Hk icth2016 13th_june2016_website version

The Health Impacts of Traffic-related Exposures in Urban Areas: Understanding Real Effects, Underlying Driving

Forces and Co-producing Future Directions

Haneen Khreis, 2nd International Conference on

Transport and Health, San Jose, 13-15 June, 2016

Session: Collaboration for a Healthy Change in Transport Planning, Advocacy, and Policy

AcknowledgementsKaryn Warsow, Health Policy

Management and Leadership

Ersilia Verlinghieri, public

participation in transport planning

Alvaro Guzman, power in

transport planning

Luc Pellecuer, Incorporation of Environmental

Impacts into engineering

Antonio Ferreira, Governance

and Transport Policies

Ian Jones, Urban and Transport

planning

Eva Heinen, Active travel behavior David Rojas-Rueda, Epidemiology and

public health

Natalie Mueller, Public health Paul Schepers, Traffic safety Karen Lucas, Transport and

social analysis

Mark Nieuwenhuijsen, Epidemiology and

public health

Background■ The world is witnessing its largest

surge of urban growth in history

■ e.g. 75% of the European

population live in urban areas

■ Urbanization being shaped by step

changes in transport connectivity

and related land-use practices

■ Transport often envisioned as a

driver for urban development and

a contributor to economic returns

■ But has negative impacts on the

health of a population

exacerbated in urban areas

Rydin et al. 2012

Background

■ Each year, > 1.3 million deaths and 78 million

injuries warranting medical care result from motor

vehicle crashes

■ Air pollution and decreases in physical activity

associated with annual estimates of 7 million and

2.1 million global deaths, respectively

■ Current land-use planning and policy patterns are

reinforcing excessive use of motorized transport

modes

■ Health impacts are disproportionately distributed,

contributing further to gross inequalities in health

Background

■ Sustainable transport infrastructure/modes effective in promoting active travel; increasing physical activity and reducing exposures

■ Can reduce health inequalities through modifying some of the pathways by which low socioeconomic position can lead to diseases

■ This evidence reinforces the need to develop and implement effective policies that define and address health consequences

Rationale– A clear scoping of traffic-related

health impacts (in urban areas)…

– Understanding and discussing the

underlying driving forces behind

where we are now…

– Is there a need for a new health-

aware perspective in the

transport/development agenda?

– Examples of good practice and

lessons learned from case studies

– Consider stakeholders involved and

make recommendations

Where are we now?

How did we get here?

Where do we want to go?

What will guide us?

How will we get there?

■ Initial meeting at the 1st International Conference of

Transport and Health 2015 – London

■ Bring together expertise in transport engineering, transport

and urban planning, research and strategic management,

epidemiology and health impact assessment

■ Built on/led to recent reviews on this topic by some authors

■ Arrange meetings amongst the authors. Full collaboration

has been made possible through the use of online tools

such as Google Docs and emails

■ Organize (4) workshops around the key synergies between

transport and health

■ Concepts presented were developed further and discussed

amongst the authors, and others attending

■ this paper emerged from a collective rather than a

solitary exercise

Methods

Where are we now?

Adverse health impacts associated

with traffic

Motor vehicle crashes

Physical inactivity

Air pollution exposure

Noise exposure

Temperature (rises) exposure

Green space reduction exposure

Motor vehicle crashes■ One of the earliest recognized traffic-related health

issues (obvious effects…)

■ Vulnerable populations and road users including the elderly, children, the economically disadvantaged and pedestrians and cyclists are the most impacted

■ Half of the world’s road traffic deaths occur amongst motorcyclists, pedestrians and cyclists, with 31% of deaths amongst car occupants (rest is unspecified)

■ Low-income and middle-income countries account for over 90% of the world’s roads fatalities despite having 48% of the world’s registered vehicles

■ Have received more policy attention partly due to the attention to crash severity and loss of life

■ Incidence rates for active travel depend on the number of active travellers resulting in a rapid decline in MVC when the number of these users increase

Motor vehicle crashes

“I'm listening to a live streaming of the

US Department of Transportation 50th

Anniversary ceremony. The overwhelming

theme is automotive safety. t is ingrained

in the culture not specific to people. This

perspective requires a cultural shift at

the policy level, which is happening

slowly in the US ”

