Why Health Care Reform Should Be a Transportation Issue (and visa versa)

American medicine is only peripherally about health; it is primarily about treating disease.   It is a sickness treatment system.  Even so-called preventive medicine is really about screening and early treatment.  What we need is pre-disease prevention:  ways to create a lived environment that directly and through its impact on behavior significantly increases wellbeing and reduces the risk of getting sick in the first place.  This is where Transportation comes in. 

Public Health has traditionally focused on wellness, championing societal measures that that improve living conditions for large populations, or make it easier for individuals to make healthy choices within their everyday life.  Clean water, effective sewerage, tobacco taxes and anti-smoking campaigns, eliminating trans fats and other food toxins, requiring seat belts, reducing neighborhood and domestic violence, gun control, vaccination campaigns – these can all be considered public health measures that work by improving the environment, providing services, or shaping the market.

So what does this have to do with Transportation?   Directly, and through its influence on land-use patterns and lifestyles, the way we move has enormous impact on our environment, our behavior, and our health.

Think of the air you breathe – a major determinant of its quality is the amount of pollutants spewed by cars and trucks, which in turn depends on their engine design, the type of fuel, and the sheer number of them on the street.  Research shows that air pollution worsens, and may even cause, asthma, heart disease, and some cancers.  Out of the 22 million people in the US with asthma – totaling roughly seven percent of adults and nearly nine percent of all children – 4,000 will die this year, and it’s a contributing factor for another 7,000 deaths.  Half to 2/3rds of US children live in areas that violated EPA air quality standards for car-pollution-caused ozone. The US cost of health issues associated with poor air quality from transportation is between $40 billion and $64 billion per year.  In the US, cars generate 31% of total CO2 emissions, 81% of total CO emissions, 49% of total Nitrogen Oxide emissions; and 60% of car emissions are generated in the first few miles of travel – distances that could easily be done on a non-polluting bicycle.

Or think about the water you drink – not only is its quality affected by the oils and chemicals carried by roadway water run-off (including sediment, bacteria, heavy metals, and petroleum hydrocarbons), its ultimate availability is impacted by the type of ground covering used on our roads, parking lots, and driveways which channels rainwater into sewers that dumps it into the ocean rather than back into emptying aquifers.

Think about safety – the US total of about 43,000 annual car-accident fatalities and 2.5 million injured people is the highest rate of any country in the developed world and costs us about $230.6 billion in medical costs, property damages, lost worker productivity, travel delays, and other expenses.  Traffic injuries and fatalities were the leading cause of death for people ages 5 to 34 in the United States and the leading cause of injury-related death among all ages.  And most of this is preventable.  Sweden’s “Vision Zero” accepts that driver mistakes will occur, but is based on the proven fact that good road design can minimize the likelihood and negative consequences of driver misconduct.   Accident rates in Sweden have dramatically fallen.  And most European countries have dealt with the fact that “speed kills” by lowering most non-highway traffic speed limits to 30 kph  — that’s about 19 mph – thereby increasing the probability that pedestrians (and cyclists) will survive being hit by a car from 20% (at 40 mph) to over 95% (at 20 mph)!

Similar arguments can be made for community vitality and even mental health.  For example, every 10 minutes spent commuting is associated with a 10 percent drop in the time spent traveling for social purposes including family, friends, and the activities that provide emotional sustenance: hobbies, religion, sports, clubs, civic engagement, and volunteer commitments. Long driving commutes are associated with stress-related health effects and physical ailments such as back pain and heart disease.

But most of all, think of your waistline and muscle tone.  Two thirds of American adults are overweight – or obese.  Less than half of us get the recommended amounts of physical activity, without which few dietary changes will have lasting weight-loss impact.  A 2004 study found that every additional hour spent in a car is associated with a six percent increase in the likelihood of obesity, and every additional kilometer walked is associated with a 4.8 percent reduction.  And the list of diseases related to either being overweight-related or not doing enough physical activity is devastating — ranging from diabetes to Alzheimer’s.  The cost of obesity and inactivity to society is enormous and growing. In 2004, the total cost (including health care and loss of wages) of being obese or overweight was estimated at $117 billion,14 and physical inactivity’s health care tab runs up to $76 billion  per year.

But exhortations, or our own good intentions, are seldom enough to get us to change our habits.  Few of us have the time, or the money, to spend time in a gym or going skiing or for multi-day bike rides.  And even those of us privileged enough to enjoy these leisure-time luxuries aren’t usually able to do it every day over our entire lifespan.  What we as a nation need are ways to integrate physical activity into the everyday patterns of our life – walking to the local store, cycling to visit a friend, taking the trolley or bus to work and walking to the station, riding a bike to work.  We need to create more compact, multi-use, and high-density neighborhoods around transportation nodes:  since residents of those areas have been shown to have lower rates of obesity. Nearly 40% of trips in the US are two miles or less – a very bikeable distance – and people who bike four miles round-trip to work instead of driving burns 36,000 calories a year, which might otherwise turn into 10 pounds of fat.

Creating the infrastructure that allows all this requires a transportation system that takes health impacts into account.  And transportation is more likely to be health conscious if the health system is more conscious of the impact of the built environment on public wellness.

While recent research questions the ability of preventive medicine to save health care dollars, improving our wellness-facilitating environment is likely to have more positive and dramatic positive effect – if only because it usually only requires minor tweaks on already-required construction projects.  But even if it didn’t save money, it would vastly improve lives – and the human nature of our society.

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