kilometre of travel) than private motorised travel. Walking and cycling emit no pollution at all.

SUTP Climate Change Module ll Detailed information on instruments avail- able to achieve GHG emission reductions in the transport sector can be found in SUTP Module 5e (Transport and Climate Change) at http://www.sutp.org.

11 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

2.1.6 Land use, access, social well- typically results from this expansion of roads being and other factors and highways in cities or on the periphery, or Land use change is one of the profound impacts between destinations. of transport, which in turn affects health By influencing these broader land use pat- directly and indirectly. Directly, expansion of terns, transport also impacts profoundly on road systems tends to stimulate more energy a wide range of health determinants (WHO intensive modes of travel, as compared to rail 2010). When road-oriented development occurs, or exclusive bus corridors, and thus stimulates a “vicious cycle” of increased dependence on more pollution of air and water. Indirectly, vehicle transport emerges, leading to less active road-oriented expansion in and around the transport, more sedentary lifestyles – and urban periphery, as well as in between major related diseases. cities reinforces car dependence. Land use planning can be seen as a process This is because cars and the roads they travel to ‘facilitate allocation of land to the uses on are intensive consumers of space. Compared that provide the greatest sustainable benefits’ with active travel or public transport, road-ori- (United Nations 1992). By trying to improve ented development increases the amount of land the proximity of people to their potential des- needed for car access and parking in, around tinations, land use planning can reduce the Figure 11 and between key commercial, office and resi- distance that needs to be travelled by motorised Urban density and dential destinations. This, in turn, makes walk- transport and improve the feasibility of using transport-related ing, cycling and even public transport far less non-motorised transport (Frank et al., 2010). energy consumption. efficient. It also reduces the land available for Another important task for smart land use plan- Source: Newman & Kenworthy 1989, via UNEP other uses such as green spaces. ning is to increase the land available for green space. Access to green spaces is associated with Transport-related energy consumption longer life expectancy (Takano et al., 2002). For Gigajoules per capita per year instance, green spaces appear to buffer people’s 80 mental health during stressful life events (van den Berg et al., 2010), and may also help ame- Houston liorate the “heat island” effect of cities, promot- 70 Phoenix ing resilience to the effects of climate change Detroit Urban density and (Lafortezza et al., 2009). Denver 60 transport-related Patterns of land use also influence the geo- Los Angeles energy consumption graphic proximity of homes and to San Francisco Boston transport hazards such as air pollution, noise 50 Washington Chicago and pedestrian injury. The negative health impacts of transport tend to be concentrated New York along busy roads and in inner-city areas with 40 high traffic density so people living and working Toronto in such areas are naturally more exposed, unless Perth North American cities 30 Brisbane mitigating measures are adopted (Dora and Melbourne Australian cities Sydney Phillips 2000). Cities with higher road capacity European cities Hamburg appear more hazardous to health, with higher Stockholm Asian cities 20 Frankfurt air pollutant levels and more road traffic injuries. Zurich These cities also have much higher transport- Paris Brussels London Munich West Berlin related greenhouse gas emissions per capita 10 Vienna Copenhagen Tokyo (Kenworthy and Laube 2002). Amsterdam Singapore Hong Kong Land use factors also are associated with child Moscow 0 and youth obesity and, in some studies, with 0 25 50 75 100 125 150 200 250 300 adult obesity (Dunton et al., 2009). Conversely, Urban density inhabitants per hectare more compact and mixed land use can be a policy tool promoting better health in terms of

12 Module 5g: Urban Transport and Health

more physical activity. This issue is explored fur- ther in Section 3. Travel in and of itself can be stressful, and heart attacks have been associated with exposure to traffic (Peters et al., 2004). While it makes sense that driving in congested traffic is stressful, long commutes by rail can also lead to stress (Evans and Wener 2006). Reducing public transport travel times, such as by buses on exclu- sive rights-of-way rather than in mixed traffic (VTPI 2010c), as well as other public transport improvements, may help reduce stress, particularly for the poor who often face long commutes, but also for the more affluent. Land use planning that increases proximity and reduces public transit commuting times, not only facilitates active travel and improves access, but also can help reduce stress levels. outpace the ability of cities to provide infra- Figure 12 structure. While residents of slums may benefit Long commuting There is some research to show that neighbour- from low housing costs and relative proximity times in crowded hoods based around active transport also are to employment opportunities, living conditions may lead to more socially cohesive. Residents on low-traffic are otherwise poor. Healthy cities need to be increased stress levels. streets are more connected to their neighbours Photo by Andreas Rau, inclusive, and strive to ensure that people from Hong Kong, 2007 (Appleyard and Lintell 1972) and more “walk- all income groups have access to adequate hous- able” communities have stronger social capital ing, water and sanitation, decent employment (Leyden 2003). As well as representing social opportunities and other basic human needs. well-being, more social networks and social cap- ital are associated with better health (Kawachi It is increasingly recognised that employment, and Berkman 2001, Kawachi et al., 1999). education, income, health care, public ser- vices and other social factors are all important Active transport can be encouraged or deterred influences on health. Collectively, these are by levels of street crime (Seedat et al., 2006), referred to as social determinants of health and patterns of land use and active transport (WHO 2008a). Transport systems and land may also influence crime rates. Rates of street use patterns strongly influence whether access crime are typically lower in locations with to these opportunities is available to all people, mixed land use and appropriate design treat- or only to those with a car. For example, lack ments (Cozens et al., 2003, Jacobs 1961, Mohan of geographical accessibility of employment 2007). In the United States, where patterns of opportunities was associated with a high risk sprawl are very pronounced, higher residential of unemployment in a US study, as was lack of densities are associated with both fewer homi- car ownership (Cervero et al., 1999). Ensuring cides and also fewer road traffic deaths – this is non-motorised access to goods, services and despite the common perception that cities are other health needs can also reduce greenhouse more dangerous than suburbs as places to live (Lucy 2003). gas emissions as well as impacting on the social determinants of health. Rapid horizontal growth of cities in developing countries has coincided with very considerable 2.2 Groups at higher risk of health slum expansion on the urban periphery. Nearly 40 % of the world's urban growth is occur- impacts from transport ring in slums (UN Habitat 2006). These are Major social differences in health exist within largely unplanned and lack basic infrastructure cities (Kahn et al., 2007). And the benefits and and accessibility to key services (WHO 2010). hazards from transport systems are often dis- Horizontal urban growth, if unrestrained, can tributed unevenly between disadvantaged and

13 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

privileged social groups. Additionally, certain among residents of developing countries. Some population groups are particularly vulnerable to African countries also continue to use leaded the health risks of transport. As already noted, gasoline (UNEP/WHO 2009). Thus, without children, the elderly, and disabled people are at appropriate policies, low- and middle-income higher risk of traffic injury. Walkers and cyclists countries risk being “pollution havens” for older also have higher injury rates than car occupants and dirtier but also cheaper vehicles and fuels. (Peden et al., 2004). In the case of air pollution, people exposed to 2.3 Regional overview of health impacts higher levels of air pollution tend to be of lower from transport socioeconomic status compared with the urban Trends in travel are important determinants population as a whole (WHO 2006a). Deprived of the future progression of the global NCD communities tend to suffer disproportionately epidemic in developed as well as developing from pedestrian deaths from crashes, and from countries. NCDs are already the leading cause social isolation due to the effects of busy roads of death in most developed countries, although dividing communities (SEU 2002). These same in absolute terms, 80 % of NCD deaths are now vehicle-related hazards are created dispropor- occurring in low- and middle-income countries, tionately by high-income groups, among whom which are experiencing a surge in NCDs as car ownership is higher. well (Beaglehole et al., 2011). By 2030, NCDs Active transport (walking and cycling) is gener- are expected to cause over three-quarters of all ally free or low-cost, while motorised transport, deaths globally (WHO 2008e). especially private car use, is typically much As noted previously, transport is closely associ- more expensive (UNEP/WHO 2009). Accord- ated with the development of many NCDs, ing to economic theory and the income elastic- including cardiovascular conditions caused ity of demand, high prices disproportionately by air pollution and traffic injury. Addition- reduce consumption for low-income groups; ally, transport-related physical – from walking, thus financial barriers to motorised transport cycling or accessing public transport – helps are relatively higher for low-income populations. prevent many NCDs, including coronary heart Cities that require private motorised transport disease, stroke, type 2 diabetes and some can- to access essential goods, services and other cers (U.S. Department of Health and Human health needs implicitly favour high-income Services 2008). Globally, growth in transport groups. Investment in roads disproportionately sector energy use is higher than any other end- benefits the well-off, while active, non-motor- use sector making it a major contributor to ised transport and low-cost public transport are climate change. This section examines a few key more evenly accessible across social groups. aspects of travel trends in developed as com- Social inequities also exist at global scale. Many pared to developing countries, with an eye to new transport technologies will be more expen- how those trends impact key transport-related sive than existing technologies (Kahn et al., NCDs and health. 2007). Thus newer, cleaner vehicles are likely to 2.3.1 Organisation of Economic be adopted first in high-income settings, with Co-operation and Development poorer communities the last to benefit from (OECD) countries technology-related vehicle pollution reductions. Older, more polluting vehicles that are exported In general, higher gross domestic product from developed to developing countries pose (GDP) per capita is strongly associated with particular health risks. Resale of such vehicles increased vehicle use and ownership, whether of at low prices has facilitated their mass export cars, two-wheelers or small commercial vehicles. to low-income countries and cities that lack However, there remains a wide variance in levels infrastructure and capacity for adequate vehicle of car use among OECD countries. Only about maintenance as well as control of fuel quality 50 % of total trips are made by automobile in (Davis and Kahn 2010). This contributes to Western Europe as compared with 90 % in the high air pollution exposures and injury rates United States (Kahn et al., 2007). Additionally,

14 Module 5g: Urban Transport and Health

urban walking and cycling may comprise as in the energy efficiency of vehicles (EEA 2010a). much as 25–30 % of travel in many western The relationship between traffic volumes, air European cities (e.g. Amsterdam, Copenhagen, pollution and other health risks such as road and Zurich). traffic injuries means that, all else being equal, Thirty years of experience with air quality increases in motorised traffic still are likely to regulations, improvements in vehicle and fuel adversely affect health. technologies, and improved transport demand In addition, emissions of health-damaging management, including investment in rail, bus, small particles (PM10, PM2.5) per unit of travel pedestrian and cycle systems, have all contrib- have increased over the last decade as a result of uted to stable, and in some cases, reduced pol- market shifts from gasoline- to diesel-powered lutant emissions in European countries. Emis- engines. This is considered to be a cause of stable sions of particulate matter decreased by 30 % in (rather than lower) PM10 levels in European cities European Economic Area (EEA) member coun- in the last decade and thus no decline in the tries from 1990–2007, considered to be largely health impacts of urban air pollution – despite due to the increasing prevalence of catalytic diesel technologies becoming cleaner. converters and other technological improve- In European conditions, where new diesel tech- ments (EEA 2010b). However, certain gains nologies are used, buses may even rival electric from technological improvements were offset rail modes for their low emissions of PM10 and by increases in private vehicle travel in many other air pollutants (e.g. CO2) – particularly in European countries. For example, European medium distance journeys of 10–250 km. In transport sector greenhouse gas emissions grew short journeys under 10 km, however, electric by 28 % from 1990–2007; this was attributed rail modes appear, on average, to be the least to overall traffic growth despite improvements polluting per passenger kilometre of travel.

