FEATURES

REFERENCES

FIGURE

TABLE

SPECIAL REPORT

Public Health: Seattle and King County’s Push for the Built Environment

Karen Roof, M.S. Ngozi Oleru, Ph.D.

Introduction The Built Environment Historically, environmental health and In Seattle and King County, Washington, and Broadly defined, the built environment is planning professionals had closer ties. In nationwide, evidence shows that decisions the human-made space in which people the early 1900s, some land use planners about how we use land and build our environ­ live, work, and recreate on a day-to-day championed health as a key issue for the ment have significant impacts on individual basis. It includes the buildings and spaces planning profession. This social planning and population health, safety, and well-being. we create or modify. It can extend overhead movement was expressly interested in ten­ Land use and built environments also impact in the form of electric transmission lines ement housing issues, public health, and community networks, economic growth, en­ and underground in the form of landfills industrial abuse conditions. The planners vironmental sustainability, and social justice. (Department of Health and Human Ser­ were also concerned about how planning In the past century, awareness of the negative vices [HHS], 2004). The design of our decisions could not only control but pre­ health effects and disparities due to impacts built environment affects the possibility of vent diseases such as tuberculosis (Wir­ from the built environment has grown, but a injury related to pedestrian and vehicular ka, 1996). Similarly, prominent planners lack of knowledge, recognition, and viable data accidents, and it also influences the pos­ as late as the 1930s reiterated that good remains about the connection between the sibility of exercise and healthy lifestyles. planning was truly efficacious in creating built environment and health (Jackson, 2003). Lack of physical activity causes overweight social harmony, but only if it “embodied problems in adults and children, increases a genuine rationality and justice in the Background the risk for serious illnesses, and contrib­ structure of society (Fishman, 1977).” But People ask why health professionals are in­ utes to premature death (Frank, Engelke, by the 1940s, with the postwar population creasingly getting involved in land use plan­ & Schmid, 2003). Given the clear relation­ and infrastructure needs, “social” plan­ ning and smart growth issues. Data from a ship between exercise and chronic diseas­ ners’ voices faded and traditional town King County study makes the answer clear: es such as diabetes, asthma, and obesity, planning gave way to a mass housing residents of “walkable” communities are building relationships between planners boom that created new suburbs and vastly more physically active and less overweight, and health officials is both timely and different lifestyles (Kelly, 2000). This was breathe cleaner air, and lead healthier life­ essential. Environmental health profes­ especially true in new communities built styles (Frank, 2005). But long before this sionals can provide added value by giv­ around driving rather than around walk­ study was completed, the Environmental ing planners strong health data to support ing and biking. Health Division of Public Health Seattle and “smart growth” designs and zoning and King County (PHSKC) was already focused initiatives that promote a healthier envi­ Seattle and King County Population on the issue. Specifically, in 2004, PHSKC ronment and improved quality of life for and Obesity chose land use, built environment, and health all. Their involvement also can help make In King County, by 2004, 54% of the 1.8 (LUBEH) as one of its top three strategic di­ the case for effective street and trail con­ million residents were overweight or obese rections. Currently, this project involves edu­ nectivity and design, allowing the public to compared to 37% in 1987; similar increases cating staff about land use planning, building move around smoothly and safely, breathe in obesity and overweight occurred nation­ relationships with planners, engaging in cleaner air, drink clean water, and interact ally. King County is the largest county (by policy development, and planning local land in quieter, more cohesive neighborhoods. population) in Washington and the twelfth use-related projects. This case study presents Conversely, planners can provide health largest in the U.S. King County is approxi­ a four-phase process (see Figure 1) used by professionals with knowledge of zoning mately the size of Delaware, with 39 cities PHSKC, Washington, to promote and inte­ and other planning practices and opportu­ and unincorporated areas. Between 1960 grate public health issues into community nities and options for engagement in the and 2000, the population more than dou­ planning and land use decisions. planning process. bled, adding to transportation deficiencies

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JEH7-8.08_PRINT.indd 24 7/2/08 6:13:00 PM FEATURES

REFERENCES

FIGURE 1

Seattle and King County’s Process for Integrating Health into Community Planning and Land Use Decisions

