Active Transportation is Primary Prevention: The Evolution of Public Health From Quarantines to Mass In Motion

Public Health has its origins in catastrophe, the realization that if an out-of-the-ordinary pestilence is suddenly sickening large numbers of people there must be a general cause rather than individual failures.  In contrast to Medicine, which traditionally is about treating an individual’s existing disease, Public Health seeks to keep large groups from getting sick.  In contrast even to Preventive Medicine, which tends to focus on increasing compliance with medical prescriptions, Public Health is about wellness and well-being – a holistic concern with an entire population’s overall quality of life.  And in Massachusetts, a national leader across a wide range of Public Health issues, one of the most innovative and powerful strategies to improve population health has been the Mass In Motion program.

Mass In Motion is, at core, a simple idea.  It starts from the reality that nearly two-thirds of the state’s adults and about a quarter of our children are either overweight or obese, with the numbers soaring in low-income communities.  Nationally, this costs us about $3.5 billion in excess health care costs each year, not to mention the pain suffered by the patients and the diminished futures facing the children.  To end the cycle, the state Department of Public Health gives small Mass In Motion grants to municipalities to set up multi-agency coordination bodies tasked to make it easier for people to secure healthy food and to make local streets and parks more walking and bicycling friendly.  The magic is that in most towns the police and public works and schools and parks departments have never before regularly met together, much less done so in the context of public health leadership.  Just getting everyone in the room to talk about how they can work together – on almost anything – is a major advance.  Having the conversation focus on how to implement a Complete Streets policy is unprecedented.  And it works: Mass In Motion communities have a statistically significant reduction in the percentage of overweight and obese school children compared with the state as a whole.

I’ve talked with the Mass In Motion coordinators in several cities and conducted workshops in a few (special shout-outs to Fall River and New Bedford!).  I’ve found that in every city there are local advocates eager to use whatever facilitating framework the government can provide to get involved.   Why government?  Because we are dealing with our shared environment, our public spaces, and because we want to improve living conditions for everyone regardless of ability to pay, it is only the government that has the legitimate authority to act for our collective wellbeing.  The strategy is not to create new prohibitions.  Rather, Mass In Motion communities create a healthier decision-making context.  They find ways to “nudge” people by making it easier, cheaper, more common, and more socially prestigious to “do the healthy thing.”  Particularly to do more walking or bicycling for which the evidence showing a positive impact on health is incontrovertible.

Street design matters.  I don’t know the statistics for other cities, but in Boston, 56% of city-owned land is taken up by streets and sidewalks.  And there are between two and three incidents every day in which a car hits a pedestrian or cyclist.  Boston has a very sophisticated Complete Street policy, but it’s new and much of the city is still dangerously car-centric.  Other cities have, at best, the same spotty safety situations. Streets designed to slow down speeding traffic, to improve sidewalks, create low-traffic-stress bike routes, make intersections safer, and promote “place-making” rather than “pass through” aesthetics reduce injuries and invite use.

The Legislature is now debating whether to continue funding Mass In Motion (line item 4513-1111).  Last year the state Legislature for the first time included explicit reference to Mass in Motion in budget language and dedicated a minimum of $250,000 for Mass in Motion as part of a larger “Heath Promotion and Disease Prevention” line item. That language is missing in the FY2016 budget proposals, forcing the Department of Public Health to squeeze Mass In Motion in among numerous other programs in a line item that has been sharply diminished over the last ten years.

At the same time, the Baker Administration is deciding what to do about the complementary Complete/Active Streets Certification/Funding Grant Program, authorized within the most recent Transportation Bond Bill.  As with most Bond Bills, this one was a “Christmas Tree” of wishes that the Administration has to choose among in order to keep total borrowing within the state’s “bond cap” and debt service payment capabilities.

Give your Representatives and Senators a call.  Let them know what you think.



Public Health began using quarantines, isolating problems from the rest of the population.  It drew upon ancient Chinese and African practices to develop preventive vaccinations, which led to the eradication or radical diminishment of once deadly assaults like smallpox, polio, measles, mumps, and others with more to come. The invention of Epidemiology in the late 1800s created a way to scientifically connect population-level problems with probable sources.  While epidemiology doesn’t prove causation it does reveal correlations which suggest origins, dispersal mechanisms, and possible preventive interventions.  Following the same process, Public Health has shown the health impact of natural environment conditions – air, water, soil, and noise pollution – and the value to both individual lives and societal budgets of improving them.  In recent years, Public Health has continued to expand its vision, providing powerful insights into how to address violence (both domestic and community) and addiction in more effective ways than through the criminal justice system.  The field has also been a pioneer in exploring ways to change population behaviors by altering the decision-making context and the cultural portrayal of particular actions – from popularizing the “designated driver” role to diminishing the social status of smoking. Drunk driving went from being cool to being murderous; smoking went from sexy to stupid.

Now, partly as a result of the overweight epidemic threatening to reverse the previous trend of longer, healthier lives, people concerned with Primary Prevention are increasingly focusing on the behavior-affecting power of the built environment.  What are the conditions that will make it more likely that larger numbers of people will eat more nutritious food and be more physically active?  As with smoking, key issues are availability, cost, ease of access, and peer-group attitudes. And the core strategy is to change both the decision-making context and the perceptual framework.  There are some attempts to deal with nutrition, from banning fast-food stores near schools to imposing a tax on sugar-sweetened beverages.  But eating interventions are complicated and controversial: food choices are emotionally loaded and food opportunities widely dispersed.  Public Health has found it easier to start with encouraging physical activity, not as an after-work recreational trip to the gym but built in to the daily routines of ordinary life.  In other words, how to make it more likely that people walk or bicycle to get to work, to shop, to visit friends, to spend time with their families?

CDC Director Thomas Frieden has drawn a pyramid with interventions that have the widest impact and the least per-person cost although only an indirect and percentage-altering impact  at the base, and the most individualized and supportive but therefore expensive and with limited impact at the top. Socio-economic conditions are at the base: income and community conditions and societal treatment.  Next, says Frieden, are things that “change the context for health (e.g., clean water, safe roads), [then] protective interventions with long-term benefits (e.g., immunizations), [then] direct clinical care, and, at the top, counseling and education.”

The most powerful actions are those that change our society’s maldistribution of resources and opportunities. Equalizing these require political action.   Mass In Motion sits just above at the environmental decision-making context level.   Public Health analysts now talk about the need to incorporate “Health in All Policies.”  We didn’t used to think of our streets as an integral part of our health system.  But they are.   And Mass In Motion has helped make that insight real in at least 60 of our state’s cities and town.  It’s one of the ways our government works well.


Thanks to Maddie Ribble, Andrea Freeman, and the entire Mass Public Health Association for their work on this issue.  All mistakes and opinions are, of course, my own responsibility.

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