35 Intentional injuries Other unintentional injuries

30 Road tra c accidents Other noncommunicable diseases 25 Cancers Cardiovascular disease Maternal, perinatal 20 and nutritional conditions Other infectious diseases HIV, TB and malaria 15 ths (m illion s) Dea ths

10 Figure 13 Projected deaths by cause for high-, 5 middle- and low- income countries. Most deaths are due to cardiovascular disease, 0 cancers and other 2004 2015 2030 2004 2015 2030 2004 2015 2030 non-communicable High income Middle income Low income diseases (NCDs) Source: WHO 2008e

15 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

2.3.2 Developing countries converters can be as clean as cars. In Dhaka, In developing countries, automobile travel Bangladesh, a significant decline was observed accounts for only 15–30 % of total urban trips in airborne concentrations of fine particulates made, much less than in OECD countries. at two experimental monitoring sites follow- Non-urban vehicle travel is also much lower in ing new policies that removed non-OECD compared with OECD countries two-stroke engines from the road and began to (OECD 2009). By 2030, however, under “busi- upgrade or convert diesel trucks and buses to ness as usual” scenarios, the number of vehicles cleaner fuels, e.g. compressed natural gas (CNG) in developing nations is projected to exceed (UNDP/World Bank-ESMAP 2004). the number in developed countries (Wright Urban population growth, due to rural-urban and Fulton 2005). The number of light-duty migration, is another key driver of trends in vehicles is projected to triple between 2000 and developing cities. Most of the world’s projected 2050, with developing country demand as the population growth between 2000 and 2030 will major driver (Kahn et al., 2007). Such increases occur in low and middle income cities (de Jong in motorisation have generally been associated 2002, Tudor-Locke et al., 2003). As noted in with increased emissions of urban air pollutants the land use section, much of this growth is hor- and climate change gases, increased road traffic izontal, low-density, which stimulates car use injury and lower rates of physical activity. (Frumkin 2002, Begum et al., 2006) and trans- Soaring growth in vehicle traffic is already a port-related energy consumption (Figure 11) major factor in high developing city air pol- (Newman and Kenworthy 1989). Population lution concentrations. Growth in motorised growth also contributes to numbers of people travel is also becoming an increasingly impor- exposed to traffic-related risks. In developing tant factor in developing country greenhouse countries, other drivers of increases in motorisa- gas emissions. Although these problems can tion may include marketing of motor vehicles, be offset to some extent by improvements in the role of cars as indicators of high social status, vehicle and road design, vehicles exported to and aspirations to affluent lifestyles (of which developing countries are often older and more car use is regarded as a component). polluting (Davis and Kahn 2010). Surges in private motorised travel are often In developing countries, diesel vehicles are an responsible for displacing other, healthier modes even more significant source of vehicle-related of travel. Walkers and cyclists, particularly particulate emissions. This is particularly the those in ‘mixed’ traffic where motor vehicles are case for older trucks and buses which may be also present, are often put at risk by increases in poorly-maintained. Motorcycles and three- traffic volumes and insufficient infrastructure wheeled vehicles powered by old fashioned two- providing for safe walking and cycling. The stroke engines also represent a disproportionate dearth of clean, safe, rapid and efficient bus or share of particulate emissions due to lower fuel rail transit in many cities may give residents no efficiency, as compared with conventional four- choice but to use motor vehicles – if they can stroke engines. However, modern three-wheeled afford it. The alternative is long and difficult vehicles using four-stroke engines with catalytic commutes on foot, bicycle, and crowded trains or buses, involving significant risks to health Table 4: Growth in transport in developed and developing countries and safety. Urban policies and investments that OECD OECD Non-OECD favour private motor vehicles over other modes Indicator (1980-1995) (1995-2010) (1995-2010) thus impose a “triple health penalty” on the car- Population +13 % + 8 % +24 % less – increasing their risks of air pollution and injury exposure as well as barriers to mobility/ GDP +44 % +35 % +123 % access. Vehicle stock +50 % +33 % +76 % Monitoring of transport-related health risks in Vehicle kilometres travelled (VKT) +65 % +42 % +70 % developing countries can be impeded by a lack Road fuel +37 % +21 % +55 % of data and basic information systems. Cur- Source: OECD 2001; IPCC 2000a; ICAO 2005. Includes historical and projected figures. rent travel mode share data is limited in these

16 Module 5g: Urban Transport and Health

countries, and may not capture all relevant forms of transport. For example, public trans- 3. Instruments: port counts may include only publicly-provided tackling the problem transport, whereas informal modes such as privately-owned buses, minibuses and converted 3.1 Policies for healthy transport pick-up trucks are frequently used by poorer 3.1.1 Improving land use planning populations due to their affordability and rela- There is a large body of research examining tive convenience, despite the lack of safety pre- potential links between land use planning and et cautions associated with these modes (Peden health. These links have been summarised in al., 2004). key reviews in the following ways: The experience in the 2008 Beijing Olympics „„ Urban form characteristics most associated provides a vivid case study of the contribu- with physical activity: 1) mixed land use and tion of traffic to urban air pollution exposures, density; 2) footpaths, cycleways and facilities and health impacts in developing . for physical activity; 3) street connectivity During the Games, stringent restrictions on and design; 4) and transport infrastructure motor vehicle use were imposed to improve air that links residential, commercial and busi- quality. Compared with the period where there ness areas (NSW Centre for Overweight and were no measures to improve air quality, asthma Obesity 2005). outpatient visits were almost halved (Li et al., „„ Community- and street-scale urban design 2010), and PM10 concentrations were reduced by and land-use policies and practices effective between 9 % and 27 % (Wang et al., 2009). at promoting physical activity (Heath et al., 2006). „„ A wider range of physical activity and/or walking determinants including: physical activity facilities, access to destinations, high residential density, land use, and urban ‘walkability’ scores (National Institute of Health and Clinical Excellence 2007). Overall, it can be concluded that land use planning that promotes good health tends to involve 1) higher density of residents and ameni- ties, 2) mixed residential and commercial land use planning, and 3) good street design that

F igure 14 Smart land use planning fosters infrastructure for cyclists and pedestrians, which in turn encourages healthy modes of travel and physical activity for leisure: Urban dwellers along the shoreline in Rio de Janeiro. Photo by Carlos F. Pardo, Rio de Janeiro, Brazil, 2007

17 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

maximises connectivity for walkers and cyclists. from car use towards walking and cycling, by These categories are sometimes known as “the making residential areas safer. 3Ds of urban design”. SUTP Land Use Module Good urban land use planning for physical ll activity can synergistically address other trans- The relationships between land-use struc- port-related health risks, generating double or tures and transport are examined in more triple health benefits. As illustrated by Figure detail in SUTP Module 2a (Land Use Plan- 11, higher urban densities are also strongly asso- ning and Urban Transport), available at http://www.sutp.org. ciated with reduced transport-related energy use, primarily from private motor vehicle travel. 3.1.2 Facilitating healthy transport Traffic volumes are also one of the most impor- modes tant influences on emissions of air pollutants, road traffic injuries and community noise levels. Different transport modes have different pat- Thus, cities and communities that are designed terns of health risks. As already noted, a large to enable access to important destinations with- number of studies show that non-motorised out the use of private motor vehicles can reduce travel (walking and cycling) is associated with air pollution and injuries as well as improving more physical activity, reduced obesity and, in physical activity levels. the case of cycle commuting, significantly lower overall rates of average annual mortality. Public In the absence of clean and efficient public transport use is also associated with more physi- transport and traffic-calming measures, how- cal activity and less obesity, since public trans- ever, higher urban densities may also increase port services are often accessed by walking and exposures and risks from air pollution, noise and cycling. road traffic injury, due to greater concentrations of traffic. This has been dubbed the ‘paradox of Public transport users also have the lowest, on intensification’, and suggests that to optimise average, risk of injury, as compared to other health, residential intensification needs to be modes of travel. However, while walkers and accompanied by effective measures to constrain cyclists generate few risks to other road users, car use in intensifying areas (Melia et al., 2011). they are exposed to higher risks of traffic injury than motor vehicle . These injury Two other land use factors are also consist- risks vary considerably depending on the ently associated with health. The presence of design of the city, volume of cycle/pedestrian more green and open spaces, parks and sports grounds is associated with a range of improved traffic, and the quality of cycle and pedestrian health outcomes in a large number of studies. networks. Likewise, the presence of more green spaces and In contrast, car use is associated with less physi- better aesthetic features in neighbourhoods is cal activity and more obesity. Increased motor associated with higher levels of physical activ- vehicle travel increases emissions of air pollut- ity (Melia et al., 2011, Kaczynski 2010, King ants, as well as risks of injury to other road users. et al., 2006, Lee and Moudon 2008, Troped et In contrast, walkers and cyclists do not emit air al., 2003) and active travel generally (Ishii et pollutants, and pose minimal risk of injury to al., 2010, Kerr et al., 2006, Larsen et al., 2009, other road users. Titze et al., 2010). In well-designed cities, the available evidence One land use strategy for reducing the health suggests a hierarchy of travel modes with impacts of air pollution is to reduce the proxim- respect to their net health impacts, with non- ity of motor vehicles to people (Krzyzanowski et motorised transport (walking and cycling) as al., 2005). This can be done by limiting traffic the most beneficial, public transport intermedi- in areas of high population density, or where ate; and private motorised transport the most vulnerable road users are present. Since heavy harmful to health. The same ordering applies to traffic also tends to discourage walking and greenhouse emissions, with private motorised cycling due to safety concerns, separation of transport having the highest emissions, and motor vehicles may indirectly facilitate a shift non-motorised transport having essentially zero

18 Module 5g: Urban Transport and Health

emissions. This relative desirability of differ- al., 2007). In other words, separating emission Figure 15a/b ent travel modes should thus be a cornerstone sources from people can improve health. Public transportation of transport policy for both health and climate However, total emissions attributable to electric and non-motorised change reasons, accompanied by land use plan- vehicles will nonetheless vary, depending on the transport are most beneficial with regard ning that preferentially enables access for users source of electricity generation. For instance, of the most desirable travel modes. An exam- to health impacts. vehicles powered by fossil fuel electricity from a Photo by Carlos F. Pardo, ple of this in practice is the development of a Pereira, Brazil, 2007 (left) and coal-fired power plant would be less beneficial Andrea Broaddus, Amsterdam, hierarchy of transport users to guide planning to health and to climate than vehicles powered Netherlands, 2010 (right) decisions, such as used by York in the United by electricity from cleaner power sources, such Kingdom (WHO 2006b). as natural-gas. And vehicles powered primarily SUTP Non-Motorised Transport Module by rechargeable solar batteries would generate ll the lowest levels both of greenhouse gases and How to foster cycling and walking and urban air pollution emissions. Also, emissions increasing their share in the modal split is from fuel combustion alone also do not consider discussed in SUTP Module 3d (Preserving the life-cycle impacts of electric car manufac- and Expanding the Role of Non-Motorised ture on GHGs, which are considerable, when Transport), available at http://www.sutp.org. compared to those of bicycle manufacture, for example. 3.1.3 Improving vehicles and fuels Biofuels are increasingly being encouraged as a Improved vehicle efficiency, and other tech- way to reduce transport-related greenhouse gas nologies that reduce pollutant emissions, can emissions. However, the effects of different bio- improve population health. In the United States, fuels on different air pollutants remain unclear. the Clean Air Act of 1970 has been credited A comparison of cellulosic and corn ethanol with reducing the proportion of cancers and with gasoline found that while cellulosic etha- cardiovascular diseases attributable to air pol- nol could reduce PM and greenhouse gas lution emissions from energy combustion; 2.5 emissions, corn ethanol may increase PM2.5 improved vehicle and fuel technologies were an emissions without reducing greenhouse gas important means of achieving those emissions emissions (Hill et al., 2009). Indirect impacts reductions (Gallagher et al., 2009, 2010). of biofuel production on health are also poten- A few decades later, emerging tially important, especially if land is diverted technologies offer the promise of even more from food production to fuel production, which substantial pollution and greenhouse gas emis- could potentially reduce global food availability, sion (GHG) reductions at tailpipe, as compared increase food insecurity and prices, and increase with conventionally-fuelled vehicles (Kahn et global malnutrition (FAO 2008).