“Perhaps mention safety concerns

were raised soon after ww2. At least

in NL in the ’60 and ’70. As a

consequence there cars were

banned and it was one of the

reasons to stimulate bicycling”

Physical inactivity■ The biggest public health problem of the 21st century

■ 2.1 million global deaths/year attributable

■ Physically inactive people have a 20% to 30% increased risk of all-cause premature mortality

■ Increased physical activity associated with a reduction in risk of chronic diseases e.g. cardiovascular disease, dementia, Alzheimer's and Parkinson's disease, type-2 diabetes, breast cancer, colon cancer depression and anxiety symptomatology

■ Emerging evidence for a role in delaying cognitive decline/improving brain health

■ Positive effect on pulmonary function, which can have a role in reducing the negative health effects of traffic-related air pollution

Active travel and physical activity

■ 20% to 50% of population do not meet physical activity

guidelines

■ Active travel could provide means to build physical

activity into daily routines

■ Active travel associated with higher levels of objective

and self-reported physical activity

■ Countries with higher levels of active travel have lower

obesity levels suggesting

■ Providing for active travel will boost its levels, although

the effects of new infrastructure may not be

immediate

■ Available resources for physical activity participation

including parks and walking and biking trails vary by

neighbourhood socioeconomic status with the pattern

of fewer options for the more deprived

Traffic-related air pollution ■ In urban areas, ambient air pollution is

dominated by motor vehicles traffic

■ Associated with all-cause mortality, childhood asthma incidence, cardiovascular disease incidence, cardiovascular mortality and morbidity, cerebrovascular mortality and morbidity, decreased lung function in children, infant mortality, lung cancer, low birth weight, pregnancy-induced hypertensive disorders, preterm birth, respiratory infections, and respiratory mortality and morbidity

■ Contributing to an estimated 370,000 premature deaths and on average a 9 month reduction in life expectancy in Europe

■ Source models not widely available

■ TRAP disproportionately distributed amongst socio-economic and vulnerable groups e.g. low-income groups and minorities, as their schools and residences are often located in high traffic exposure areas

Traffic-related noise■ Ambient noise are associated with the road

network, junctions, traffic flow, speed and load

■ Health effects of traffic-related noise are increasingly being recognized as attributable to a large burden of disease that may be comparable to that of air pollution

■ One million healthy life years are lost every year from traffic-related noise in the western part of Europe alone

■ Ambient noise has been associated with all-cause mortality, cardiovascular mortality and morbidity, annoyance and sleep disturbance, adverse reproductive outcomes, cognitive problems in children, diabetes type-2, high blood pressure in children, mental health and well-being problems and stroke

■ Cardiovascular effects by ambient noise have been shown independent of air pollution exposures

■ Low-income individuals and visible minorities tend to be located in the areas most polluted by road traffic noise

Urban Heat Islands and Greenhouse Gases

■ High density urban settlements and roads heat absorbing concrete and asphalt structures dominate the landscape = heat island effect

■ Traffic also release anthropogenic heat by way of tailpipe emissions (black carbon, carbon dioxide, methane, nitrous oxide) and can amplify urban temperatures

■ High ambient temperatures have been associated with all-cause mortality, cardiorespiratory morbidity, children’s mortality and hospitalization, heat stress, hospital admissions, increased health service use for chronic diseases, including respiratory diseases, hypertension and diabetes, preterm birth, reduced lung function in children and MVC

Green infrastructure ■ Associated with a number of beneficial health effects,

including decreased premature mortality, reduced cardiovascular disease, higher birth weight, improved mental health, improved sleep patterns, recovery from illness, reduced children's behavioural problems, reduced incidence of childhood asthma, increased social contacts

■ Other beneficial effects on cognitive development, physical activity and obesity

■ Possible mechanisms for health benefits are due to increased physical activity, more space to enable social interaction, psychological restoration and stress reduction, and mitigation of environmental exposures including air pollution, noise and heat

■ Distribution of (access to) green spaces can be differential by socioeconomic status in favour with those with resources to move to greener areas

■ Amount of green space is often limited in cities

■ Varies considerably between and within cities, European cities average around 18.6% green space

■ Transport and utilities use significant amounts of land which could arguably be or be used for green infrastructure

Results– A clear scoping of traffic-related




where we are now…








Where are we now?



What will guide us?