PHASE 1 PHASE 2 PHASE 3 PHASE 4

Educate Staff Get Involved in Collect Data to Focus on Health and Build Policy Change Support and Impact Assessment Partnerships and Planning Prioritize Efforts (HIA) TABLE Processes

and poor air quality. The county’s southern quality, toxic exposure, safety, injury pre­ Commissioners, King County planning di­ region and metropolitan Seattle have higher vention, environmental and social injustice, rectors, and a variety of regional council populationsSPEC ofIAL low incomeREPOR residents T and physical inactivity, obesity and overweight, policy boards. people of color. The south region also has mental health, and social cohesion. a significantly higher average rate of obe­ Several opportunities were then provided Phase Two: Get Involved in sity (60.8%) than the rest of the county. to all staff to become more familiar and en­ Policy Change and Planning Obesity and overweight rates, diabetes and gaged in the LUBEH issue. For example, the Processes heart disease are highest among certain health department hosted presentations by PHSKC next began to focus on policy change ethnic groups, such as African Americans, local and national speakers, including cur­ by incorporating health language into re­ American Indians, and Alaska natives (King rent and former leaders at the Centers for gional and local land use plans. The health County, 2006). These inequities in overall Disease Control and Prevention National department was successful in advocating for health status are based on race, education, Center for Environmental Health (CDC/ the inclusion of public health considerations and economic status (Communities Count, NCEH): Dr. Andrew Dannenberg, Dr. How­ into regional, county, and city planning docu­ 2005). Regrettably, negative impacts from ard Frumkin, and Dr. Richard Jackson. Ad­ ments, including the PSRC Vision 2020 plan, land use decisions are not fairly distribued ditionally, the 2005 environmental health a countywide resolution, and the King County through all communities, thereby resulting education conference was dedicated solely comprehensive plan. in health inequity for populations of color to LUBEH and featured several local public and persons with disabilities. health, planning, and transportation practi­ Puget Sound Regional Council—Vision tioners and experts. 2020 Plan Phase One: Educate Staff and The next task for PHSKC after initiating In 2004, PHSKC learned that the four-county Build Partnerships internal capacity building was to reach out regional plan for the Puget Sound region— PHSKC’s environmental health (EH) division to planners across the region. PHSKC made Vision 2020—was going to be updated. began focusing on the issue of health, land great progress developing partnerships with PHSKC provided a list of health issues and use planning, and the built environment in planning agencies, including the Puget comments on those issues for consideration. December 2003. Discussions began with an Sound Regional Council (PSRC), planning PHSKC also met with PSRC to offer support internal interdisciplinary team called the en­ agencies of King County, city of Seattle, and and expertise. PHSKC convened the other lo­ vironmental health community assessment a number of suburban cities. PHSKC cur­ cal health directors in the region to discuss team (EHCAT). The team consisted of the rently consults with planners from these the importance of land use policies, and the EH director, deputy director, health educa­ organizations on a routine basis, not only need for local health jurisdictions to be at the tor, and the section manager, all from the about individual development plans, but table and advocate for a chapter on health in EH division. Other members include staff also for jointly conducting outreach and the Vision 2020 plan update. The regional from the community-based public health advocacy activities. For example, PHSKC council invited the regional health depart­ practice unit (regional health officers and participated in planning meetings for the Se­ ments to draft a health issue paper titled, health educators), epidemiology, planning attle neighborhood business district strategy “What’s Health Got to Do with Growth Man­ and evaluation unit, and the prevention di­ and the Seattle street design manual. The agement, Economic Development, and Trans­ vision. EHCAT was convened to facilitate planning agencies continue to participate portation? (Puget Sound Regional Council, the integration and visibility of EH issues in in PHSKC’s overweight prevention forum 2004)” that was jointly presented in 2005 to the day-to-day activities throughout the de­ and environmental health annual education PSRC’s growth management policy board by partment. One team priority was to develop conference. EH staff make joint presenta­ PHSKC’s health director, King County’s board a list of areas of concern of adverse health tions with planners to state and local associ­ of health chair, and PSRC staff. effects due to the built environment, includ­ ations with decision-making power, such as The issue paper included items such ing ambient and indoor air quality, water the Washington State Association of County as guidance for addressing health issues,