19 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

It has previously been suggested that while of stable (instead of lower) PM10 levels and no shifting from gasoline to diesel-powered vehi- decline in the health impacts of air pollution – cles could improve fuel economy and reduce despite the introduction of progressively more GHG emissions insofar as diesel fuel tends stringent standards for both fuel production to generate less GHGs per unit of travel than and vehicle particulate filters. (Krzyzanowski et gasoline. However, per unit of travel, diesel al., 2005). fuel also is a proportionately greater contribu- Finally, while low-emission motor vehicles may tor to health-harming air particulate pollution reduce air pollution-related health impacts, they (Walsh and Walsh 2008). As noted in Section 2, are unlikely to reduce other important health higher average urban air concentrations of small risks such as road traffic injuries or lack of particulates (PM10 and PM2.5) are associated in physical activity. long-term studies with higher premature mor- tality as well as higher levels of hospital admis- 3.1.4 Comparison of policy options sions and daily morbidity/mortality, primarily While all of the three policy options discussed from cardiovascular conditions. Diesel exhaust here appear likely to improve health, improv- has also been identified as a probable carcinogen ing land use, increasing non-motorised trans- (cancer-causing agent) (IARC 1989), although port, and shifts from private motorised travel the evidence supporting this is still contested by to public transport appear to have the greatest some (Bunn et al., 2004). There is less evidence combined potential for generating health ben- to suggest that gasoline exhaust is carcinogenic. efits. Modifying vehicles and fuels may lead to Among studies that separately assess the effects additional reductions in air pollution, but is of diesel and gasoline exhaust on health, some unlikely to reduce other health risks. find no difference in the effects of diesel and gasoline exhaust (Guo et al., 2004a, b,) but at Growth in motorised travel may continue to least one study has found lung cancer to be offset many of the per-vehicle reductions in associated with exposure to diesel exhaust but pollutant and carbon emissions from improved not gasoline exhaust (Parent et al., 2007). vehicles or fuels (Krzyzanowski et al., 2005, EEA 2010a). First, vehicles that consume less Some researchers have attempted to quantify fuel have lower running costs, which could the likely air quality impacts of a shift to diesel incentivise motorised travel (a “rebound effect”) vehicles. One study modelled the effect on pho- (VTPI 2010d). Additionally, as already noted, tochemical of converting the US gasoline- the growth in motor vehicle traffic tends to powered fleet to modern diesel vehicles, and generate demands for even more motor vehi- concluded that such an approach may increase cle travel, and more use of urban budgets and smog (Jacobson et al., 2004). Another study space on road and parking infrastructure to modelled the air quality impacts of UK con- accommodate growing traffic. This, in turn, can sumers switching from gasoline to diesel cars, make other modes comparatively less effective and estimated that this would increase air pollu- to use, as well as weakening the relative impact tion deaths related to particulate matter (Mazzi of investments in rail/bus and walking/cycling and Dowlatabadi 2007). modes. Indirectly, then, an exclusive emphasis Whether shifting from gasoline to diesel will on improved vehicle and fuel technologies can worsen health very significantly is likely to be even have a net negative health impacts. In one strongly dependent on the strength of the envi- modelling study examining the health impacts ronmental standards applied to diesel vehicles, of different transport development scenarios in especially with respect to the quality of diesel Delhi, India and London, United Kingdom, the fuel produced by refineries (especially sulphur level of health benefit obtained by mode shifts content) and the quality of particulate filters on from motorised to non-motorised travel was vehicles (Walsh and Walsh 2008). However, as thus estimated to be higher overall, than the already noted, large shifts of the vehicle fleet health benefit obtained from shifting to lower- from gasoline to diesel fuels in European cities emissions vehicles alone. Health benefits for a in the last decade are considered to be a cause mode shift scenario were seven times higher for

20 Module 5g: Urban Transport and Health

Delhi, and over 40 times higher for London. A and to assess progress towards identified trans- combined scenario using both policy strategies port and health goals. It outlines how transport yielded almost double the reduction in green- modelling can incorporate health issues along- house gas emissions, but only slightly increased side other important outcomes such as environ- health benefits compared with the mode shift ment and climate change effects. The main scenario alone. This analysis took into account focus here is on examples of validated and non- health effects from air pollution, physical activity commercial tools that can be used to quantify and road traffic injury (Woodcock et al., 2009). the expected health effects of different policy In summary, a combination of policies, with options. References with more detailed informa- the greatest emphasis on land use planning and tion are also provided for readers considering facilitating healthy transport modes, appears using these tools. likely to have the most beneficial effects for urban health in the short term. Improved vehi- 3.2.2 Types of assessment tools cle and fuel technologies remain, however, an There is a wide variety of tools that can be used important component of measures to reduce to assess the health effects of transport policy GHGs and the climate-change related health options; these can be classified in a number of impacts of transport. broad categories (Figure 16): 1) Planning/procedural tools. The key tool 3.2 Tools for assessing the health used is health impact assessment (HIA) impacts of transport systems which can be conducted on its own, or in 3.2.1 Introduction association with other forms of impact While previous sections in this report identi- assessment, such as environmental impact fied the best strategies and goals for health- and assessment (EIA) or strategic environmental/ climate-friendly transport policy, this section impact assessment (SEA/SIA), to determine identifies tools that can help select the right the potential health impacts of policy options strategies to be implemented in a given setting, and to propose improvements.

Procedural Involvement of Environmental Impact Assessment (EIA) stakeholders Strategic Environmental Assessment (SEA) + 1 – Impact Assessment Sustainable Impact Assessment (SIA)

Social Impact Assessment (SIA) Health ct Impa A ss e ment (HIA) System of Economic and Environmental Accounting (SEEA)

Interviews SWOT Analysis Focus Groups 2 – Qualitative methodologies Scores and Weights Discourse Analysis DELPHI Mental Maps Participant Observation

Risk Analysis Link of existing models Multi Criteria Analysis 3 – Integrated analytical tools Cost-Bene t Analysis Dedicated softwa re Genuine Savings Life Cycle Cost Assessment

Transport indicators

Health indicators 4 – Monitoring and evaluation Indicator sets Social well-being indicators F igure 16 Environmental indicators – Tools to assess potential Analytical health impacts of transport policies.

21 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

2) Qualitative tools (e.g. interviews, focus biophysical, social, and other relevant effects of groups, stakeholder discussions) can be used development proposals prior to major decisions to support both planning or evaluation pro- being taken and commitments made (IAIA, cesses, supplementing hard data with local 1999). knowledge, feedback and perceptions. In many countries, EIA is supported by legally- 3) Integrative analytical tools quantify and binding frameworks, which require impact model actual or expected health outcomes. assessment for many major forms of devel- These include methods such as burden of opment, including transport infrastructure. disease analysis, quantitative risk assessment, Health is considered part of the environment and modelling, often used in combination. and of the EIA processes, however the health Economic modelling (e.g. cost-benefit analysis assessment are implemented only partially and cost-effectiveness analysis) can further (using a few environment risks to health) or, be used to translate transport's health-related more frequently not implemented at all. external costs, including deaths, illness and lost productivity, into economic terms. This Health impact assessment is discussed briefly here and in more detail in Health Impact Assessment (HIA) has been Section 3.3. defined as “a means of assessing the health 4) Monitoring and evaluation tools often impacts of policies, plans and projects in diverse include the use of indicators to progress economic sectors using quantitative, qualitative against goals. Qualitative approaches may and participatory techniques”. (WHO Regional also be important here, however, particularly Office for Europe, 1999). The HIA process is when there is a dearth of hard data, e.g. on issues such as pedestrian connectivity. HIA described in Figure 17. processes are also sometimes used retrospec- While health impact assessment (HIA) is gener- tively for monitoring and evaluation. ally not legally mandated, it can be integrated with other impact assessments to predict the Impact assessment health impacts of different policy scenarios Environmental impact assessment (EIA) was or projects. The underlying principles of HIA the first widely-used impact assessment process; include sustainable development, equity (i.e. the it has been defined as “the process of identify- distribution of health effects) and the ethical ing, predicting, evaluating and mitigating the use of evidence (Joffe 2002, European Centre

Screening Quickly establishes ‘health relevance’ of the policy or project. Is HIA necessary? Policy and programme Identi es key health issues & public development Scoping concerns, establishes ToR, phase for sets boundaries. prospective assessments. Rapid or in-depth assessment of health Appraisal impacts using available evidence – who will be aected, baseline, prediction, signi cance, mitigation.

Conclusions and recommendations to Reporting remove/mitigate negative impacts on Policy health or to enhance positive. Figure 17 implementation phase The health impact Action, where appropriate, to monitor assessment (HIA) actual impacts on health to enhance process. Monitoring existing evidence base. Source: Based on WHO http://www.who.int/hia/tools/en

22 Module 5g: Urban Transport and Health

for Health Policy 1999). A particular emphasis quantitative methods (Love et al., 2005). Critics of HIA is that views and concerns of diverse claim that over-reliance on quantitative impact stakeholder groups are incorporated into the assessment “may encourage policy-makers and assessment process (Ness et al., 2007). others to attach more importance to those In recent years, the integration of health impact impacts that are easier to quantify but which assessment (HIA) into transport assessment do not necessarily have the greatest associated has advanced, particularly in Europe (Dora burden” (O'Connell and Hurley 2009). Essen- and Racioppi 2003) and more recently in the tially, both qualitative and quantitative methods USA (National Academy of Sciences 2011). For provide useful information for assessment pro- example, large infrastructure changes and high- cesses such as HIA. ways were assessed by means of HIA in different Integrated analytical tools contexts (e.g. East End Quality of Life Initia- tive 2001, Public Health Advisory Committee Integrated tools connect different quantita- 2002). In the Netherlands two simulations tive assessment methods (e.g. spatial models of were conducted that considered the impacts of dispersion of pollutants and epidemiological 1) reduced speed limits and 2) a traffic diver- estimation of health impacts) within a model- sion project to move traffic away from a very ling framework, in order to provide a more com- dense area to a lower-density one by building a prehensive and definitive measure of impacts. new highway. Dannenberg et al., (2008) have These tools represent a further refinement, and compiled a list of 27 US case studies. Web- integration, of quantitative tools discussed at sites maintained by the Transport, Health and length elsewhere in the health and environment Environment Pan-European Programme (http:// literature (see http://www.who.int/heli). These www.thepep.org), co-sponsored by the World include burden of disease estimates, spatial Health Organization and the United Nations measurements of pollutants and cost-benefit Economic Commission for Europe (UNECE), analysis. For example, an air pollution model as well as the WHO Health Impact Assessment might apply traffic modelling for different gateway (http://www.who.int/hia/en) provide policy scenarios, with results passed through other general examples and guidance. pollutant emission and dispersion models. This can yield estimates of population exposure and Qualitative tools health impacts not only from average urban These tools include a set of very diverse meth- odologies that rely largely upon qualitative, B ox 2: descriptive evidence, rather than quantitative, Geographical information systems statistical analysis. Evidence is gathered from: A geographical information system (GIS) is a interviews, focus groups, field notes, videos procedure for linking together geographical and audio recordings, pictures and analysis information, such as the coordinates of a set of documents, and other forms of stakeholder of individuals in a defined area, to some data testimony. In practice, qualitative tools are used about events or characteristics linked to that where it is important to convey to policy-makers location, such as the number of people killed in floods or hospitalised for respiratory outcomes the perceptions, expectations and experiences of in that area in a given period. Using GIS ena- individuals, groups and organisations that may bles the different kinds of information for each be affected by policies (Fitzpatrick and Boulton time and place to be linked. Trends in exposure, 1994). modifying factors and disease outcomes in Qualitative research can investigate the question space and time can be mapped, and the linked of how evidence is turned into practice, and it data can be exported in a format that allows appropriate statistical analysis. This ensures can pursue systematically research questions that any correlations between the exposure that are not easily explored using quantitative data and the outcome data are drawn from tools or experimental methods (Green and Brit- the same place at the same time (Campbell- ten 1998). In recent years, qualitative assessment Lendrum et al., 2003). has increasingly challenged the dominance of

