Pediatricians and Planning Commissions: The Built Environment and Children's Health
The American Academy of Pediatrics doesn't issue policy statements all that often. When it does, the statements tend to be deeply researched and full of fodder for future stories. That's the case with the "The Built Environment: Designing Communities to Promote Physical Activity in Children," which appears today in the AAP journal Pediatrics.
Not surprisingly, safe, walkable communities with good air quality and access to nutritious food are better for children's health than those that are dangerous, polluted and filled with junk food. What is surprising, however, is that only recently has research on the environment and children's health progressed to the point where the AAP felt comfortable weighing in.
On Friday, I discussed the policy statementwith Dr. Richard Jackson, former health officer for the state of California and an author of "Urban Sprawl and Public Health." Jackson, who served as a consultant on the statement, chairs the environmental health science department at the University of California-Los Angeles School of Public Health. Our conversation has been edited for space and clarity.
If you're interested in covering this report, Jackson is taking calls from reporters today. He can be reached at (310) 206-8522 or dickjackson [at] ucla [dot] edu. Another physician who worked on the report is Stanford University pediatrician Elizabeth Baca, who also speaks Spanish. She can be reached at (650) 330-7400 or eabaca [at] lpch [dot] org (eabaca [at] lpch [dot] org).
Q: What exactly is the "built environment" and what is its relationship to children's health?
A: The built environment is basically where we spend most of our lives: our houses and our cars, the larger infrastructure of our city, streets, farmland and parks that is constructed by humans. What we build - the physical structures around us - is the result of how human beings think about the world. The bottom line is that we design America for automobiles and for very short-term benefits. We don't design it for children, pedestrians and the long-term well-being of our people.
Q: The built environment as a health issue has been percolating for a long time, particularly in the public health community. Why is the American Academy of Pediatrics issuing a statement now?
A: Ten years ago, there was very little research on this topic. There's since been a profound flourishing of studies looking at the effects of the built environment on health. At this point it's hard to keep up with the literature. As the science becomes really incontrovertible, the medical system is willing to step up and say there's strong evidence linking community design to children's health
Q: What is the significance of the American Academy of Pediatrics issuing this statement, as opposed to, say, the American Public Health Association?
A: You'd expect the public health association to issue something like this report and they did, five or six years ago. Urban planners have begun to touch on that statement, too. I think many physicians are feeling helpless in the face of an epidemic of children becoming obese diabetics. They're realizing they're going to have to make upstream changes in the world we're living in rather than at the end of the pipeline, because we have very little effect. Some changes do work - such as getting TV out of bedroom and not having soda in the house. But we have to start looking at environmental changes, not simply behavioral changes.
If you want to change a few people at a time, a one-on-one intervention can well work. But when you're talking about millions of people, environmental changes really have an effect. Fluoride toothpaste had an effect on some people, but the big change occurred when we added fluoride to our water. You can cover your mouth when you cough, but to prevent the spread of disease, you have to look at population changes like immunization. The American Academy of Pediatrics has been convinced that population changes work - we didn't have the data then, but we have it now.
Q: In terms of children's health, how does a poorly-built environment compare as a problem to a lack of health insurance?
A: Every child ought to have health insurance, access to immunization and good preventive care. Given that our entire future is based on children, we shouldn't have to choose between health insurance and a good environment for them. All of these things need to be taken care of at the same time.
Q: California has a reputation for being a state with active, healthy, less obese people. What have you noticed while living in the Sacramento and Los Angeles areas about how the built environment actually affects children?
A: The built environment affects all kids, but especially poor children. If you're a poor child and you are taken by bus to school, the local food availability is largely fast food. The local store has beer and Twinkies, not fresh fruit and vegetables. If the neighborhood is dangerous, kids can't roam around. But there are positive things that are happening. A good half of county health departments in California are going to planning committee meetings. Traditionally the planning committees did environmental impact reports, but there wasn't a focus on what would happen to children, disabled, elderly. The county health departments have now been much more active in rewriting county governments' general plans. Having the health departments say, "where is the access to fresh fruits and vegetables, to transit?" has been pretty effective in the planning process.
Q: Doctors are often asked to do more with less. What exactly do you want them to do to advocate for a better built environment for children? Are doctors really supposed to go to planning commission meetings?
A: The average physician is often desperately frustrated with his or her inability to have real influence. They don't want to tell patients to eat fresh fruit when there's no fresh fruit nearby or tell a child to walk when there's nowhere to walk. It has happened that physicians are going to planning meetings. In Colorado, Kaiser Permanente is releasing physicians to do that. They don't all have to do it, but it's all part of the job.