What role for environmental public health practitioners in promoting healthy built environments?

Rideout, Karen ; Kosatsky, Tom ; Lee, Karen K. 等

While the built environment (BE) has long been of interest to public health practitioners, widespread reengagement of public health agencies in community planning is a phenomenon of the last decade. In 1854, John Snow identified the Broad Street water pump as the source of a cholera outbreak in London. (1) Since then, public health authorities have championed introduction of sanitary and safe water infrastructures to control infectious disease. (2) Early efforts to separate urban residents from industrial pollution culminated in modern zoning bylaws. (2-4) To address the roots of chronic diseases, many public health agencies now seek to reduce negative and augment positive attributes of our human-built physical surroundings through greater social connectedness, more physical activity, and improved access to affordable healthy food. While some agencies have partnered with and funded community organizations to initiate BE projects, most focus on advocacy and support for local government initiatives. Doing so involves injecting a population health focus into local government planning based on an understanding of how the BE influences health.

Historically, public health agencies sought to protect people from hazards in the BE, but increasingly they promote healthier BEs as a way to support healthy behaviours. A 2003 commentary in the Journal of Law, Medicine and Ethics reviewed the historical links between public health and urban planning and advocated for increased public health intervention in the built environment as a tool to both prevent illness and promote well-being. (2) Although the authors noted the value of BE interventions to protect communities from environmental toxins, they did not specify a role for environmental public health (EPH) practitioners per se.

EPH practitioners in North America have clear mandates to protect people from infectious or toxic agents in food, water and other environmental sources, including those mediated by the BE. They are thus well situated to take a lead in advocating for--and implementing interventions in--BEs that both protect and promote health. With strong evidence for the influence of BE features on behavioural risk factors for non-communicable diseases (e.g., walkable communities reduce physical inactivity (5)), the time is right to explore the role of EPH and other public health professionals in supporting healthier built environments. In this paper, we use examples from the authors' experiences in British Columbia (BC) and New York City to show how EPH practitioners have begun to incorporate BE initiatives into their practice and suggest ways to expand this role across health departments in Canada.

Existing intersections between environmental public health and the built environment

Some environmental health agencies have integrated a BE focus into traditional mandates and practices of EPH; some have created parallel teams to promote healthier BEs; and others work with health promotion professionals on BE issues. Although not always framed specifically as BE work, their efforts fall into three main areas of practice. First, typical EPH roles include food premises inspection and permitting, waste management, safe housing, and oversight of air and water, all of which impact the quality of the built environment. Second, EPH practitioners assess and respond to innovative local-level BE interventions that flag concerns for health protection, such as backyard poultry by-laws, standards for siting community gardens, active transportation networks and mixed land use zones. Third, some EPH professionals participate in community planning processes around land use and transportation, allowing them to raise awareness of the links between the BE and chronic disease prevention. (6) In some jurisdictions, approval of local public health authorities is required for land-use plans, (7) a powerful tool to ensure that both acute and chronic health considerations are incorporated into BE planning.

Expanding the scope of environmental health

Many public health agencies have tasked EPH professionals with using BE initiatives (e.g., active and sustainable transportation, mixed-use neighbourhoods, green space, community gardens, safe and accessible housing) as a tool to support their ongoing role in health protection while contributing to chronic disease prevention. (6) This is aligned with public health's increasing focus on the determinants of health and healthy communities, (8) along with a recognition that hypertension, physical inactivity and overweight/obesity are the leading risk factors for mortality today (responsible for 7.5, 3.2 and 2.8 million annual deaths globally). (9) In addition to support from health system management, assumption of this expanded responsibility demands that practitioners reimagine their roles, develop competency on BE issues related to chronic diseases, strengthen relationships with other public health professionals, and collaborate with other sectors.

We see four areas where EPH practitioners could leverage their skills and authority to operationalize a BE focus (see Table 1 for additional details and examples):

* Inspections and/or Permitting. BE interventions could be added to existing functions without requiring significant resource requirements. In BC and New York City, oversight of menu labelling and trans-fat restriction has been incorporated into routine restaurant inspections (Table 1). A similar application of public health authority could require building features that reduce pollutant and noise exposure (for example, through building permits and during inspections in response to health and safety complaints) as well as promote minimum physical activity time allotments in daycare licences.

* Oversight of Land Use Planning. Many health authorities review community or regional land use and transportation plans (Table 1). (7) EPH professionals could further develop relationships with planners and leverage this opportunity to promote, or even require, healthy development that includes amenities for active transportation, gardening and healthy food access. Similarly, they could advocate for zoning bylaws or land development policies that ensure access to green space or healthier food options.

* Health Hazards Legislation. Public health officials have legal authority to enact special measures to safeguard the public from health hazards. These measures typically address immediate or acute hazards associated with drinking water or the spread of communicable disease, but could be used to control hazards in the BE that lead to chronic disease outcomes. The BC Public Health Impediments Regulation was used to restrict trans fats in foods offered at licenced food premises (Table 1). EPH practitioners could work with provincial authorities to invoke health impediments regulations to require access to green space, prevent a high concentration of fast-food outlets in specific areas, or implement other health-based modifications to the built environment.