23 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

air pollution concentrations but also from whereby outputs from the first model comprise exposures of particular population groups or the inputs for the next stage. of particular neighbourhoods to that pollution as software tailored to the scenario in question per its pattern of dispersion in the atmosphere may also be required. (e.g. close to residential areas, close to transport Several challenges must be faced when inte- routes). On the transport side, models using grating models. One challenge is ensuring that Geographical Information Systems (GIS) are conventional transport models provide sufficient often a key component of such integrated ana- input data for the air pollution, physical activity lytical tools. On the health side, epidemiological and injury risk/exposure models to which they data, as represented by “years of life lost” analy- may be linked. sis is important (see Box 2 and 3). The problem is that conventional traffic simula- Much work is being done globally to assess the tion models generally represent only a limited health impacts from different transport sce- part of a city’s street geography and travel. For narios using integrated analytical tools. This instance car travel is fully represented in a traf- may require several stages, or modelling layers, fic model, but travel by public transport may be incompletely represented, and pedestrian/cycle B ox 3: The concept of travel is often missing altogether. This means Years of Life Lost (YLL) significant groups of “users” are invisible in the assessment. Integrating motor vehicle models R ationale for use with models of public transport travel (bus, Years of life are lost (YLL) take into account the tramway, metro and train networks) as well as age at which deaths occur by giving greater models of pedestrian and bicyclist networks is weight to deaths at younger age and lower weight to deaths at older age. critical, however, for comprehensive exposure assessment. Ensuring technical compatibility of Definition the outputs of one model with inputs into the YLL are calculated from the number of deaths next model provides additional challenges. multiplied by a standard life expectancy at the age at which death occurs. The standard life Monitoring and evaluation – retrospective expectancy used for YLL at each age is the assessment same for deaths in all regions of the world and is the same as that used for the calculation of While most “impact assessment”, as such, is Disability Adjusted Life Years (DALY). Addition- prospective, retrospective assessment can play ally 3 % time discounting and non-uniform age an important role in transport and health weights which give less weight to years lived at assessment. Monitoring and evaluation tools young and older ages were used as for the DALY. support retrospective assessment by analyzing With nonuniform age weights and 3 % discount- trends in transport and correlating those with ing, a death in infancy corresponds to 33 YLL, environment and health trends and outcomes. and deaths at ages 5 to 20 to around 36 YLL. Retrospective assessment may involve processes Associated terms such as health impact assessment, and a range The Disability Adjusted Life Year or DALY is a of quantitative and qualitative tools. However, health gap measure that extends the concept routine and rigorous monitoring and evaluation of potential years of life lost due to premature can often be performed most efficiently through death (PYLL) to include equivalent years of the use of standard indicators and indices (Ness ‘healthy’ life lost by virtue of being in states of et al., 2007). poor health or disability. DALYs for a disease or health condition are calculated as the sum In the case of transport and health, progress of the years of life lost due to premature mor- towards healthy transport goals can be read- tality (YLL) in the population and the years lost ily monitored and evaluated by collecting data due to disability (YLD) for incident cases of the on key transport and health indicators and health condition. analyzing patterns with respect to geographic Source: WHO locale, populations, and time sequences. Many transport trends (e.g. number of vehicles, paved

24 Module 5g: Urban Transport and Health

) are carefully monitored at global, that total transport-related greenhouse gas emis- country and urban levels, making this a rich sions continue to rise. However, while TERM field of exploration. However, indicators of key assesses progress on environmental outcomes transport-linked health and social well-being including greenhouse gas emissions, air qual- factors are often incomplete or missing from ity and noise, other important health outcomes conventional reporting of key transport indica- such as road traffic injury and physical activity tors by governments, industry and international are not considered. agencies or banks (Litman 2007). Without While a number of transport and health indi- those critical indicators, it may often be difficult cator sets have been developed or proposed by to assess progress towards healthy transport individual agencies, researchers or institutions, goals. these are usually quite large, often including For example, while vehicle traffic volumes are more than 30 indicators; and no single set has usually recorded and reported systematically, been systematically implemented. To achieve similar data on volumes of pedestrians/cyclists this, there is a need to identify briefer, more using the transport system is often not routinely manageable sets of core indicators (Borken collected by Transport Ministries. Similarly, 2003). data on vehicle crashes may be routinely col- While TERM provides a promising example of lected by police, less so data on pedestrians transport and environment system monitoring injured or killed by vehicles. Infrastructure for Europe, low- and middle-income countries ministries may report upon kilometres of road require different monitoring approaches due to paved annually; similar indicators for sidewalks their differing levels of resources available for or bike paths are slim to nonexistent in most data collection. One possible solution would be developing countries and much of the devel- to implement a standard set of surveys collect- oped world. Nor is data routinely collected on ing information on a limited set of the most key social well-being factors such as pedestrian factors, e.g. modal split, pedestrian/cycle injuries, traffic in correlation to crime or measures of and other health risks and outcomes, for statisti- neighbourhood cohesiveness. Consideration of cally significant samples in key urban areas and/ health requires that essential data on transport- or for different population groups. This would related human health and social factors, and not help monitor key transport and health links, only vehicle data, be collected and monitored in and enrich analysis of actual and expected a balanced transport indicator set (TRB 2008). impacts of policy changes on public health. Collecting and reporting indicator data allows public assessment of whether transport systems SUTP Technical Document Nr. 7 – are moving in the right direction, whether pro- Review of Sustainable Transport Evaluation gress is rapid enough and thus whether the right ll policy settings are in place. On behalf of the Federal Ministry for Envi- Given the evidence that socioeconomically ronment, Nature Conservation and Nuclear Safety (BMU), GIZ has reviewed existing disadvantaged groups typically bear more of assessment and indicator schemes for sus- the burden of transport hazards and also have tainability in the transport sector to determine poorer access to current transport systems, the which are most appropriate for sustainable social distribution of transport effects should transport planning and policy purposes on also be monitored as part of such health-ori- an international level. The study outlines ented analysis. options for choosing appropriate indicators One example of a formalised transport and and evaluation tools, encompassing environ- mental, social, economic and governance- environment indicator set is the Transport and related dimensions. It also summarises the Environment Reporting Mechanism (TERM) benefits of an evaluation scheme not only (EEA 2010a). The most recent TERM report for national and local governments, but also assesses progress towards reducing greenhouse for donors and the scientific community. The gas emissions, and finds that although vehicle document is available for download at http:// efficiency is improving, growth in travel means www.sutp.org.

25 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

3.2.3 Applying qualitative and by WHO. A similar tool is the Fast Environ- quantitative tools – case studies mental Regulatory Evaluation Tool (FERET) and examples developed by Carnegie-Mellon University and This section provides further case study exam- the University of Washington, which includes ples in the application of various tools. Many a cost-benefit analysis component (Farrow et al., different applications are possible, ranging from 2001). simple to very complex , and ranging Emission scenarios for the HEARTS simula- from urban to international levels. Particular tion identified improvements in the transport emphasis is given to case studies of integra- network and the vehicle fleet, compared with tive analytical tools, which are summarised in the 2003 reference scenario, and estimated a Table 5; examples of qualitative tool use are reduction of 129 deaths, 596 acute bronchitis also provided. As noted previously, both types cases (aged <15 years), 5 869 restricted-activity of tools can contribute to a successful health days (aged 15–64 years) and 1 400 years of life impact assessment process. lost per year.

Integrative analytical and quantitative Health Economic Assessment Tool (HEAT) tools The Health Economic Assessment Tool (HEAT) HEARTS for cycling developed by WHO estimates the The WHO project entitled Health Effects economic value of reduced mortality from and Risks of Transport Systems (HEARTS) cycling. For further details about the tool see (WHO – Regional Office for Europe 2006) is Box 5 in Section 3.3.1. a project that includes three case studies to test models for quantitatively assessing effects of dif- Urban Outdoor Air Pollution Database ferent urban land use and transport policies on The Urban Outdoor Air Pollution Database, human health. developed by WHO, is the most comprehensive One of the three case studies was undertaken in compilation of air pollution levels measured

Florence, Italy. This assessed the effects of a new in particulate matter (PM10 and PM2.5). The transport plan, which included new lines, database contains measured data for more than parking facilities at the terminus of tram lines, 1 000 cities representing more than one third use of railways for urban transport, rearrange- of the world's urban population. The database ment of the urban bus network, new connecting aims to be representative for human exposure, roads within the metropolitan area, a new ring and therefore primarily captures measurements road to the north and increased highway traf- from monitoring stations located in urban back- fic capacity. In addition, the consequences of ground, urban traffic, residential, commercial changing the fleet composition i.e.( improved and mixed areas (WHO 2011b). This database vehicle technology) were considered. is also underlying the latest estimates of disease Scenarios were constructed for the existing burden caused by urban outdoor air pollution. transport network compared with the new transport network, for the existing vehicle fleet Estimates of disease burden from urban compared with the improved vehicle fleet, and outdoor air pollution for combined changes in both transport net- The air pollution data of the WHO Urban Out- work and vehicle fleet. Based on geo-coded traf- door Air Pollution Database was linked to vali- fic modelling results, a chain of different models dated epidemiological models that reflect excess was implemented, including a mortality due to increased concentrations of model, an emission model for traffic air pollut- small particulate exposure in urban areas. All in ants and air dispersion and exposure models. all, the WHO exercise found that an estimated Air pollution modelling was undertaken using 800 000 premature deaths in the year 2000 and AirQ, a simple software tool designed to assess 1.3 million premature deaths in the year 2008 health impacts of air pollution in a specified were due to excessive particulate air-pollution population using a methodology developed related exposures. The findings, in cities of over

26 Module 5g: Urban Transport and Health

100 000 people, include about 5 % of mortal- ity attributable to cardiopulmonary disease in adults, about 9 % of mortality attributable to cancers of the trachea, bronchus and lung, and about 1 % of mortality attributable to acute respiratory infections (WHO 2009a; Cohen et al., 2004).

B ox 4: Netherlands: Scenario modelling of the health benefits of modal shift from car to bicycle Hypothetical scenarios based on national statistics 3 to 14 months of life gained) than the potential can offer interesting insights into the expected mortality effect of increased inhaled air pollution health impacts of modal shift to active travel (de doses (0.8 to 40 days lost) and the increase in Hartog et al., 2010). For the individuals who shift traffic crashes (5 to 9 days lost). Societal benefits from car to bicycle, it was estimated that ben- were even larger due to a modest reduction in eficial effects of increased physical activity are air pollution and greenhouse gas emissions and substantially larger (with estimates ranging from traffic crashes.