July/August 2008 • Journal of Environmental Health 25

JEH7-8.08_PRINT.indd 25 7/2/08 6:13:00 PM employees as model work sites), supporting leaders. While the initial goals of the study the implementation of “safe and active routes were to look at ways of improving integra­ to schools and transit” program, supporting tion between land use and transportation the completion of deficient pedestrian and planning, the significance and relevance bicycle links in King County, and partner­ of public health issues led the county ex­ ing with academia and our communities to ecutive to expand the study to explore the promote evidence-based practices and evalu­ health implications and potential strategies ate and disseminate results regularly. To see for integrating health, land use, and trans­ this resolution, go to: http://www.metrokc. portation planning. Among the findings of gov/health/Boh/res0508.pdf. For an updated this groundbreaking study (Frank, 2005) 2007 version, go to: http://www.metrokc.gov/ are the following: health/Boh/res0703.pdf. • Residents of the most pedestrian-friendly ar­ eas of King County were more physically ac­ King County Comprehensive Plan tive and less overweight than those in areas In 2004, PHSKC also was involved to a with fewer pedestrian-friendly amenities. lesser extent in the update and adoption of • Transit and walking go together—people the King County comprehensive plan. King choose to walk more when transit choices County developed one of the first compre­ are near. A community offering sidewalks and street hensive plans in the nation that prioritizes • Greater amounts of interconnectivity in connections encourages healthy physical activity, such as biking and walking, for both public health, outlines several health-relat­ an area translates into fewer miles driven children and adults. ed goals, and uses health as a rationale for in cars. creating livable communities. The follow­ • Individuals in the most pedestrian-friendly ing is taken from the comprehensive plan: neighborhoods are 2.4 times more likely to preliminary implementation actions and “Focusing development in urban areas can get 30 minutes of exercise a day. strategies, and guidance for measurable ob­ have a positive effect on public health. The For summary of this study, visit: http:// jectives to monitor health considerations. percentage of King County residents who www.metrokc.gov/exec/news/2006/pdf/ Some of the guidance recommended in the are overweight or obese has risen rapidly LUTAQHupdated.pdf. issue paper included identifying public since the late 1980s. With obesity comes health benefits in urban growth and trans­ an increased risk for diabetes and heart Phase Four: Focus on Health portation provisions, incorporating provi­ disease. Evidence demonstrates one ma­ Impact Assessment sions for health and well-being into local jor reason for rising obesity is the lack of Health Impact Assessment (HIA) is a tool comprehensive plans, establishing goals physical activity. Growth patterns in sub­ that uses qualitative or quantitative data to to increase bicycle and pedestrian travel, urban areas, which discourage walking assess the public health consequences of a and improving access to health facilities. and promote a reliance on private auto policy, project, or program with a special fo­ The council’s board agreed to incorporate use, have contributed to this public health cus on social equity. This includes identifying health concerns into all chapters in the Vi­ problem. Communities that feature many and assessing potential positive and negative sion 2020 plan. This is a dramatic achieve­ land uses, higher housing density, side­ health impacts due to various development ment and is extremely unusual nationwide. walks and street connections and nearby projects and plans. Information on the plan is at PSRC’s Web services encourage physical activity such With funding from the HHS Steps to a site, www.psrc.org. as walking and bicycling (King County HealthierUS initiative, PHSKC began to Comprehensive Plan Update, 2004).” (See examine how the use of an HIA could cre­ County-Wide Resolution photo at left). To view the entire King ate more opportunities to consider health in PHSKC was also instrumental in the devel­ County comprehensive plan, go to: http:// land use projects and policies. PHSKC con­ opment of a 2005 resolution that was adopt­ www.metrokc.gov/ddes/COMPPLAN/2004/ vened an internal steering group to review ed by King County’s board of health titled, index.htm; see chapters on “Urban Com­ the methodology and invited experts from “Recommending a Comprehensive Strategy munities” and “Transportation.” around the country to speak on their experi­ to Promote Healthy Eating and Active Liv­ ences with HIA. ing in King County.” The resolution was cre­ Phase Three: Collect Data to PHSKC has been involved in a pilot HIA ated and adopted as part of the department’s Support and Prioritize Efforts project looking at health factors related to focus on the obesity epidemic and its goal PHSKC played a key role by providing data neighborhood development near a future of decreasing the prevalence of this public in scoping the “Land Use, Transportation, rail transit stop. The HIA has included health problem. Among the action steps in Air Quality, and Health” (LUTAQH) study reviewing the potential relationship of the resolution are assisting school districts’ that was commissioned by the King County changes to health promoting factors, such development and implementation of nutri­ executive and supports the health goals of as physical activity, safety, social connect­ tion and physical activity policies, enhanc­ the comprehensive plan. The findings sup­ edness, and equal access. The HIA process ing employers’ efforts to promote nutrition port an aggressive and collaborative ap­ has increased PHSKC’s presence in city and physical activity through work site well­ proach to built-environment challenges planning efforts and allowed for continued ness programs (starting with King County with strong engagement from political discussions and involvement.

