THE HEALTHY TRANSPORTATION COMPACT: Public Health Needs To Reclaim Leadership

The Healthy Transportation Compact section of the 2009 Transportation Reform Bill continues to influence state policy, but the formal inter-agency bodies created to advance and advise the process have been allowed to falter.  While the program is a MassDOT responsibility, it would be important for the state Public Health Department to get involved in reviving the effort and using the Compact as leverage for moving its multi-issue preventive programs to the next level.

The 2009 Transportation Reform Bill didn’t only merge the historically bickering agencies that ran the Turnpike, State Highways, Mystic Bridge, and (to a lesser extent) the MBTA and Regional Rail.  It also changed the underlying vision of what purpose transportation is supposed to serve.  Mobility is not an end in itself but a means to something else – in addition to general economic growth, the Healthy Transportation Compact section of the bill added public and environmental health as explicit goals and decision-making criteria.  (Representative Denise Provost, acting on behalf of the Somerville Transportation Equity Partnership (STEP) group was the initial Legislative sponsor for the Compact as well as another section on fine particulate pollution – also related to transportation.  A similar bill was filed by then-Representative, now Sheriff, Peter Koutoujian.)  The Compact, and Secretary of Transportation Rich Davy’s follow-up 2013 Healthy Transportation Directive, were based on an understanding that any chance Massachusetts has for future prosperity both depends on and will result in increased transportation in a context where it is simply no longer possible to build highways.  If we want to have more jobs and population we have to find non-automotive and non-quality-of-life-destructive ways to move the growing number of people and things.

The Legislative designers of the Reform Bill also realized that success was only possible through unprecedented coordination at the policy and operational levels across multiple departments.   It’s not a new idea.  Governor Romney appointed Conservation Law Foundation (CLF) founder Doug Foy as a “super secretary” overseeing transportation, housing, environment, and energy agencies.  Governor Patrick had multiple Secretariats sign-on to the “Planning Ahead for Growth” effort to coordinate transportation and land use planning.  The Healthy Transportation Compact created an Executive Policy Group located within Dept. of Transportation but composed of the “Secretaries of Transportation, Health & Human Services, Energy & Environment, the Administrators for Highways and for Mass Transit, and the Commissioner of Public Health.”  It also created an Advisory Council explicitly including “private and nonprofit advocacy groups.”

[Full Disclosure:  I sit on the Compact’s Advisory Council and participated in the program-design discussions leading up to then DPH Commissioner John Auerbach’s creation of Mass In Motion.]

The Compact’s wording is inspirational even today:  “… promote inter-secretariat cooperation and…increase access to healthy transportation alternatives that reduce greenhouse gas emissions, improves access to services for persons with mobility limitations and increases opportunities for physical activities… increase bicycle and pedestrian travel… encourage the construction of complete streets… implement the use of health impact assessments to determine the effect of transportation projects on public health and vulnerable populations… expand…the Safe Routes to Schools program…”

It’s understandable that the Baker Administration has dropped almost all mention of its predecessor’s programs.  Fortunately, the appointment of former CLF attorney Stephanie Pollack has meant that MassDOT is still paying attention to many of these issues.  However, the formal meetings of the Policy Group and the Advisory Council seem to have ended.  In this and in other areas, it would be helpful for the state Public Health Department (DPH) to assertively claim its rightful leadership role.  Public Health’s frame of understanding – it’s insight on the huge if not predominate impact of the surrounding social and physical environment on the wellbeing of large populations, and how the disparities in the institutional environment create disparities in the lives of subgroups – could help revitalize the Compact’s pioneering efforts and give a boost to preventive programs such as DPH’s highly impactful Mass In Motion program.   We need a revival of the multi-agency Healthy Transportation Compact, with full Public Health involvement, to ensure that we maintain our momentum.

 

CLIMATE, LAND USE, AND TRANSPORTATION:  The Pull and the Push

Massachusetts’ 2008 Global Warming Solution’s Act committed the state to reduce overall greenhouse gas emissions by 25 percent from 1990 levels by 2020 and by 80 percent from 1990 levels by 2050.  This nationally-leading effort was itself shaped by an innovative 2001 regional Climate Change Action Plan negotiated among the New England States and eastern Canadian Provinces and the subsequent Regional Greenhouse Gas Initiative (RGGI) signed by Governors of northeastern states from Maryland to Maine creating a limited “cap-and-trade” program.   As a major source of Greenhouse Gas Emissions – nearly 40% in Massachusetts, transportation has a central role to play in the process.