F igure 18a/b Evidence from the Netherlands points at the potential benefits of increased physical activities: Cycleways in Amsterdam (left) and Nijmegen (right). Photos by Andrea Broaddus, Amsterdam, Netherlands, 2007 (left) and Jeroen Buis, Nijmegen, Netherlands, 2007 (right)

27 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities stimated. Annual % e

terms of life years gained Restricted-activity days Mortality (aged ≥30 years, (aged <15 years). (aged <15 (aged 15–64 years). savings of NZD 765 000. excluding accidental excluding long-term. causes) on all-cause mortality in or lost, using life table calculations. Quantification of the impact impact the of Quantification Acute bronchitis bronchitis Acute A reduction in mortality of Years of life lost.Years 17.5 „„ „„ „„ „„ „„ „„ Outcomes by loose-coupling by the for air pollution, traffic reviews supplemented with recent studies. key HEAT Integrated modelling system Integration of the literature various models within a GIS. accidents and physical physical and accidents activity using systematic Tool Policy and become regular the existing and the Florence to bicycleto for modelled in 2010. in municipality Netherlands. Hypothetical urban commuter planned transport scenarios scenarios scenarios by What if 1000 (ages 20–64) scenario, basedscenario, statistics, involving shift from car short trips on a cyclists. additional adult adult additional on Netherlands daily basis in the Application to to Application Population in observed population population population population people (18–64 Whole adult adult Whole area (about of 500 000 years of age). Adults 190 000). parameters Florence municipality National National Modelled Scale and/or and/or Scale Urban: the

2.5

. Measures and 2.5 levels of physical activity; Description of case study case of Description to PM to bicycleto in terms of for cycling estimate to New Zealand, used HEAT Integrated modelling within Integrated modelling within Study of health effects 20–64) regular urban samples. system (GIS) of exposures elemental analysis of PM of analysis elemental a geographical information information geographical a changes in mortality associated with 1000 (ages adult additional cyclists. commuter of modal shift from car pollution air decreased gas greenhouse emissions, increased and emissions and risk of traffic injury. The University of Auckland, u S impacts impacts Florence Netherlands urban New modal shiftmodal modal shift planning planning (HEARTS) (HEAT) (study) Area Zealand Table 5: 5: Table mmary integrative analytical case of tools studies applying

28 Module 5g: Urban Transport and Health in the general the population in 0–4 years) impacts Numbers of attributable Morbidity from and PM Infant mortality from PM deaths among those aged 30 over adults and children (aged ozone among adults and in the general population Chronic mortality from PM Valuation of mortality Valuation of infant mortality Valuation of morbidity VSL VOLY Acute mortality from ozone Years of life lostYears (YLL) for „„ „„ „„ „„ „„ „„ „„ „„ „„ „„ „„ Outcomes and 10 concentrations using: using: concentrations 2.5 marginal policy changes. policy marginal i.e. the value of a statistical life intensity of economic economic of intensity the cities or countries under or cities the PM population density, 5) local 5) density, population per capita, 7) time trends, 2) atmospheric2) and 8) binary variable for each If no data are available for Use of values in terms of (VSL) and, either directly or through computational through or analysis, the value of a life applicable for assessing the changes between scenarios, study, it is possiblestudy, model to geographical factors, 3) city population national and density, local 4) urban activity, 6) national income country. year The (VOLY). CAFE estimates of annual PM CBA methodology is only Tool 1) energy1) consumption,

benefits of current Policy and in 2000 and 2020, built, including a scenario. base-case modelled EMEP and RAINS models for baseline uses the CAFE CBA methods. pollution data data pollution policies this over period. It assesses the scenarios scenarios state as its starting point generated the by and conditions, of the environment and looks at The analysis takes Ten scenariosTen were f the % o

211 211 national

Population Data were population, population, modelled for 559 million, populations populations population). Whole Whole 28 3 (around (around approx. approx. capitals and with cities of >100 000 or about urban global 450 million. 2010 parameters national Scale and/or and/or Scale (EU 25) and(EU 25) and sub- continental Continental Global 2008, de Hartog et al., 2010, Dannenberg 2010, et al., health impacts of ozone ozone of impacts health being undertaken as part Description of case study case of Description best city-level prediction of basis of the limited amount burden of disease. uniform relative reduction in emissions. urban Particulates (GMAPS) Model of Ambient (CAFE) program. Results such, they represent something of an average of within each country. As wide range of cities on the economic valuation of the and particulate matter for cost-benefit analysis(CBA) of the Clean Air For Europe are based on modelling a emissions of each pollutant damages between rural and Quantification and and Quantification designed to obtain the the obtain designed to concentrations for of PM a of data from monitoring Model-based available. estimate to used estimates Application of the Global the Application of impacts impacts Europe urban air pollution pollution Source: Kahlmeier et Kahlmeier al.,Source: (CAFE) (GMAPS) (study) emissions emissions Global Area

29 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

Qualitative tools Examples of the use of qualitative tools in the appraisal of transport projects are summarised in Table 6, and include SWOT (strengths, weaknesses, opportunities and threats) analysis, scores and weights, and DELPHI (EU 2009b).

Table 6: Examples of qualitative tools used for transport projects Case Tool Strategic overview of transport issues for the Republic SWOT of Ireland “Corridor Ranking Framework” in Greece, Ireland and Scores and weights Portugal Forecasting the development of transport telematics technologies (in the year 2015 in medium-size DELPHI European cities) Appraisal of central Asian transport projects Small sample surveys of road users

Source and further information: http://ec.europa.eu/regional_policy/sources/docgener/evaluation/evalsed/sourcebooks/themes_policy/policy/transport/ approaches_en.htm.

3.2.4 Modelling greenhouse gas (from increased emissions of small particles emissions and health associated with diesel fuel) were predicted to Emissions modelling tools that have been result in 90 additional deaths annually (range developed to assist transport decision-makers 20–300) (Mazzi and Dowlatabadi 2007). can simultaneously address health and climate To date, researchers have gained more experi- change impacts. For example, models that ence modelling the health impacts of transport employ “back-casting” methods enable policy- in European and North American settings. makers to estimate the scale of the measures However, these models can also be adapted required to reach a given emission reduction for developing countries, as illustrated by the target, to assess the relative impacts of different study of Delhi in Woodcock et al., (2009). components of policy “packages”, and clearly While lack of data may be a particular bar- indicate whether or not targets will be met rier in some developing countries, useful effect based on existing policy settings. estimates may still be generated either by A 2009 study used models to estimate in more initiating new data collection where needed detail the health outcomes related to physical or by making assumptions based on the data activity, air pollution and road traffic injury available. Incomplete data are also a common from different mitigation policies for the trans- problem in developed-country settings. Ensur- port sector. This allowed emissions and health ing that sufficient modelling skills are available impacts to be concurrently estimated, and indi- in developing countries could require workforce cated that emissions reductions from vehicle development as well as building international fuel efficiency measures were associated with partnerships with centres with established mod- smaller health gains than emissions reductions elling expertise. from modal shift towards active transport. This Increasing the extent to which health outcomes finding held for very different settings such as are robustly incorporated alongside emissions London and Delhi (Woodcock et al., 2009). in the outputs of transport models is thus a Health and emissions outcomes were concur- useful strategy for promoting healthy transport rently examined by a study that examined a and land use policies. Given the wide range scenario of United Kingdom consumers switch- of available methods for estimating the health ing from petrol to diesel cars. Although this impacts of transport, many of which have been switch was estimated to reduce discussed here, transport scenarios should rou- emissions by 7Mt, adverse effects on air quality tinely be assessed for both health and emissions

30 Module 5g: Urban Transport and Health

outcomes. Doing so would help ensure that mit- stimulates additional vehicle travel, known igation strategies with the greatest co-benefits as induced travel. Induced travel can lead to are preferentially selected by policy-makers. future indirect health impacts that are not fully measured, such as increased pollution over 3.3 Economic mechanisms time, increased reliance upon private car travel, 3.3.1 Health in the economic reduced efficiency of public transport systems, evaluation of transport systems barriers to walking and cycling, and reductions in physical activity. Economic evaluation, particularly cost-benefit assessment (CBA), is commonly used to inform The land use impacts of transport development transport investment decisions by governments. also have health impacts that require considera- However, most CBA applications in the trans- tion in economic assessment. Per passenger-km port sector remain focused on economic evalu- of travel, roads require far more urban space ation of proposed road projects, without refer- than transit. Land used by roads will not be ence to alternative modes of development. Such available for other health-promoting uses such CBAs assessments typically analyse factors such as green spaces or public services. Over time, as savings in vehicle operating costs (VOCs) road and car-oriented investments also tend and economic savings resulting from reduced to reduce urban densities, reduce mixed-use travel times on particular road segments. They development and promote street design that dis- often underestimate, or fail to consider, the full courages walking and cycling, and thus physical range of health impacts that may emerge from activity. road development over time, particularly in In contrast, investments in public transport comparison to alternatives that emphasise more infrastructure can free up more space for parks investment in mixed modes and modal shift to and walking/cycle infrastructure and support rail/bus modes, cycling and walking. more compact, accessible cities. These land use There are a number of standardised cost-benefit effects on health are not typically considered assessment tools used by a wide range of inter- in the evaluation of transport projects, though national development agencies to guide inter- some methods for incorporating these effects national transport investment decisions. One in transport planning do exist (VTPI 2010a). example is the HDM-4 (Highway Development CBA that does not fully account for induced and Management-4), which is sponsored by the travel and the land use impacts of transport World Bank, the UK Overseas Development projects tends to ignore many important trans- Administration/Department for International port-related health impacts, and to favour car- Development (ODA/DFID), Asian Develop- oriented transport planning over non-motorised ment Bank, Swedish National Road Adminis- travel. This is a major gap in policy assessment, tration, along with the World Road Association with far-reaching implications for transport and the Inter-American Federation of Cement investments, requiring greater attention by Producers (World Bank, 2011). Recent versions national ministries, development agencies and of this tool have been adapted to consider lim- multi-lateral development banks. ited environmental and health (e.g. accident) Recognising these challenges, the World Bank impacts. However the full spectrum of changes recently developed initial guidance for more in land use and transport mode choices are yet inclusive, multi-modal assessment of urban to be fully considered by any single standard- transport investments (World Bank, 2008). ised transport modelling tool, particularly with However such guidance recognises the con- respect to health costs/benefits in terms of inju- tinuing barriers to investment decisions based ries, air pollution, access, physical activity, non- on economic evaluation using standard tools: motorised travel, etc. “Because funding for strategic roads and rapid For instance, expanding road capacity may transit systems tends to come through different reduce in the first years of institutional channels, evaluation studies most the road's operation, saving time and vehicle often look at uni-modal sets of options”. (World operating costs. However, in doing so, it also Bank, 2008)

31 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

Also, the report notes, public transport infra- the full range of benefits from a transit invest- structures, particularly rail, typically are much ment (see also Section 3.3.2). more complex and costly public sector under- A full-cost accounting of health costs of trans- takings, as compared to roads. Rail and transit port alternatives can help ensure that transit require a larger dimension of projects are reviewed in light of their true continuing public sector involvement in their economic rate of return over time. Along with operation, as well as public subsidy of capital the urban transport issues discussed here, multi- and operating costs not covered by ticket fares. modal assessment of rural and interurban Such support for public transit's operation can transport options in developing countries also be readily generated through a “virtuous” needs closer consideration. Here, too, the split cycle of dedicated vehicle fuel and parking between road and rail passenger and freight – but that requires policymaker recognition of travel may have far-reaching impacts on rural

B ox 5: Health Economic Assessment Tool (HEAT) for cycling Investments in road transport infrastructure are cycling or to assess the impact of a transport traditionally assessed in terms of vehicle operating intervention that is expected to change current costs and time saved in vehicle travel. However, levels. What is needed is mainstream integration the health factor as noted in Chapter 3.2 is often of such tools into standard CBA processes for neglected. Recently, a number of validated models transport evaluation. have been developed that quantify, monitor and One HEAT case study in New Zealand has been evaluate the financial return of investments in included in Table 5. Another example of HEAT cycling infrastructure, in terms of health ben- application from Austria estimated that the 412 efits obtained. The Health Economic Assessment lives are saved due to current levels of cycling, Tools (HEAT) for walking and cycling is one such which has a modal share of 5 % of all travel. This tool, offering transport planners an easy-to-use is due to mortality reductions associated with tool means of assessing economic benefits from increased physical activity, and is equivalent to reduced mortality due to increased physical activ- EUR 405 million in monetary terms. Achieving the ity from walking and cycling. This tool, consisting national goal of 10 % cycling share would increase of a user-friendly spreadsheet (Figure 19), can be lives saved to 824 annually, for an annual benefit used to evaluate current levels of walking and of EUR 812 million (Kahlmeier et al., 2010).