* Collaboration and Advocacy. EPH practitioners have worked with clients and partners within public health and in social services, education, local government planning and transportation on BE initiatives (Table 1), including advocacy for and implementation and evaluation of BE policies and interventions, and participation in community consultation processes. Together, their actions could encourage BE features or policies such as: neighbourhood designs that incorporate mixed land uses and complete streets to encourage walking and cycling; kitchens, exercise facilities, public transportation links, and secure bicycle commuting facilities in workplaces; low emissions building materials; social housing policies that protect residents from exposure to environmental tobacco smoke through better building construction and indoor air quality regulations; subsidized housing with healthy amenities, such as gardens and physical activity spaces, that are already present in many market rate housing developments; or messages to increase awareness and use of those features. (10)

While reorganization of financial and human resources may be necessary to enlarge the scope of environmental health to explicitly include the BE, early efforts have led to measureable health improvements. Dedicated pedestrian and cycling infrastructure has been associated with increased physical activity, (5) decreased traffic injuries among pedestrians, cyclists and motorists, (11) and could lead to improved air quality. (12) Although not a modification of the built environment per se, BC's AirCare vehicle emission control program resulted in decreased traffic pollution and cardiovascular-related hospital admissions. (13) Bans on smoking in public places throughout North America have lowered public exposure to environmental tobacco smoke. (14) Such "big picture" interventions make healthy behaviours not just an easier choice, (15) but the default choice. They expand traditional regulatory approaches for acute hazard control to include chronic health hazards, as well as advocacy and education to facilitate prevention and control of chronic diseases. A broadened scope for environmental health could 1) create BEs with fewer acute health hazards, decreasing the need for conventional health protection, 2) impact a wider range of population-wide behaviours needed to prevent and control the current chronic disease epidemics, thus realizing multiple health benefits with modest resource additions, and 3) increase access to resources for EPH through collaboration.

Beyond removing the pump handle: Long-term improvements to public health

A broadened environmental health mandate would mean a shift from safeguarding health merely through control of immediate hazards and infectious disease agents to protecting people from environments that do not broadly support health. While John Snow protected Londoners from an ongoing cholera outbreak by removing the Broad Street pump handle, clean water infrastructure is a contemporary BE intervention that supports health by preventing water-borne disease. Just as North Americans have come to expect protection from food- and water-borne illness, residents of BC and New York now expect to have access to separated bike routes in busy urban neighbourhoods and to dine out in environments protected from trans fats. Shouldn't that combination of environmental health protection and promotion be the case everywhere?

REFERENCES

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Received: July 15, 2015

Accepted: September 27, 2015

Karen Rideout, PhD, [1] Tom Kosatsky, MD, MPH, [1-3] Karen K. Lee, MD, MHSc [4]

Author Affiliations

[1.] Environmental Health Services, BC Centre for Disease Control, Vancouver, BC

[2.] National Collaborating Centre for Environmental Health, Vancouver, BC

[3.] School of Population and Public Health, University of British Columbia, Vancouver, BC

[4.] Dr. Karen Lee Health + Built Environment + Social Determinants Consulting, New York, NY

Correspondence: Karen Rideout, PhD, Environmental Health Services, BC Centre for Disease Control, 0073-655 West 12th Avenue, Vancouver, BC V5Z 4R4, Tel: 604-829-2544, E-mail: karen.rideout@bccdc.ca

Acknowledgements: The authors thank Sandra Gill, Claire Gram and Dr. Lisa Mu for clarifying how built environment teams were integrated into regional health authorities, and Tina Chen and Emily Peterson for comments on an earlier version of this manuscript.