Unfortunately, the convergence of public concern about climate change and business concern about rising fossil fuel prices that provided the political context for the creation of the RGGI and the passage of the Global Warming Solution’s Act has loosened in recent years.   Fuel is cheap these days – emboldening car manufacturers to fight the Obama Administration’s new fuel efficiency regulations for future cars.   Despite the dropping gas prices, Massachusetts voters have also voted down the Legislature’s proposal to allow future gas taxes to rise with inflation, probably condemning the state to additional years of declining transportation-dedicated revenue.  While the effects of, and general unease about, climate change continues to grow, the political appetite for accepting the cost of change seems weaker at a time when family incomes have stagnated for so long and the “government is the problem” message has had such wide play.  Still, it’s unlikely that the law requiring the state to continue reducing greenhouse gas emissions will be repealed and public concern won’t go away.

The land-use side of the process is also running into opposition.  Massachusetts has a broad set of regulations and incentives to promote Transit Oriented Development (TOD), a cousin to the broader policy of Smart Growth, that encourages focusing mix-use development (e.g. residential and retail or other non-disturbing commercial) around train, trolley, and bus stops as well as creating facilities to encourage walking, bicycling, and vehicle sharing in the surrounding neighborhood.   But people already living in TOD areas have begun complaining about the lack of car parking in these developments – some of the newcomers will own cars even if they don’t use them very much.  In low-income areas, TOD has raised concerns about gentrification and the typically too-small-for-families size of the units.  In suburban areas, residents fight the projects on the grounds that their density changes the nature of the town and that they may bring in families whose school-age children will crowd classrooms and raise taxes.   But the region’s desperate need for more non-luxury housing will continue to force policy-makers hand – we will simply not attract or retain high skilled professionals if they can’t afford to live here.  Secretary of Housing and Economic Development Jay Ash and Policy Director Paul McMorrow addressed the issue through disposition of state land and other incentive programs.  Boston Mayor Walsh has made moderate-income housing a cornerstone of his Administration.  The popularity of the goal isn’t lost on other politicians.

 

No More New Highways

At the same time, transportation planners are coming to realize that it is simply impossible to end road congestion with car-focused remedies.   There is no room for new highways.  Increasingly expensive projects to relieve “spot congestion” simply push the traffic jam further down the road.  Despite the attractions of urban life, our suburban population is still growing (even if more slowly) and the average number of cars-per-household is increasing – especially among people who still live in spread-out communities that lack any alternative to individualized car use.  While road projects designed to improve safety or repair serious pavement problems still make sense, reducing car congestion should no longer be a legitimate reason for construction.  However, most transportation planning is done at the regional level through the state’s thirteen separate Metropolitan Planning Organizations (MPOs), which have traditionally favored road expansion projects desired by local commercial developers, and by municipal transportation officials who bend even further in the same direction.  Actual design and construction is mostly done by private contractors, many of whom will simply keep doing what they’ve always done without very clear new instructions, training, and oversight.  And it’s not always obvious that all of MassDOT’s own staff – both in the central office and in the six regional Departments -- has the training, experience, or desire to impose the new direction on their long-time colleagues in the construction industry.   

On the other hand, MassDOT’s most recent long-range capital investment plan (CIP) seems to be pulling back from traditional open-ended commitment to road building.  In addition, it still calls for (slowly) advancing plans for major rail and transit projects, emphasizing Complete Streets projects, as well as spending up to $15 million a year to advance bicycling and walking facilities.  This is particularly important to our urban areas.  Metro Boston already generates nearly two-thirds of the state’s GDP. The “transit shed” of walkable distances from MBTA trolley and bus lines includes only 4% of the region’s land but contains 22% of its population, and about 28% of those households don’t even own a car.  If the Administration sticks to its guns, the CIP could start a huge shift of resources towards more a sustainable and economic-growth facilitating direction.   

But the future of transportation is simply too important to be left to transportation planners.  As goes mobility, so goes land use, quality of life, and the world we will leave to our children.  And there are many transportation issues that Advocates will simply not be able to push forward without support from the Public Health community.