F igure 19 Health Economic Assessment Tool (HEAT) for cycling. More information: http://www.euro.who.int/HEAT

32 Module 5g: Urban Transport and Health

development and health, rural sprawl, equity, from road traffic injury and air pollution (Leigh pollution and greenhouse gas emissions. It is and Geraghty 2008). In another study, it was thus critical that conventional economic assess- estimated that 'optimum' transport pricing ment of road development generally be inte- would reduce road traffic injury mortality by grated with the best available models for health about half (VTPI 2011b). Lower levels of obe- assessment of transport to account more inclu- sity have also been associated with higher fuel sively for the economic costs and benefits of prices (Rabin et al., 2007). In general, pricing the full range of health impacts emerging from policies that provide incentives for travel by different transport modes and development sce- modes other than motor vehicles are regarded as narios (VTPI 2011a). having the potential to both reduce health risks as well as greenhouse gas emissions (Pew Center 3.3.2 Transport pricing measures on Global Climate Change 2003). There is a large body of literature discussing Fuel taxes as a pricing tool are often both both the environmental and the travel impacts politically lucrative and controversial. In rapidly of fuel and congestion pricing (e.g. Goodwin et motorising developing countries fuel taxes may al., 2004, Sterner 2007, Kim et al., 2011, Seik represent a considerable source of government 1997, World Transport Policy and Practice 1999, revenue. Fuel taxes may also quickly become ADVA Center 1999, Royal Commission on the object of populist protest if fuel prices rise Environmental Pollution 1994). Reviews of the sharply and unexpectedly. Nonetheless, dedicat- direct impacts of pricing strategies on health ing a significant proportion of fuel tax income are more limited. However, in cities at compa- to sustainable transport modes, including public rable stages of development, higher fuel prices transport, walking and cycling infrastructure, are typically associated with comparatively less has been described as one of the most effective motor vehicle travel and more travel by alterna- ways for developing countries to self-finance tive public transport, walking/cycling modes healthy and sustainable transport improvements (Rashad 2009; World Transport Policy and (World Bank, 2008). Doing so recognises the Practice 1999; Royal Commission on Environ- “polluter pays” principle of sustainability, and mental Pollution 1994). promotes equity by investing taxes on alterna- In one study, a 20 % increase in fuel prices was tive travel modes that benefit society widely as estimated to lead to reductions in mortality well as improving the health and mobility of groups least able to afford motor vehicles. B ox 6: Clean Air for Europe (CAFE) Downtown and highway congestion charging The CAFE program is an example of a region- is another common measure used to manage wide assessment of the economic costs and traffic more sustainably. Studies of congestion benefits, including health benefits, of potential charging have concluded with mixed results. measures for improving air quality in Europe One study of congestion charging effects in (for EU–25 countries). In the year 2000, CAFE London and Stockholm concluded that there estimates found that the annual impacts of air had been relatively small city-wide reductions in pollution amounted to 3.7 million years of life air pollution-related mortality that were great- lost (YLL) each year, equivalent to 348 000 pre- est inside the charging zone (Tonne et al., 2008, mature deaths. Particulate matter (PM) exposure was also responsible for 700 infant deaths per Eliasson et al., 2009). year. These estimated health damages for 2000 Another pricing approach provides incentives were estimated to correspond to 3 % to 10 % for the use of improved vehicles and fuels. This of EU–25 GDP (based on low and high damage will reduce air pollution, but will not likely influ- estimates). The estimated health benefits of ence other transport-related health risks such as implementing current European air quality leg- physical inactivity. In some cases, incentives for islation up to 2020 were valued at between EUR 87–181 billion per year, which translated into improved vehicles and fuels could, even increase an average benefit of between EUR 191 and motorised travel, whereas raising the price of EUR 397 per person per year (EU 2005). undesirable vehicles or fuels would, in principle, be more likely to decrease overall motorised travel.

33 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

In summary, the health effects of a pricing strat- This section examines the extent to which egy are likely to be strongly dependent on the health co-benefits are considered in the financ- way the pricing strategy is designed, what aspect ing of transport projects, and the methods used of the system it targets for taxation and what for that purpose, in two types of International aspect for incentivisation. financing mechanisms: the clean development mechanism (CDM) available via the United 3.3.3 International financial Nations Framework Convention on Climate mechanisms Change (UNFCCC); and financing available The availability of international finance for through international development finance different types of transport projects has an institutions (in this case, the World Bank). important influence on trends in infrastructure Further in-depth consideration of financing development globally, especially in develop- mechanisms is considered by the UNEP Green ing countries. Such finance, while it may be Economy report (UNEP 2010). supplementary or “packaged” with private and International development funding F igure 20 national financial backing, can make the dif- ference between a feasible or unfeasible project, Many international development financial World Bank transport lending by and also sends an important market signal in mechanisms are available for transport infra- type, 2002–2004. terms of trends in lending for new infrastruc- structure lending. For example, lending from Source: World Bank 2005a ture development overall. the World Bank has historically focused on road infrastructure that served primarily transport by freight and private motorised vehicles Average Annual Lending (2002–2004) (Figure 20). Low-carbon transport modes, in particular rail and urban transport schemes with mixed bus rapid transit (BRT)/rail/bus and 5% 3% 9% Roads & highways walking/cycling systems that have greater health General Transportation co-benefits have received far less emphasis. 17% 66% (including urban transport) More recently, the World Bank has created Railways policy frameworks and guidance that emphasise urban transport design of healthier and more Ports and waterways sustainable modes, including modal shifts to walking/cycling and public transport (World Bank, 2008). However, the extent to which these new guidelines will shift overall funding priorities is yet to be determined. The most recent available data (Figure 21) reflects an increase in World Bank lending for 12 000 Roads & highways “general transport” projects. This category typi- 10 000 Railways cally includes, but is not limited to, urban trans- Pub admin-transport port projects such as bus rapid transit, light rail, 8 000 Ports/water/shipping and active transport. Gen transport sector More explicit and precise reporting on transport 6 000 Aviation lending by modal type, particularly for urban

USD Millions 4 000 and interurban rail, BRT and walking/cycling would allow better evaluation of key trends in 2 000 international finance for transport, and how

0 FY05 FY06 FY07 FY08 FY09 FY10 Figure 21 (”Firm” & World Bank transport lending trends, “Likely”) 2005–2010. FY: fiscal year. Source: World Bank, 2011

34 Module 5g: Urban Transport and Health

those trends are contributing to health, sustain- case of transport, this is a particular gap in the ability and carbon footprints. CDM process, given the great opportunities for health co-benefits. Clean Development Mechanism Paradoxically, projects that involve shifts to less The Clean Development Mechanism (CDM) is “travel-intensive” forms of land use together with a financial mechanism that allows high-income shifts to carbon-neutral, active transport may countries that have committed under the Kyoto be highly efficient mitigation measures with Protocol to reduce GHG emissions, to do so important health co-benefits, but may be less through investing in projects that reduce emis- attractive as CDM projects since “compliance” sions in low- and middle-income countries. This and “outputs” may be difficult to measure in is intended to allow emission reductions to currently accepted frameworks. occur where they are less costly. Revision of CDM protocols to estimate such One example has been the TransMilenio health co-benefits from transport mitigation, system in Bogotá, which has been registered and to consider them in the project qualifica- as a CDM project by the UNFCCC, and as a tion and financing process, would increase result is expected to receive as much as USD incentives for healthy transport initiatives. 350 million from the sale of emission credits by the year 2026 (Grütter 2007). This exam- 3.4 Governance frameworks and ple demonstrates how CDM can facilitate the implementation of projects such as mass transit mechanisms for transport, systems that can reduce emissions and improve environment and health health by making them more financially attrac- This section describes some of the processes tive. Encouraging greater application of CDM and mechanisms that may be used to support for such projects could be one useful strategy to healthy and sustainable transport policies. The F igure 22a/b foster transport systems that reduce GHG emis- experience of Europe, which has a long record One of the first sions and increase health co-benefits. of policy action on sustainable transport, is used transport projects to While many CDM projects may improve health, here as illustration. be registered under the presence or absence of health co-benefits Beginning in the mid-1980s, growing awareness the CDM mechanism does not currently affect CDM qualification in Europe about health and environment led to is the TransMilenio criteria or subsequent revenues, which are calcu- the convening of the First European Ministe- BRT system in Bogotá. Photos by GIZ, Bogotá, lated solely on greenhouse gas emissions. In the rial Conference on Environment and Health (in Colombia, 2007

35 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

1989). Out of the first Ministerial conference, a international organisations. It was agreed to European Environment and Health Committee implement a program of joint action. This joint was created to support and facilitate what is still program became known as the Transport Health an ongoing European environment and health and Environment Pan European Programme (The process, including regular ministerial meetings PEP). every five years. The EEHC is a multi-stake- holder committee including health and environ- The Transport Health and Environment ment ministries, WHO, European Commission, Pan European Programme (The PEP) UNEP, OECD and UNECE. The Transport Health and Environment Pan The European Environment and Health Com- European Programme (THE PEP) was estab- mittee's first activity was a state of the art review lished in 2002 at the Second High Level Meet- of environment, development and health issues ing of Ministers of Transport, Health and in Europe. The review, Concern for Europe's Environment. It pools capacities and skills from Tomorrow (WHO 1994), clarified how differ- Europe, Caucasus, Central Asia and North ent sectors of the economy, including transport, America, translating national policy into local were key affecting health and environment, and action. It offers a unique tri-partite platform for identified effective interventions. countries to share information and know-how This review led to a series of regional meetings and benefit from experience. It has the support and discussions culminating in a European from the World Health Organization Regional Charter on Transport, Environment and Health, Office for Europe and the United Nations Eco- which was adopted at the Third Ministerial nomic Commission for Europe, which facilitate Conference on Environment and Health in effective use of resources and coordination London in 1999. The Charter described the at the national and international levels. THE costs of unsustainable transport to health and PEP provides a policy framework around four environment, reviewed actions so far, and pro- priorities: posed a way forward for more integrated poli- „„ Investment in environment- and health- cies that included: friendly transport; 1) A framework of principles and approaches for „„ Sustainable mobility and more efficient transport sustainable for health and environ- transport systems; ment, including the “polluter pays” principle, „„ Reduction of emissions of transport-related “integrated decision making across the sec- greenhouse gases, air pollutants and noise; tors”, “public participation”; “access to infor- and mation”, and “precaution and prevention”. „„ Promotion of policies and actions conducive 2) Policies that would be pursued, including a to healthy and safe modes of transport. reduction of the need for motorised transport, THE PEP promotes the development of more a shift towards healthy and clean modes of comprehensive approaches to consider the transport. health and environment implications of trans- 3) Tools for selecting transport policies with port policies and interventions. Support is best results, including the use of health and given to countries, regions and cities through environment impact assessments, of indica- the provision of expertise and joint projects tors and monitoring. from across the region (THE PEP Partner- 4) Environmental health targets for transport, ship), exchange of experience and good practice including a reduction in diseases and deaths (THE PEP Toolbox and THE PEP Clearing attributed to transport-related air pollution, House)and national and local workshops on road traffic injuries, noise and lack of physical policy integration and healthy and safe urban activity. walking and cycling (THE PEP relay race). The three sectors cooperated through a work- Special attention is given to the needs of the ing group and identified ways to implement eastern, south-eastern European and central the Charter objectives, through a series of dis- Asian countries, as well as to particularly envi- cussions involving governments, NGOs and ronmentally sensitive areas.

