Health and Our Home
Step outside and walk around your neighborhood. Take notice of the presence and proximity of freeways, vacant lots, housing types, industries, modes of transportation, and grocery stores. These are just some examples of factors that affect the health of a neighborhood.
Typically, many of us do not immediately connect our everyday surroundings to our health. Yet some neighborhoods, such as West Oakland in California, are nearly surrounded by highways. Long-term exposure to diesel truck and auto emissions increases one’s chances of developing lung cancer and asthma, among other cardiovascular and pulmonary complications.
Our surroundings signal the health risks we face. Take Oakland overall: life expectancy rates rank the fourth lowest in Alameda County at an average of 79.1 years of age compared to the county at 81.4 and Piedmont 85.7. Chronic diseases such as heart disease (23.8 percent) and cancer (22.1 percent) hold as the leading causes of death in Oakland. Major risk factors for heart disease include lack of exercise, unhealthy food habits, and obesity. Within the city, the quality of life, health, and overall lifespan of residents varies by race, income, and neighborhood – with low-income communities of color facing the greatest burden of poor health outcomes.
Health and City Planning
While studies have linked socio-economic factors to health outcomes, there is also growing recognition of how the built environment impacts public health. The “built environment refers to the human made surroundings that provide the setting for human activity, from the largest-scale civic surroundings to the smallest personal place.”
Cognizant of the growing cost and burden of chronic illness, some jurisdictions are developing policies that explicitly incorporate health into community design. Some of these policies leverage a jurisdiction’s supreme guiding document – the General Plan – to introduce a stand-alone Health Element or integrate public health objectives. Some cities and counties have broadened the definition of health beyond preventing disease and chronic illness to include an equity analysis that addresses the disparate health outcomes within their communities.
Health and Planning in Oakland
In response to reports of the growing health disparities within Oakland, in 2010 the City Council adopted a resolution authorizing the development of a Health Element for its General Plan. Adopting and implementing a Health Element requires that we understand the strengths and gaps in Oakland’s General Plan. In a report prepared for the Alameda County Public Health Department and Oakland City Councilmember at Large Rebecca Kaplan, I created a framework for developing a Health Element that examines how health issues are discussed in Oakland’s General Plan. Specifically, I analyzed policies within the General Plan that promote health. To confine the broad topic of health, I drew on the definition of healthy communities from Life and Death from Unnatural Causes: Health and Social Inequity in Alameda County and Healthy Planning Policies. The report also includes findings from interviews with planners and community stakeholders from California cities who have prominently integrated health into their planning documents and processes.
Oakland’s General Plan contains ten elements (as seen in Table 1). Some elements include data that demonstrate health implications of car-centric development within the city, such as the Bicycle Master Plan and the Pedestrian Master Plan. These elements incorporate data on health outcomes from increased physical activity, for example. Some elements include explicit health statements, such as the Housing Element and the Land Use and Transportation Element (LUTE). Overall, all of the elements include numerous goals, objectives, policies, and actions that explicitly or implicitly promote health.
However, the General Plan’s elements are not consistent in their promotion of public health. Some provide stronger health indicators and data, address equity more fully, and contain more comprehensive health promoting policies. But the LUTE and other elements lack a definition of community health and an overall health strategy, which can act as a general guiding principle. For example, the Safety Element addresses numerous topics including providing plans and mitigating measures for seismic and geologic hazards, liquefaction, water supply, and minimum road widths among other issues. Though the element covers major health hazards, it does not have a comprehensive definition of community health and health objectives. The LUTE also lacks health data that can draw attention to the prevalence of chronic diseases and other health issues. Table 1 summarizes the strength of health policies in each element of Oakland’s General Plan.
Table 1. Summary of Healthy Policies in Oakland’s General Plan
While there are many policies within Oakland’s General Plan that do promote community health and equity, there is an absence of tracking progress toward meeting the policy and implementation recommendations. The Housing Element is the only one required to submit an annual progress report. The LUTE implementation plan recommends adhering to the state law requirement of submitting an Annual General Plan Progress Report. However, according to a representative from the California Office of Planning and Research, the law does not apply to charter cities such as Oakland. The office also has no record of ever receiving a report from Oakland; the city’s planning department confirms this. Oakland does produce an annual Sustainable Oakland Report that includes a chapter titled, Housing, Land Use and Transportation. However, the chapter is only two pages and does not include an assessment of specific policy objectives from the General Plan’s LUTE.
Without tools to track progress towards the goals and guiding principles in the General Plan, we really have no sense of how development within the city is meeting the various visions and policy recommendations.
Innovative Healthy Plans: Lessons Learned
In order to understand the implications and challenges of developing a comprehensive and responsive health in planning strategy we can look to early adopters in California. I interviewed city planners from four cities that have enhanced the role of health in their General Plans. I asked respondents about community engagement, evaluative measures, outcomes, implementation barriers, and lessons learned. The cities include South Gate, Richmond, and San Pablo all of which have a stand-alone Health Element, and San Jose, which incorporated health objectives throughout its General Plan (as seen in Table 2).