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JEH7-8.08_PRINT.indd 26 7/2/08 6:13:01 PM Wisdom from Experience Successes and Looking Ahead Due to the degree that land use decisions • Don’t center all discussions around the PHSKC chose land use and the built en­ influence underlying determinants of envi­ “popular” obesity issue, because at some vironment as a priority within the health ronmental and community health, it is of the point that will be out of the headlines. The department and has made great strides in utmost importance that local governments built-environment and health issue is much quickly advancing this effort; they also develop coherent strategies and purposefully more comprehensive—encompassing air, are seen as a leader on this issue through­ continue to integrate health considerations water, land, food, and social justice. out the state and nationally. This has been into land use planning. Today, most regions • Engage staff in understanding “institu­ achieved mainly through educating agency like Seattle and King County must diligent­ tional racism” and how to undo it. Ad­ staff, building strong relationships and ly ensure that more efficacious planning, dressing racism is critical for a shared credibility with planners, and actively and policies, and collaboration are attained for understanding of the root causes of health effectively engaging in policy development healthier and more just communities. inequity embedded in land use and built- and in land use planning projects. The cre­ environment decisions and in meaningful­ ation of the multidisciplinary team early on Acknowledgements: Thanks to Nadejda ly engaging the community and ensuring in the process was key to their past and to Mishkovsky from International City/County health equity and social justice. PHSKC their future success. The continued diverse Management Association (ICMA), Hilary sends staff to the “Undoing Institutional viewpoints and expertise will help shape Karasz from Public Health-Seattle and King Racism” workshop. For more informa­ agendas, planning documents, priorities, County, and Andrew Dannenberg from tion, visit: http://cityofseattle.net/human­ and outcomes. After laying this foundation, Centers for Disease Control and Prevention services/uir/Fact_Sheet.htm. PHSKC, specifically the environmental National Center for Environmental Health • A broad definition of environmental health health division, is now poised to take the (CDC/NCEH) for reviewing this document. is needed to ensure sustainability of fund­ next important steps. This entails focusing Thanks also to Susan Jerles from NEHA for ing, programmatic momentum, and sup­ primarily on education and engaging the coordinating efforts throughout this process port. For example, the definition needs community more in partnerships; develop­ to complete this article. to encompass how the built environment ing a literature library of research and case affects chronic diseases. This argument study information; identifying future col­ Corresponding Author: Ngozi Oleru, Director, should be used to acquire funding for en­ laborative planning activities; involving the Environmental Public Health Division, Public vironmental health and land use planning business community; and building more Health-Seattle and King County, 401 5th Ave., issues, particularly disease prevention. partnerships locally, statewide, and nation­ STE 1100, Seattle, WA 98104. E-mail: ngozi. • Planning professionals welcome health ally. Additionally, PHSKC wants to include [email protected]. agencies at the table when these agencies developers as partners in future initiatives can be seen as another advocate for good and to educate state-level officials about Karen Roof has a consulting business and is FcommunityEATURES design. Also, the ability to pro­ health concerns, so that they become vest­ faculty at the University of Colorado Denver. vide evidence-based information on the ed contributors in creating healthier com­ E-mail: [email protected]. connection between the built environment munities by building safer environments and health is powerful. and supporting policy decisions.

REFERENCES

Communities Count. (2005). Social and Health Indicators Across Kelly, E.D., & Becker, B. (2000). Community planning: An introduction King County (pp. 73–86). Retrieved August 26, 2006, from http:// to the comprehensive plan (p. 211). Washington, DC: Island Press. www.communitiescount.org/Cc2005d_SafetyAndHealth.pdf King County. (2006). Health of King County 2006. Retrieved Octo­ Fishman, R. (2003). Urban Utopias: Ebenezer Howard, Frank Lloyd ber 2006, from http://www.metrokc.gov/health/hokc Wright, and Le Corbusier. In S. Campbell & S. Fainstein (Eds.), Puget Sound Regional Council. (2004). Vision 2020 + 20 update. Issue Readings in Planning Theory, 2nd ed. (pp. 21–23). Malden, MA: paper on health: What’s health got to do with growth management, eco­ FBlackwellIGUR Publishing.E nomic development and transportation? Retrieved October 19, 2007, Frank, L. (2005). A study of land use, transportation, air quality, and from http://www.psrc.org/projects/vision/pubs/health.pdf health in King County. Retrieved October 2006, from http://www. U.S. Department of Health and Human Services. (2004). Obesity metrokc.gov/kcdot/tp/ortp/lutaqh/execsummary092705.pdf and the built environment. Retrieved February 1, 2006, from http:// Frank, L., Engelke, P., & Schmid, T. (2003). Health and communi­ grants.nih.gov/grants/guide/rfa-files/RFA-ES-04-003.html ty design: The impact of the built environment on physical activity Wirka, S.M. (1996). The city social movement: Progressive women (p.79). Washington, DC: Island Press. reformers and early social planning. In M. Corbien Sies & C. Silver Jackson, R.J. (2003). The impact of the built environment on (Eds.), Planning the twentieth-century American city (pp. 55–75). TABhealth: LEAn emerging field. American Journal of Public Health, 93, Baltimore: Johns Hopkins University Press. 1382–1383.

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