 

PUBLIC HEALTH VERSUS MEDICINE:  Outside In versus Inside Out

Although the connection is not likely to jump to most people’s minds, one possible frame for better transportation is Public Health.   There is a way in which Public Health is like Complete Streets.   Complete Streets Policy contains the idea that road design should “start from the outside and work in” – meaning a reversal of the traditional process of reserving enough space for all the always-assumed-to-be-increasing car traffic plus a bit extra for safety margins, and then see how to squeeze everything else into what’s left.   Instead, the slogan says to first set-aside space for a sidewalk capable of handling the increased number of pedestrians who will come “if you build it”, and then do the same for the bicycle facilities, and then for the bus or trolley, and then see how to fit car traffic into what’s left.  It’s not that cars are unimportant, it’s just that they are no more important than providing safe and inviting facilities for everyone else.   It’s likely that no mode will be able to get all the space it “wants” – but the pain of insufficiency needs to be spread across them all rather than dumped on the most vulnerable.

Public Health has a similar outside-in approach.   In contrast to Medicine – whose holy grail is totally personalized treatment for each individual’s illness – contemporary public health is about keeping people well in the first place.  And the “patient” isn’t an individual but a population, in fact, not really a patient but a partner:  meaning that Public Health focuses on creating conditions in the everyday life of large groups that promote healthy eating and physical activity, positive family and social relationships, a safe and clean environment, decent living and working conditions, the respect and dignity required for mental health.  It’s not that running a state lab for testing, providing (or overseeing) vaccination programs, or the other clinical interventions that the state Department of Public Health (DPH) does aren’t important.  But unlike traditional Medicine, Public Health is about overall wellbeing and it starts from the societal and built-environment conditions in the world we all share so that people have the greatest and relatively equivalent opportunity as everyone else to keep themselves healthy.

 

Illustrating The Paradigm

The Massachusetts DPH’s Mass In Motion program exemplified this nationally emulated approach to Primary (or even Primordial) Prevention – strategies rooted in awareness that the Social Determinants of Health set the context for individual wellbeing.   Rather than directly provide services, DPH gives small grants to municipalities who set up inter-agency committees – police, schools, DPW, public health, and others – to coordinate efforts to make it easier and safer to walk, bike, or otherwise be physically active as well as have access to healthy food choices.  In many communities, the group is focusing on implementing a Complete Streets policy (partly because another state program created with a lot of input from public health advocates provides another set of grants for this).  And it works – although there have been some Mass In Motion grants in rural Hampshire, Franklin, and Berkshire counties, most applicant communities are low-income urban areas which have seen a statistically significant reduction in the percentage of overweight and obese school children compared with the state as a whole.  

The approach is summarized in two diagrams.  The first is the CDC’s “social ecology model” which simply shows the concentric circles of influence surrounding and impacting individual health – from individual specifics to close relationships to surrounding community to general societal.  The model’s connection of the personal and the general in a preventive (rather than treatment) context has prompted its adaptation to a huge number of more specific health topics from cancer to child abuse and even other non-health fields. The second diagram is CDC Director Tom Frieden’s now-famous “Impact Pyramid” showing that changing socio-economic factors, while the most politically and financially difficult, have the largest impact and the smallest per-person-affected cost, while traditional one-on-one counseling and education are the easiest to do but have the least overall impact and the highest cost.  Most relevant for transportation is the second tier, “Changing the Decision-making Context” which stressed environmental designs that make the easy, convenient, affordable, and desirable to “make the healthy choice” about behavior, eating, physical activity, and social interaction.  Streets with no sidewalks make choosing to walk very difficult.  Protected or separated bike lanes make choosing to cycle much easier for more people. 

Massachusetts has an incredible heritage of national leadership in Public Health issues.  From small pox vaccination to the first regulation of industrial pollution, from child welfare to children to workplace safety, this state has been an innovator and pioneer.  We’ve shown that prevention is important for both individual wellbeing and societal health, for family resilience and regional economic growth.  It’s time for our state – and municipal – public health leaders to take the lead again and (continue to) push us towards a better future.

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Thanks to the many people whose conversations over the past months have shaped my understanding the current situation, particularly the people at the Mass Public Health Association which continues to be one of the most effective groups I’ve ever known – special thanks to Maddie Ribble.  Obviously, all opinions and remaining errors are my responsibility.

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Related Previous Posts:

>ACTIVE TRANSPORTATION IS PRIMARY PREVENTION:  The Evolution of Public Health from Quarantines to Mass In Motion

>Transportation & Public Health Fact Sheet

>LIVABILITY, PUBLIC HEALTH, AND MOVING AROUND

>ACTIVE TRANSPORTATION CREATES HEALTHY COMMUNITIES: How To Use Your Roads To Lower Your Doctor (and Insurance) Bills

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