Table 2. Cities’ Healthy Plans
Every city indicated health issues were primarily identified in community engagement workshops. Each city’s plan included innovative health topics unique to its community. San Jose prioritized creating urban centers equipped to meet the needs of seniors who can no longer drive. In respective cases, stand-alone Health Elements became an umbrella for identifying health-promoting policies in other elements of the General Plan.
South Gate and San Pablo’s Health Element included measurable health indicators to be tracked over time. Richmond was the only city to include a policy of creating a progress report that would incorporate health indicators that assess the effectiveness of the city’s policies and programs. Richmond and South Gate were the only cities to incorporate health assessments into the approval process of new developments in the form of identifying checklists and criteria. Other major lessons include:
- The General Plan update process is an expensive and intensive multi-year endeavor
- City Council, planning department, and consultants need to be highly invested in the process
- Implementation remains a challenge for city planners with stretched budgets and reduced capacity
- It is still too early to tell if the trend of integrating more comprehensive health promoting policies, including a stand-alone Health Element, necessarily improves a community’s health outcomes
Although it is too early to tell if the trend of Health Elements translates into improved community health outcomes, adopting implementation tools and evaluative measures provide opportunities to assess effectiveness and appropriateness of health policies and programs. Other examples of implementation and evaluative tools include:
- Health Impact Assessment (HIA) informs public officials and the community of the health implications of development and land use policies in order to improve health outcomes and mitigate negatives ones
- Form-Based Codes take into consideration the impact and fit of a development project proposal on the character of an area rather than only the land uses
- Oakland’s existing planning checklists and standards include two tools that have health implications: the Crime Prevention through Environmental Design (CPEN) Checklist and Green Building Standards
- San Francisco’s Health Development Checklist assesses the health implications of new projects – primarily large-scale residential, commercial, or mixed-use
- Annual California General Plan Progress Report informs local legislative bodies on the progress of implementation of the General Plan
- Sustainable Oakland Report highlights major outcomes for the city in a given year
What Should Oakland Do?
While introducing a stand-alone Health Element signals the importance of taking into account the public health implications of development, alone it does not ensure health outcomes will improve. As analysis of Oakland’s General Plan and current planning practices illustrates, implementation is not a guarantee. Moreover, the city’s progress towards implementing the General Plan is currently unknown. The lack of evaluative measures creates a gap in understanding the effectiveness and appropriateness of city’s policies and programs. Thus, the backbone of my recommendations is about incorporating evaluative measures. Specific recommendations to improve the linkage between health and land use in Oakland are two-fold:
- Maximize current opportunities that can also set the stage for future development of a Health Element
- Utilize a framework for developing a Health Element once resources have been secured
Maximizing current opportunities includes:
- Working with Oakland’s planning department on developing HIAs and a Health Checklist
- Expanding the Sustainable Oakland Report to include a simple matrix assessing progress toward policies in the General Plan, including health promoting policies
- Raising funds, strengthening partnerships, and leveraging resources
Framework recommendations draw on lessons learned from Oakland’s General Plan implementation process and cities interviewed. Figure 1 is a visual representation of the framework.
Figure 1. Framework for Developing a Health Element
The two main objectives are to identify health topics to include in the Health Element and ensure its utility. In order to determine priority topics, the city must identify and gather data on the existing health conditions and distribution of outcomes in the city. The Alameda County Public Health Department (ACPHD), the Oakland Unified School District (OUSD), Kaiser Permanente, and Community Based Organizations (CBOs) can support data finding efforts. Priority topics can inform community workshop topics. In addition, workshops provide another opportunity to identify issues community members face. It will be important to leverage OUSD and CBOs to enhance community outreach, representation, and engagement. Lastly, the city should use the Health Element to highlight other health promoting policies in the General Plan to demonstrate a comprehensive vision of healthy development and alignment.
The second objective is to ensure the Health Element is useful and relevant. Developing tools such as a healthy development checklist, instituting HIAs, and/or adopting form-based codes are ways to expand health considerations in the day-to-day practice of approving development projects. This will require working with the planning department, community stakeholders and the ACPHD to develop manageable tools. In order to ensure the Health Element is relevant, identify and track measurable health indicators, policies, and actions. Ongoing tracking and reporting provide an assessment of effectiveness and appropriateness of city’s policies and programs to improve health outcomes equitably.
General Plan elements are both implicitly and explicitly about improving the quality of life and health of residents within its jurisdiction. A stand-alone Health Element provides an opportunity to amplify the importance of evaluating health implications linked to development. Moreover, it provides a strategic framework for addressing health and equity issues linked to the built environment. It is an opportunity to strengthen health considerations in Oakland’s land use planning decisions.
But we must keep in mind that effective implementation is not guaranteed. In order to improve community health outcomes, promote a culture of healthy living, and mitigate the negative effects of particular kinds of city developments, it is important to adopt implementable policies. It is also important to institute ongoing evaluation of policies and programs in order to assess the effectiveness of improving health outcomes.
Note: ACPHD and Oakland have since used a healthy checklist for various developments throughout the city. ACPHD is continuing to seek funding to support the creation of a Health Element.Laura Flynn is an independent journalist based in the SF Bay Area. She uses the art of storytelling and policy analysis to make engaging media for radio. Since 2010 she has produced radio stories, covering topics ranging from energy to education. You can hear her stories at New America Media, KALW (San Francisco), and KUSP (Santa Cruz).