■ A significant burden of disease associated with transport practices

■ Suggest that transport design, planning and policy are operating separate from health at some level

– Trends of development,

– (lack of) Public policies

– Public’s perceptions and awareness,

– The state of the transport investment appraisal

– and the influence of powerful actors in leading to the current state and maintaining it

Rapid and car-centred urbanization

■ Advanced a car-centred planning approach

dominated urban and transport planning since

post-Second World War

■ The car has become socially, culturally,

economically, politically, ethically and

environmentally ingrained in westernised

countries

■ The very nature of urbanization enhances

exposure to heat, air pollution, and radiation via

street canyons, heat island effects, depleting

green space

■ Given the global trends towards a more

urbanised world population, impacts are

forecasted to continue and intensify

■ The car has become socially, culturally,

economically, politically, ethically and

environmentally ingrained in westernised

countries

meaningful public transport system and a

gradual abandonment of these urbanised areas

■ Reinforces policy focus on ‘economic centres of

agglomeration’

■ Fosters a self-reinforcing cycle of car

dependence by creating a system of ‘auto-

mobility’

■ Auto -mobility systems

– increased the fraction of the exposed

population living and working in close

proximity to highways and roads

– decreased physical activity

– and reduced the feasibility and

convenience of active travel and of public

transport provision

■ The very nature of urbanization enhances

exposure to heat, air pollution, and radiation via


■ Car-centred urbanisation increases the physical

separation of activities and the need for

motorized transport

■ Increased spatial separation of activities lowers

urbanised population densities, and results in

lower commuter numbers needed to support a

meaningful public transport system and a

gradual abandonment of these urbanised areas

■ Reinforces policy focus on ‘economic centres of

agglomeration’

■ Fosters a self-reinforcing cycle of car

dependence by creating a system of ‘auto-

mobility’


■ Auto -mobility systems

– Increased the fraction of the exposed

population living and working in close

proximity to highways and roads

– Decreased physical activity

– Increased the need and convenience for

motorized transport

– and reduced the feasibility and

convenience of active travel and of public

transport provision

“The transport sector is susceptible

to long term effect on design

decisions. Urban form does not

change as rapidly (or even at all) as

building or roads are built or

demolished, for example many roman

road still exist in the landscape or still

serve as roads”

In regard to transport policy measures : “Why

land use policy measures seem to receive the

least attention whilst they could be most

effective?” – “I agree with you! Is true, there are

the most effective because there are the cause

of the cause. But at the same time is the harder

to be changed from a politician perspective, is a

change of model. But is the most important and

effective intervention”

Mass Motorization and Ethical Positions Towards Human Life

■ Increasing the number of vehicles and infrastructure priorities

■ Manifested most clearly in the substantial deaths due to MVC, and less clearly in the rise of chronic diseases related to traffic exposure and practices over the same periods that car traffic undergone large changes

■ Systems approach; such as the Vision Zero initiated by Sweden and Sustainable Safety in the Netherlands based on an ethical position in which it is unacceptable to have people seriously injured or killed on the network

■ Transport infrastructure design is inherently conceived to drastically reduce crash risk

■ This clarity in policy and guidance may have led to a substantive influence for human life in the transport design agenda

The Car Lobby■ Acknowledge car industry as a powerful and diffuse

force in advocating for mass motorization through

marketing strategies to increase uptake and

maintenance of driving

■ Opposing measures that may reduce car use, e.g.

fuel duty increases, reduction in parking supply,

proposals for car-free zones, improvements in traffic

safety and delayed EU emissions regulations

■ Little public support for measures to rectify the

impact

■ The car industry with its economic reach to provide

jobs including manufacturing, dealerships, hire

companies, parking garages, motoring organizations,

oil and gas companies, construction and engineering

firms, insurance industry and others, make it difficult

to regulate

■ It is moving into new markets in low and middle-

income countries

Public Policy Favouring Car Mobility

“For national and local policy makers, I suggest the following ranking of priorities in

transport policy: (1) stimulate the economy by facilitating the smooth flow of goods and

people, (2) ensure social equity by facilitating access to mobility for disadvantaged

groups (especially via public transport), and (3) addressing negative externalities in the

following order of importance: (a) congestion, because it has negative social and

economic implications, (b) local ‘quality of life’ problems such as air pollution, parking

and spatial problems, (c) safety (traffic deaths and injuries), and (d) environmental

sustainability such as climate change. This externality ranking explains why most

transport policy programs address congestion (via congestion charging, dynamic traffic

management, and demand management)” (Geels 2012)