36 Module 5g: Urban Transport and Health

Although THE PEP is not legally-binding and depends entirely on voluntary donations it has 4. Good practices been successful in bringing together the three 4.1 Principles of healthy transport sectors at the international, national and local level and continues to raise the awareness of the The literature discussed earlier in this report issues. It has proven to be a useful framework suggests that higher density and diversity of for implementing international commitments at land use in urban areas is associated with posi- national as well as local levels. For more infor- tive outcomes including more active transport, mation: http://www.thepep.org. more physical activity and reduced obesity. Pro- motion of walking, cycling and public transport, B ox 7: THE PEP tools and activities such as by providing better infrastructure for these modes, is also associated with more active TH E PEP Toolbox transport and physical activity. Conversely, car The Healthy Transport website (THE PEP-tool- use is not only less active but also poses hazards box) was developed to help policymakers and to other travellers, and moderating these haz- local professionals solve transport problems ards is especially important in cities with high that affect health and the environment. In addi- population density and more vulnerable road tion to tools and promising practices, it contains users such as walkers and cyclists. These strate- policy briefs on selected topics and provides access to information from relevant sources. gies, which aim to concurrently achieve health, It also provides guidance on transport-related transport and climate goals, are summarised in health impacts and sustainable solutions with Table 7. a focus on issues such as road-traffic injuries, Several of these strategies act through the path- air pollution, noise, climate change and physi- way of reducing vehicle kilometres travelled cal activity. More information: (VKT). Reducing VKT can lower emissions http://www.healthytransport.com of air pollutants and of noise. Lower VKT is TH E PEP relay race also associated with fewer road traffic injuries, THE PEP organises regular workshops on inte- although mode shift from car use to walking grating health and environment in transport and cycling needs to be accompanied by meas- policy making at national, regional and local ures to improve safety for users of these vulner- level and on promoting safe and healthy walk- able modes. ing and cycling in urban areas. As such, these workshops encourage cooperation between Improving access by walking, cycling and authorities, industry and civil society and pay public transport can reduce greenhouse gas special attention to national or local conditions. emissions associated with people accessing Experience from neighbouring countries and essential goods, services and other require- cities from across the region inform these work- ments for health and well-being. Travel by these shops and help introduce long-term changes. modes is also more physically active, and pro- Recent workshops included Prohunice (Czech Republic), Skopje (The former Yugoslav Repub- vides more opportunities for social interaction lic of Macedonia) and Batumi (Georgia). than car use. Enabling access by these modes is more equitable, especially for low-income groups who lack access to a car. Increased residential density has the potential to increase proximity to potential destinations, and thus improve access while reducing the need for private motorised transport. However, to maximise benefits, densification of housing needs to be matched by increased density of key destinations such as health and social ser- vices, education and employment opportunities, transit nodes and green spaces. Densification can also bring people in closer proximity to

37 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

the hazards of motorised transport, making it review of strategies to promote active travel to important that dense cities adopt measures to work and school found that the evidence that moderate these hazards. These include reducing the selected strategies were effective at achiev- speed, increasing the separation of vehicles from ing mode shift was very limited (Hosking et al., walkers and cyclists, and improving vehicle 2010). Effective strategies for reorganising land technology to reduce the emissions of air pollut- use may be even more challenging to identify. ants and noise per vehicle. Reducing these haz- However, the effectiveness of some other rel- ards can also remove safety barriers to walking evant measures, such as 30 km/h zones and traf- and cycling – facilitating a shift to these healthy, fic calming for reducing vehicle speeds and inju- climate-friendly modes. ries, is much clearer (Bunn et al., 2003, Grundy While there is increasing evidence that better et al., 2009). A systematic review has also iden- land use planning, increasing walking and tified some effective interventions to promote cycling, and mode shift from cars to public cycling, including infrastructure improvements transportation are all likely to lead to improve- (Yang et al., 2010). Economic measures such as ments in some domains of health, the most fuel pricing, parking charges and pay-as-you- effective strategies for achieving these goals drive pricing may also help encourage mode are not always clear. For example, a systematic shift (VTPI 2010d).

Table 7: ‘Win-win’ transport strategies to maximise health and climate gains

Strategy Key pathways 1. Land use systems that „„ Increases proximity of destinations, reducing need for car travel increase density and and reducing VKT; diversity of uses; „„ Improves access by walking, cycling and rapid transit/public transport; 2. Investment in and provision „„ Improves access by walking and cycling; of transport network space „„ Encourages shift from car use to walking and cycling, reducing for pedestrian and cycle VKT; infrastructure; 3. Investment in and provision „„ Improves access by rapid transit/public transport; of transport network space „„ Encourages shift from car use to rapid transit/public transport, for rapid transit/public reducing VKT; transport infrastructure; 4. Engineering and speed „„ Reducing speed improves safety of walking and cycling; reduction measures to „„ Increasing separation of vehicles from walkers and cyclists moderate the leading improves safety of walking and cycling; hazards of motorised „„ Encourages walking and cycling by reducing safety barriers; transport; „„ Technological improvements reduce production of hazards per vehicle (greenhouse gases, pollutants, noise); VKT: vehicle kilometres travelled

38 Module 5g: Urban Transport and Health

B ox 8: Health Paths in Koprivnica, Croatia To increase the number of people walking for everyday trips, a network of safe, pleasant, barrier-free, well lit and maintained walking paths were designed and implemented in Koprivnica.

B ackground & Objectives Maps detailing the Health Paths were printed in The need to improve walking conditions was per- the form of tear-out pads and delivered to health ceived as an important requirement for increasing professionals and pharmacies alongside the paths, the number of daily walking trips for local people and also the local tourist information office to dis- in Koprivnica. However, in order to attract more tribute to potential users. The reverse side of the people to walk the quality of walking areas must map contains motivational text written by members meet the needs of their most vulnerable users, while of City hospital's Active Access team. Seven sign- the attractiveness of the scenery should also moti- posts were placed at central points of the network vate more citizens to walk for health and which contain enlarged printed maps of the network purposes. To achieve these goals, members of the and a number of information pointers indicating Active Access project team (consisting of health the distance to town landmarks expressed in the professionals, health and sports clubs representa- average walking times. tives as well as town planners and tourist officers) R esults and conclusions were in charge of the design of new improvement There have been several promotion campaigns for of existing walking routes. By studying examples of the Koprivnica Health Paths and evaluation of the similar walking paths networks in Europe (especially new paths revealed the following results: Walk 4 Life), they conducted a detailed walking audit and designed the new walking path network. „„ The health paths network has stimulated organ- ized walking for health amongst local residents. I mplementation „„ Promotion via medical professionals has Prior to their implementation, the potential Health increased the usage of health paths. According to Paths network was audited by various user groups, the medical team's report, about 12 % of patients, including walking and health clubs, and school chil- who have been advised to walk for health, have dren. Suggested improvements included pavement been using the Health paths regularly. repairs, improved crossings, curbs removal, new „„ The percentage of schoolchildren walking to benches and fountains with safe drinking water. school has risen by 2 % in a year, due to the Following these audits, improvements were made increased safety of the walking paths network. by the City of Koprivnica and Municipal utility com- „„ There has been interest for the introduction of pany. The new network contains 4 walking paths of new walking paths to the existing network, espe- 1 km, 2 km, 3 km and 3.5 km respectively, and was cially among formal and informal walking clubs. opened in June 2010. They were named according „„ As a knock on effect to the success of the walk- to their position in the city, important landmarks or ing paths, improvements of pedestrian facilities their sponsors. Sponsors of the paths are organi- in the town centre have also begun. sations responsible for further promotional events Source: Helena Hecimovic, ELTIS Case Study, or activities. http://www.eltis.org

39 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

4.2 Co-benefits of healthy transport reduce emissions while preserving current travel systems behaviours, which avoids the need for substan- tial behaviour change and which may be more Investments in walking, cycling and rapid politically attractive. Entrenched travel behav- transit/public transport can assist the transport iours are thus an important transitional barrier sector to achieve its own objectives by reducing to be overcome if large mode shifts are to be congestion and the need to fund costly road achieved in developed countries. In developing infrastructure (Mohan 2010). Motorised trans- countries that are undergoing rapid motorisa- port has been estimated to lead to social costs tion, there may be particular opportunities to in Beijing of 7.5–15 % of the city’s GDP, with act to restrain growth in car travel before these congestion, along with health and climate costs, travel behaviours become entrenched. a major component of this. Internalising these external costs of motorised transport could thus An important feature of land use and transport lead to congestion, climate and health benefits planning is that decisions relating to these areas (Creutzig and He 2009). Other economic ben- are often made at the local level. This stands in efits arising from reduced motor vehicle use contrast to improved vehicle and fuel technolo- include reduced parking costs and reduced costs gies, which may be more strongly influenced by to consumers (VTPI 2010d). Transport systems decisions at national or global levels. The local with strong walking, cycling and public trans- nature of land use and transport planning may port provisions are also less vulnerable to future make it difficult to ensure that good policies are interruptions in supply of oil or other fuels. consistently implemented for all urban areas. Local decision-makers are thus likely to require Investments in rapid transit/public transport strong guidance and support from national and may also stimulate transit-oriented development, global levels. This may include making local in which urban densification occurs adjacent decision-makers accountable to national gov- to transit nodes, increasing the extent to which ernment for progress on measures to improve potential destinations are accessible without health, as well as technical support to ensure use of private motorised vehicles. Thus, public that the rationale for such measures is fully transport may not only transfer current trips recognised. from car to public transport, it may also have additional land use effects that further reduce Globally, there is still insufficient emphasis on car use, an effect sometimes known as ‘transit the promotion of alternatives to private motor- leverage’. While designing robust studies to ised travel. A WHO survey found that less accurately measure the magnitude of transit than a third of countries had national or local leverage is challenging, existing evaluations sug- policies that promoted walking and cycling gest that long-term reductions in car travel may as an alternative to motorised transport, and be several times higher than the initial increase many also lacked policies to encourage public in public transport travel. Similar effects may transport (WHO 2009b). Transport data and also exist for walking and cycling infrastructure indicators often focus disproportionately on car (VTPI 2010b, FTA 2010). use to the exclusion of walking and cycling, as reflected in a recent European Union report 4.3 Barriers to progress on healthy (EU 2009a). Improvements in these areas are transport likely to be an important part of global efforts to shift travel behaviours. While this module suggests that land use changes and mode shift are the most promis- ing strategies for health, as well as other out- comes such as climate change, many existing recommendations for transport systems (such as those from the Intergovernmental Panel on Climate Change) give greater emphasis to improved vehicles and fuels. One reason for this is that improving vehicles and fuels can

40 Module 5g: Urban Transport and Health

B ox 9: for at least 150 minutes per week. Measuring public health for a sustainable Only 3 % walked 150 minutes per week for leisure, and only 3 % of residents cycled 150 minutes per week transport project in Arequipa, Peru for transport, suggesting that only a small minority of The city of Arequipa, Peru, has been reorganising its residents were getting enough physical activity to meet transport system to include a new 23 km Bus Rapid recommended levels through walking and cycling. There- Transit (BRT) corridor running through the city centre, fore, the results showed that the transport system was and including modernised fleet and feeder lines and not promoting a healthy lifestyle among a large majority bicycle and walking infrastructure. of Arequipa residents.