Conflict of Interest: None to declare. Table 1. Opportunities to expand the scope of EPH action on health and the built environment Existing Examples in current Suggestions/ roles practice opportunities for expanded mandate Inspections Food premises: In BC and Enforce standards or and/or New York City, inspectors regulations for features permitting enforce restrictions on such as healthy food and trans fats in foodservice beverages and scheduled operations. *, ([dagger]) physical activity time Daycares: In New York for children. City, daycare inspections include a review of daily lesson plans for exercise periods (60 min/day is mandated) and of menus and purchase orders to ensure food and beverage options meet standards for daycares. ([double dagger]) Oversight In BC's Interior Health Include impacts such as of land Authority, public health food security, food use officials, including access, walkability, etc. planning dietitians and in land use/development environmental health assessment/approval officers, review processes. Develop zoning development applications bylaws and incentives to to assess impacts on foster voluntary health. ([section]) The initiatives that create New York City Department healthier environmental of Health and Mental supports. Hygiene created a new category of permits for street food vending that are faster to obtain if selling fresh fruit and vegetables in neighbourhoods with insufficient availability of fresh produce. ([parallel]) Health In BC and New York City, Declare BE features as hazards trans fat is considered a health hazards, e.g., legislation health impediment and neighbourhoods without therefore is not walkable connections or permitted in food served stairwells that are by licensed food locked or not clearly premises. *, ([dagger]) marked, and require that the public not be exposed to such hazards. Collaboration The New York City Advocate for policies and advocacy Department of Health and that support healthier Mental Hygiene worked BEs, e.g., smoke/free with 11 other departments policies or childcare to produce the Active services in social Design Guidelines for the housing developments. city ([paragraph]) as Develop guidance and well as supplements regulations that are addressing safety, designed to impact affordable housing and current disease epidemics sidewalk design. ** By and/or encourage healthy working with the behaviours. Department of Buildings, building code changes were also made to allow magnetic hold open devices on stair doors to increase visibility of stairwells in buildings while maintaining fire safety. ([dagger][dagger]) In BC, a group of public health, local government, research and planning professionals collaborated to produce the Healthy Built Environment Linkages Toolkit to highlight evidence for the links between BE features and health outcomes. ([double dagger][double dagger]) Existing Public health roles Opportunities and roles co-benefits Inspections Public health inspectors Front-line inspectors and/or or licensing officers can have access to indoor permitting incorporate into existing areas, and can identify inspection procedures. challenges and barriers Population health to compliance. Research professionals (e.g., on public response and dietitians and physical behaviour change can activity professionals) inform more effective or childcare approaches. professionals can identify levers for action, develop policies and/or provide implementation guidance. Bylaw officers can aid in enforcement. Oversight Specific BE teams within Public health of land EPH take responsibility participation in use for healthy planning. development processes planning Alternatively, staff will directly influence involved in reviews and determinants of health in approvals of land use the BE and highlight how plans could be trained to the built environment include considerations influences health. for environments that Evaluation of uptake of protect health incentives and outcomes comprehensively. Health with respect to behaviour inspectors can promote change will inform future minimum standards for programs. Opportunity for comprehensive health and/ public health or voluntary initiatives professionals to when new businesses apply collaborate with other for permits. Planners, sectors to create BEs engineers, local that better support governments, and private health. sector developers can work with public health staff in planning processes. Health Officials such as medical Enforcement activities hazards health officers can are also opportunities to legislation declare evidence-based engage in health health impediments. promotion. Using Specific BE teams within legislation in this way EPH can enforce through provides an opportunity inspection, planning or for a cross- permitting processes. jurisdictional approach to public health. Collaboration EPH and other public Policy, regulations or and advocacy health professionals can institutionalized work together to plan and guidelines create advocate. Inspectors can universal change for more enforce or engage in equitable approaches to protection of health addressing the comprehensively during determinants of health, inspection and permitting and are resilient to processes. Dedicated BE changes in government teams within EPH can work priorities. Public health with planners, engineers, can influence non-health local governments, policies by partnering architects, financiers, within public health and industry, schools, park with non-health sectors. officials and others. Intervention research can clarify how BE changes impact health. Existing Limitations and challenges roles Inspections Inspections may require more time and thus and/or moderate increases in personnel. Field staff and permitting supervisors need training and capacity building to understand, implement and interpret new regulations. Oversight Mandated requirements are needed to support the of land authority of public health officials in review and use approval of development applications; to start, planning voluntary checklists to assess and make suggested improvements to healthy food access, walkability, etc. can be incorporated into development application reviews. Public health officials will need to engage across sectors and with multiple levels of government. Health Inspections may require more time and thus hazards moderate increases in personnel. Field staff and legislation supervisors need training and capacity building to understand, implement and interpret new regulations. Collaboration Support from non-health jurisdictions is required and advocacy to enact legislation outside health. * Yandel M, Cadenhead K, Pawa B, Cramb L. BC's new trans fat regulation. BC Medical Journal 2009; 51:268. ([dagger]) New York City Health Code, Section 81.50: http://rules.cityofnewyork.us/tags/section-8150. ([double dagger]) Notice of Adoption of Amendments to Article 47 of the New York City Health Code: http://rules.cityofnewyork.us/tags/article-47. ([section]) Interior Health--Subdivision of Land.Available at: https://www.interiorhealth. ca/YourEnvironment/HBE/Pages/Subdivision-of-Land.aspx (Accessed May 16, 2016). ([parallel]) New York City Department of Health and Mental Hygiene--Green Carts: https://www1.nyc. gov/site/doh/health/health-topics/green-carts.page. ([paragraph]) Active Design Guidelines: Promoting Physical Activity and Health in Design: http://centerforactivedesign.org/guidelines/. ** Active Design Guideline Supplements: 1.Active Design Supplement: Promoting Safety, 2.Active Design: Affordable Designs for Affordable Housing, 3.Active Design: Shaping the Sidewalk Experience: http://www.drkarenlee.com/resources/usa. ([dagger][dagger]) The New York City Council, Hold-open devices and automatic closing of exit doors serving vertical exit enclosures: http://legistar.council.nyc.gov/ LegislationDetail.aspx?ID=1687949&GUID=CE583810-3E77-452C-966F- CCDD9AFC8B74&Options=&Search. ([double dagger][double dagger]) Healthy built environment linkages: A toolkit for design, planning, health: http://www.phsa. ca/Documents/linkagestoolkitrevisedoct16_2014_full.pdf.