Public Policy Favouring Car Mobility ■ Historic strong association between economic development and an increase in the demand

for transportation and number of road vehicles

■ Infrastructure banks and governmental agencies have funded road construction for several

decades

■ Motorized mobility remains a criterion for measuring country-level economic success

■ Economic investment in roads is seen as an important determinant of economic growth

■ Traffic optimization and travel time savings remain the lead principles in transport planning

■ Technical-orientation in practice (mainly an engineering and economic focus) underestimate

the negative externalities of transport infrastructure decisions

■ Even solutions supposedly aimed at alleviating car use such as transit and bus rapid transit

are directly measured by travel time savings

■ Road investment strategies continue to support motor vehicle travel, thereby attracting more

cars whereas considerably less is allocated to active and public transport modes or mobility

management strategies

100 major schemes funded by £15.2 billion of public money

The State of the Practice of Transport Appraisal ■ Cost Benefit Analysis (CBA) is the most commonly used

instrument to determine whether a certain transport project

is to be preferred over another

■ A project that has the highest positive monetary value, or

the highest benefit to cost ratio is the preferred project by

decision-makers

■ Monetized items include (changes in) travel times,

consumer surplus, (changes in) employment, business

activity and earnings, MVC, casualties, carbon and air

quality emissions and noise impacts

The State of the Practice of Transport Appraisal■ But many inherent limitations:

– CBA accept transport users’ willingness-to-pay as an appropriate indicator factored in the

calculations

– CBA are embedded in an econometric ontology that associates lower economic benefits and costs

to events taking place in the future due to economic depreciation rates. As a result, short-term

economic benefits (e.g. higher accessibility to jobs, lower travel costs) are likely to be overvalued

when measured against more complex and distant costs such as long-term environmental and

health impacts

– CBA assumes the outputs of transport planning models in the calculations

– It is acceptable to consider the time savings for existing travellers that use the services of a new

transport project as benefits. It also establishes that it is valid to sum time savings to the time

spent by travellers that were induced to travel by the new project (induced demand)

– CBA logic assumes that time savings are a benefit when time spent travelling can be positively

valued by transport users, especially those using transit and active travel modes

– Impacts on morbidity are not addressed

The State of the Practice of Transport Appraisal

“Would it be the solution to conduct

an overall appraisal/evaluation of a

plan/intervention. Not just health or

economic benefits, but as wide as

possible? I guess that is the main

problem at the moment that

evaluations/appraisals are mostly

done by domain”

Results from transport practitioners

Economic GrowthTravel Time Savings

Cost EffectivenessLand-use

Accessibility

Noise Reductions

EqualityProviding for Cars

Efficiency

SafetyS

usta

ina

bilit

yPolicy Integration

Connectivity

Economic GrowthTravel Time SavingsCost Effectiveness

Accessibility

Carbon Reductions Noise Reductions

EqualityProviding for Cars

Efficiency

Safety Policy Integration

ConnectivityS

usta

ina

bilit

y Air

Qu

ality

Public Perceptions and Awareness

■ Historically, societal acceptance and preference toward private

car ownership was celebrated as a process of democratization

fulfilling individual desires of flexibility and self-determination

■ It also symbolized the idea of freedom and independence as

well as, power, superiority, and social status

■ Behind public perceptions are driving forces of this

development such as “the leading industrial sectors and the

iconic firms within 20th-century capitalism (Ford, GM, Rolls-

Royce, Mercedes, Toyota, VW and so on), and the industry from

which the definitive social science concepts of Fordism and

Post-Fordism have emerged.” (Urry 2004)

■ These forces are behind a persistent car-mobility paradigm

making car dependence a phenomenon that operates societally

■ Cultural norms reinforced by public policy and institutions that,

although should represent the public interest and are oriented

around sustainability tend to exercise power to protect special

interests

■ Health impacts of transport were not widely recognized until the 1990s

■ Lack of public awareness of these impacts, even those which have been receiving

increasing media coverage such as air pollution; reinforce the lack of political

commitment and initiative to address these problems





where we are now…








Where are we now?



What will guide us?