The project’s goals include reducing greenhouse gas Personal exposure to PM2.5: Average outdoor PM2.5 emissions from transport sources, enlivening public concentrations of 164 µg/m3 (24 hours mean) were spaces and creating a vibrant transit system, alleviating found at bus stops along the future BRT corridor, well the cost of travel and increasing economic competitive- above the WHO guideline value of 25 µg/m3. Inside the ness. Another major goal is to address key public health buses themselves, where passengers were exposed issues that arise from traffic-generated air pollution, to trapped bus fumes, PM2.5 concentrations were even injuries and barriers to healthy physical activity. higher at 222 µg/m3. The very high concentrations found In 2010, the Pan American Health Organization (PAHO), in the buses and their immediate vicinity suggested that working with EMBARQ, the Center for Sustainable introducing low-emission buses as part of the BRT imple- Transport at the World Resources Institute, helped fund mentation could potentially lead to direct and immediate a baseline assessment of traffic safety, physical activity reductions in PM2.5 exposures for those riding the buses, and air pollution before implementation of the transport as well as for people driving and walking along the cor- system changes. PAHO also helped fund a road safety ridor, while also contributing to air pollution mitigation audit, which outlined specific recommendations for in the city as a whole. improvement of the future BRT corridor. The baseline As part of the reorganisation of the transport system, the assessment was a data-driven, field-based review. An public transportation fleet will be renewed and optimised international expert in road safety provided analysis over a four-year period, and will be improved to meet at of traffic fatalities and injuries. A public health expert least Euro 3 standards. The fleet will also use cleaner measured levels of biking and walking activity among fuels, including liquefied gas and ultra-low city residents, among other factors. Lastly, measure- sulphur diesel. While currently there are no bike lanes ments were taken along the future BRT corridor for in Arequipa, the project includes 70 km of bike lanes two weeks of ambient air concentrations of PM2.5, the and 4 km of new pedestrian paths. vehicle-related pollutant most directly associated with excess mortality. A follow-up study, measuring the same To date, the Provincial Municipality of Arequipa has factors, is planned after implementation. The results of built 1.6 km of the trunk corridor infrastructure (Bolivar- the baseline assessment confirmed anecdotal evidence Sucre). Road safety audit recommendations are being of substantial transport-related health impacts, includ- incorporated into BRT infrastructure designs, and the ing the following: remaining works are expected to begin in July 2011, with the integrated transport system to begin opera- Traffic fatalities and injuries: From 2007 to 2009, there tion in early 2013. were 2 288 crashes involving 5 128 people, 320 deaths and 1 081 serious injuries in the city as a whole. Pedes- A follow-up evaluation will be conducted in 2015, and will trians are the major injury victims. Although pedestrians measure public health indicators including air pollution are involved in only 30 % of all traffic accidents, they exposure, road safety and physical activity, enabling constitute 59 % of injury-related fatalities, and 51 % of comparison with the baseline study in 2010. The follow- seriously injured victims. up evaluation will allow policymakers to assess and improve upon decisions, and guide costs and benefits Along the future trunk BRT corridor, there were 350 traffic for future actions. accidents and a total of 321 fatalities and injuries from 2007–2009. Pedestrians were involved in 26 % of the total While much attention has been given to congestion and crashes, nearly double the rate found in northwestern carbon emissions from transport, a public health base- Europe. A large number of these incidents occurred when line can add a public health element to any assessment pedestrians crossed the main road in areas between of a sustainable transport project. This can improve not intersections – where no pedestrian facilities exist. only the environment and urban economy, but help save lives and create a more livable and lovable city. Physical activity: In the baseline study, only 9.9 % of residents citywide were found to regularly walk as a Source: Claudia Adriazola, Salvador Herrera, Alejandra Acosta

41 Sustainable Transport: A Sourcebook for Policy-makers in Developing Cities

cities more accessible by walking, cycling and 5. Summary improved rapid transit/public transport, based Some transport measures are much better for on evidence available that these make a differ- health than others. A rich body of evidence ence to several domains of health. This module accumulated over the past 30 years indicates that has summarised this evidence on the health ben- reduced private motorised travel, increased active efits and risks of different transport strategies. transport and public transport, and improved This module suggests that the goal of healthy land use planning have much greater health transport can be achieved via four main strategies: co-benefits than policies that focus on improv- 1. Land use systems that increase density and ing vehicles and fuels alone. These strategies are diversity of uses; complementary, and should be pursued concur- 2. Investment in and provision of transport rently, but much greater emphasis is needed on network space for pedestrian and bicycle improving land use and travel mode shift. Tar- infrastructure; gets for reducing private motorised travel need to 3. Investment in and provision of transport net- be more ambitious, and achieving these targets work space for rapid transit/public transport; will carry substantial health co-benefits. 4. Engineering and speed reduction measures There are a range of factors that have historically to moderate the leading hazards of motorised favoured private motorised travel over alterna- transport. tives. Transport funding, such as through inter- Several policy-support instruments are available national development mechanisms, has empha- to promote healthy transport, including techni- sised road infrastructure over public and active cal methods for predicting the health impacts transport. Evaluation of transport projects has of transport policies and projects, such as health often neglected or underestimated the health impact assessment (http://www.who.int/hia); eco- and climate change effects of transport, while nomic and financial instruments for promoting transport indicators have often given more healthy transport; and governance mechanisms attention to car-focused measures such as road- that can enable a shift in strategic direction way level of service than to measures applicable towards healthy transport policies. to public transport and active transport. While Healthy transport systems can not only improve data on the relative use of different travel modes population health and wellbeing within cities and is incomplete globally, data quality for active countries, they can also help address key trans- travel, including injuries to walkers and cyclists, port challenges such as congestion and reduce Figure 23a/b/c has often been especially poor. Changes are transport-related greenhouse gas emissions. underway in some of these areas, but will need Increased active The barriers to achieving better land use plan- transport and to be expanded if the goal of healthy transport ning and greater shifts to walking, cycling and public transport, systems is to be fully realised. transit are primarily political rather than tech- and improved Historically, much of the original focus around nological. With greater understanding of their land use planning transport policy and health has been air pol- immediate health benefits, as well as other ben- offer the greatest lution abatement – largely through vehicle efits such as their longer-range climate change health co-benefits. improvements. To obtain greater health co- Photos by Carlos F. Pardo, Bogota, mitigation potential, political interest and will Colombia/Utrecht, Netherlands, benefits, transport strategies should place greater can be bolstered. The sooner such measures are 2007 (left and middle) and Dominik Schmid, Belfast, 2011 (right) emphasis on land use planning that makes implemented, the better for health.

42 Module 5g: Urban Transport and Health

R elated GTZ/GIZ sourcebook R eferences modules and other publications „„ ADVA Center (1999) Road transport, environ- ment and equity in Israel. Tel Aviv. „„ Fletcher J (2011) GTZ SUTP Sourcebook Module 5e: Urban Road Safety (revised ver- „„ Andersen LB et al., (2000) All-cause mortality sion). Eschborn. associated with physical activity during leisure time, work, sports, and cycling to work. In: „„ Grütter J (2007) GTZ SUTP Sourcebook Arch Intern Med, 160(11):1621-8. Module 5d: The CDM in the Transport Sector. Eschborn. „„ Appleyard D & Lintell M (1972) The Environ- mental Quality of City Streets: The Residents' „„ Xie, Q & Alter, C (2010) Urban Transport and Viewpoint. In: Journal of the American Plan- Health: Recommended Reading and Links. Lit- ning Association, 38(2):84-101. erature list available for download at http:// www.sutp.org. „„ Asian Development Bank (ADB) (2002a) Indo- nesian multi-sectoral action plan group on vehicle emissions reduction. Integrated vehi- cle emission reduction strategy; Greater Jakarta, Indonesia. Reducing vehicle emissions in Asia (RETA5937). „„ Asian Development Bank (ADB) (2002b) Multi-sectoral action plan group: integrated action plan to reduce vehicle emission, Viet- nam. Reducing Vehicle Emissions in Asia RETA5937. „„ Asian Development Bank (ADB) (2010) Appli- cability of post 2012 climate instruments to the transport sector: final consultants report. Manila. „„ Babisch W (2008) Road traffic noise and car- diovascular risk. In: Noise Health, 10(38):27-33. „„ Bassett DR, Jr et al., (2008) Walking, cycling, and obesity rates in Europe, North America, and . In: J Phys Act Health, 5(6):795-814. „„ Beaglehole R et al., (2011) Priority actions for the non-communicable disease crisis. In: The Lancet, 2011. „„ Beck LF, Dellinger AM & O'Neil ME (2007) Motor vehicle crash injury rates by mode of travel, United States: using exposure-based methods to quantify differences. In: Am J Epi- demiol, 166(2):212-8. „„ Begum BA, Biswas SK & Hopke PK (2006) Temporal variations and spatial distribution of

ambient PM2.2 and PM10 concentrations in Dhaka, Bangladesh. In: Science of the Total Environment, 358(1-3):36-45. „„ Benkhelifa F, Quang Cu T & Le Truong N (2002) Air pollution and traffic in Ho Chi Minh City: the ETAP approach. In: Transport Plan- ning, Demand Management and Air Quality, Manila, Philippines, 26–27 February, 2002.

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„„ Berglund B, Lindvall T & Schwela DH (Eds) „„ Cervero R, Rood T & Appleyard B (1999) (1999) Guidelines for community noise. Tracking accessibility: employment and hous- Geneva: World Health Organization. ing opportunities in the San Francisco Bay Area. In: Environment and Planning A, „„ Bhatia R & Wier M (2011) “Safety in Numbers” 31(7):1259-1278. re-examined: Can we make valid or practical inferences from available evidence? In: Acci- „„ Cohen AJ et al., (2004) Urban air pollution. In: dent Analysis & Prevention, 43(1):235-240. Ezzati M et al., (Eds) Comparative Quantifica- tion of Health Risks: Global and Regional „„ Boone-Heinonen J et al., (2009) Walking for Burden of Disease Due to Selected Major Risk prevention of cardiovascular disease in men Factors. Geneva: World Health Organization, and women: a systematic review of observa- 2004(2):1353-1433. tional studies. Obesity Reviews, 10(2):204-217. „„ Costello A et al., (2009) Managing the health „„ Borken J (2003) Indicators for sustainable effects of climate change: Lancet and Univer- mobility – a policy oriented approach. In: Jour- sity College London Institute for Global Health nard R (ed) “1st International Symposium Envi- Commission. In: Lancet, 373(9676):1693-733. ronment & Transport”, Avignon: INRETS. „„ Cozens P et al., (2003) Managing crime and „„ Branca F, Nikogosian H & Lobstein T, (Eds) the fear of crime at railway stations - a case (2007) The challenge of obesity in the WHO study in South Wales (UK). In: International European Region and the strategies for Journal of Transport Management, 1(3):121-132. response. Copenhagen: World Health Organization. „„ Creutzig F & He D (2009) Climate change miti- gation and co-benefits of feasible transport „„ Brugge D, Durant JL & Rioux C (2007) Near- demand policies in Beijing. In: Transportation highway pollutants in motor vehicle exhaust: a Research Part D: Transport and review of epidemiologic evidence of cardiac Environment,14(2):120-131. and pulmonary health risks. In: Environ Health, 6 (23). „„ Dannenberg AL et al., (2008) Use of health impact assessment in the U.S.: 27 case studies, „„ Bunn F et al., (2003) Area-wide traffic calming 1999–2007. In: Am J Prev Med, 34(3):241-56. for preventing traffic related injuries. Cochrane Database Syst Rev, 2003(1):CD003110. „„ Davis LW & Kahn ME (2010) International in Used Vehicles: The Environmental „„ Bunn WB, 3rd et al., (2004) A reevaluation of Consequences of NAFTA. In: American Eco- the literature regarding the health assessment nomic Journal: Economic Policy, 2(4):58-82. of diesel engine exhaust. In: Inhalation Toxicol- ogy, 2004, 16(14):889-900. „„ de Hartog JJ et al., (2010) Do the Health Ben- efits of Cycling Outweigh the Risks? In: Envi- „„ Campbell-Lendrum DH, Corvalán CF & ronmental Health Perspectives, Prüss–Ustün A (2003) How much disease 118(8):1109 -1116. could climate change cause? In: McMichael AJ, ed. Climate change and human health: risks „„ de Jong R (2002) The environmental impact of and responses. Geneva: WHO, WMO, UNEP. cities. Habitat debate; UN-Habitat, United Nations Human Settlements Programme, „„ Cavill N, Kahlmeier S & Racioppi F, (Eds) 8(2):5. (2006) Physical activity and health in Europe: evidence for action. Copenhagen: World „„ Dijkema MBA et al., (2008) Air quality effects Health Organization. of an urban highway speed limit reduction. In: Atmospheric Environment, 42(40):9098-9105. „„ Centers for Disease Control and Prevention (2000) How land use and transportation sys- „„ Dora C & Racioppi F (2003) Including health tems impact public health: a literature review in transport policy agendas: the role of health of the relationship between physical activity impact assessment analyses and procedures in and built form. Atlanta. the European experience. In: Bull World Health Organ, 81(6):399-403. „„ Cervero R et al., (2009) Influences of Built Envi- ronments on Walking and Cycling: Lessons „„ Dora C and Phillips M (2000) Transport, envi- from Bogotá. International Journal of Sustain- ronment and health. Copenhagen: World able Transportation, 3(4):203 - 226. Health Organization.

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