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America's health threat: Poor urban design

Researchers can have revelatory moments in remarkable places—the African savannah, an ancient library, or the ruins of a lost civilization. But Richard J. Jackson's epiphany occurred in 1999 in a banal American landscape: a dismal stretch of the car-choked Buford Highway, near the Centers for Disease Control and Prevention in Atlanta.

Dr. Jackson, who was then the head of the National Center for Environmental Health at the CDC, was rushing to a meeting where leading epidemiologists would discuss the major health threats of the 21st century. On the side of the road he saw an elderly woman walking, bent with a load of shopping bags. It was a blisteringly hot day, and there was little hope that she would find public transportation.

At that moment, Dr. Jackson says, "I realized that the major threat was how we had built America." His center had already been dealing with problems that he suspected had origins in the built environment—asthma caused by particulates from cars and trucks, water contamination from excessive runoff, lead poisoning from contaminated houses and soil, and obesity, heart conditions, and depression exacerbated by stressful living conditions, long commutes, lack of access to fresh food, and isolating, car-oriented communities.

Treatments could come in the form of pills, inhalers, and insulin shots, but real solutions had bigger implications. "More and more, I came to the conclusion that this is about how we build the world that we live in," he recalls, speaking over the phone from San Francisco.

Dr. Jackson, who is now a professor and chair of environmental health sciences at the University of California at Los Angeles's School of Public Health, has become one of the leading voices calling for better urban design for the sake of good health. Georges C. Benjamin, executive director of the American Public Health Association, says that Dr. Jackson's work has been highly influential in public health and public policy. Dr. Benjamin first started talking with Dr. Jackson about the links between urban design and public health in the 1990s.

"It was an eye-opening moment for me," Dr. Benjamin says, adding that those links have since become widely accepted among public-health specialists. Dr. Jackson's work, he says, "gets people who do not view themselves as health providers or health practitioners to begin thinking about their role in public health."

John Norquist, president of the Congress for the New Urbanism, a group that advocates more walkable and transit-oriented cities and neighborhoods, says that urbanism has often been sold on aesthetic or energy-efficiency rationales, which are "hard to translate into political capital." Dr. Jackson's work has made good urban planning more politically palatable. "He is fearless," Mr. Norquist says. "He is willing to go out there and take his lumps."

Public Opinion

In 2001, while still at the CDC, Dr. Jackson was a co-author of an article published by Sprawl Watch Clearinghouse that contended that poorly planned built environments had adverse effects on air quality, physical activity, and public safety, among other things. The National Association of Home Builders responded that the article had flimsy scientific foundations, and a dozen members of Congress wrote to the CDC, calling for Dr. Jackson's head.

Libertarians were also offended. "Unsurprisingly, the free market has come up with its own walking cities," scoffed one Harvard University economist in response to Dr. Jackson's work. "They are called shopping malls." (Dr. Jackson left the CDC in 2004, after the Bush administration appointed new members to his advisory committee who had anti-regulatory backgrounds or ties to energy or chemical industries.)

Dr. Jackson acknowledged that his assertions were based more on intuition than research, but he pushed ahead, following up with a book-length treatment titled Urban Sprawl and Public Health: Designing, Planning, and Building for Healthy Communities (Island Press, 2004), written with Howard Frumkin, now the dean of the School of Public Health at the University of Washington, and Lawrence Frank, a professor of urban planning at the University of British Columbia. Since then, many studies have come out linking urban design to health, confirming some of the early assertions of Dr. Jackson and other researchers.

In recent months, Dr. Jackson has released another scholarly book, an edited collection on the topic, called Making Healthy Places: Designing and Building for Wealth, Well-Being, and Sustainability (Island Press), and he is also the host of a four-part miniseries called Designing Healthy Communities, which will air on public television. The series, which features a companion book, is clearly meant to sway public opinion.

"If we are going to change the way we build our communities, it has got to be done because of the demand of the citizenry—a demand that the average, very busy local political leader can understand," Dr. Jackson says. "We humans are so adaptable that we look at the world that we are in and we think, It has to be this way. But everything around us was an idea in someone's head before it was built. In large part, the idea behind the series is to alter what's in our head."

'Unhealthy and Unhappy'

In the mainstream media, the work of Dr. Jackson and researchers with similar interests has been pithily condensed to a variation of this eye-grabbing headline: "Suburbia Makes You Fat." But his focus in Designing Healthy Communities is actually broader than that, with as much emphasis on our need for social connection and beauty as on our need for physical activity. The series features efforts near Denver and Atlanta to redevelop old rail lines and abandoned malls into walking paths and mixed-use areas. The Italian-American town of Roseto, Pa.—with its strong social ties, backyard gardens, and walkable streets—is held up as a lost "Shangri-La," a community that had virtually no heart disease in the middle of the 20th century (but has since come to resemble the rest of the nation).

The series also laments the loss of a social contract in America, looking at places like Detroit, Syracuse, and Oakland, Calif., where crushing poverty or pollution have hampered or even dissolved once-thriving communities. Having begun his medical career in pediatrics, Dr. Jackson is particularly worried about the effects that bad design and polluted environments might have on children, who suffer from spiking rates of obesity and asthma.

As the series' host, Dr. Jackson is at times polemical. "I think that in many ways our generation is guilty of generational child abuse," he says at the opening of one segment. He also challenges the free-market, individualist ideology that has become popular in recent years. Communities and public health are things we build together, with the help of good planning and effective government, Dr. Jackson contends—even as companies that sell junk food, oil, cars, and sprawl pump money into politics and advertising to try to push society in the other direction.

"The fundamental paradigm that nobody else matters but me is making us fundamentally unhealthy and unhappy," he says. "This is a myth that has been foisted upon us by those that profit from this belief system."

But living up to Dr. Jackson's ideals is not easy, given the current car-dependency of the American landscape. Even Dr. Jackson's own living situation is a conundrum. He works in Los Angeles, but his wife and children live and work in the Bay Area, and he travels up to them twice a month. "I do have a larger carbon footprint than I would like," he admits. He and his wife are looking for a home near Berkeley, but they are finding the search difficult.

"Homes that are in attractive, walkable areas, where you can meet your life needs without getting into a car, are selling at an absolute premium," he says. "If I wanted to live in a car-dependent area with a great big house, those would be quite affordable."

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