■ Mitigating or preventing adverse health impacts will have a long run benefit to

society in terms of overall well-being, productivity, economic prosperity, reduction in

healthcare costs societal investments rather than societal costs

■ An integrated cross-disciplinary planning effort to move away from a car-based

society to high quality and equitable public and active travel systems

■ More importance to health in the development and transport agenda

■ Knowledge transfer and collaboration in research, policy, and practice will play a

fundamental role in promoting healthy transport practices





where we are now…








Where are we now?



What will guide us?


What will guide us?

■ Example of good practice emerging from a collaborative and open-ended project bringing together expertise in health, environmental sciences, air pollution, transport planning, economics, practice and advocacy and policy making

■ HEAT aims at making the health benefits of regular cycling and walking visible to transport and urban planners

■ Whilst addressing the importance of CBA in transport design and planning decisions

■ The tool offers economic estimates of health benefits of walking and cycling by estimating the economic value of reduced mortality that results from specified amounts of walking or cycling in a defined population

■ Been used in research, policy making recommendations, advocacy and in practice

■ Was recommended in the official toolbox for transport investment appraisal (WebTAG) in England and in the Action Plan for Improving the health of Londoners by Transport for London

What will guide us?

■ iConnect study aimed at measuring and evaluating the changes in travel, physical activity and carbon emissions related to Sustrans' Connect2 programme

■ Connect2 an ambitious UK-wide project that transformed local travel in more than 80 communities creating new crossings and bridges to overcome barriers increasing physical activity

■ Initial funding for this programme came from a non-transport source, the UK Big Lottery Fund (£50 million), in which public vote demonstrating the huge amount of public support for this programme was essential

■ This funding was used to unlock other sources of funding necessary to complete the programme at an overall value of £175 million

What will guide us?

■ Bradford Metropolitan District Council recently undertaken

a low emission zone feasibility study

■ Involved stakeholders, researchers and practitioners from

different disciplines including transport planning,

environmental sciences, public health and health

economics alongside collaboration with other city councils

in the West Yorkshire

■ The relative impact of several transport interventions

scenarios beyond the ‘business as usual’ case were

modelled

■ The impact that these scenarios may have on projected

air quality concentrations, health of the local population

and the costs and benefits associated with each

intervention measure were calculated and presented

■ Was used to provide strong evidence in support of two

funding bids at an approximate value of £1 million that

aim at improving air quality in the region





where we are now…








Where are we now?



What will guide us?


What action and from who?

■ No “one size fits all” approach and policy

transfer is a highly politicised process

justifying preferred solutions

■ Technological improvements are not it!

Counter-productive in instances such as

the failure of the massive technology

change from petrol towards to mitigate

climate change

■ Public transport and active travel

provision and behavioural and societal

transformations are needed

■ Active involvement and collaboration of

engineers, planners, economists,

epidemiologists, and medical providers to

ensure health is at the top of the list of

competing priorities


■ Transport Engineers and Planners

■ Try and bridge the gap between design, planning,

economics and health

– Bring the health agenda to the table

– Consider the health impacts of engineering and

planning decisions as more explicit outcomes of the

transport design and appraisal process

– Expand transport planning curriculums beyond the

functional quality of infrastructure

– Engage more with the public

– Consider health through transport design as an

additional objective

– Adopt tools and methods that would enable

assessing health impacts of transport design and

planning (e.g. Health Impact Assessment tools


■ Health practioners

– Improve understanding of the urban and transport planning agenda

– Play a proactive role to include health as a transport project objective

– Advocate for effective policies that encourage active travel and reduce car use

– Partner with urban and transport planners from the start of design and

planning process to ensure that health is a recognized objective

– Support transport engineers and planners in conducting health impact

assessments for possible transport scenarios

– Develop innovative and usable health economic assessment tools to be added

to existing or novel transport design and planning tools


■ Researchers

– Start appraising tools that are being used in transport planning to provide a holistic point of view in regards to impacts on health

– Advocate for co-production and cross-disciplinary work

– Increasing the outreach and communication between the research community and transport practitioners, local governmental entities and the public constituency

– Epidemiologists and health researchers can contribute to resolving open scientific issues and improving the evidence base for health impact assessment

– Follow-up to how policy guidance/recommendations will be interpreted or altered

– Increase public outreach and awareness of health impacts of transport choices and practices


■ Policy makers

– Include long-term health impacts that are difficult to grasp or measure on the

short term

– Reallocate funding streams at the policy level to include health impact

assessment

– Expand CBA and similar appraisal methods

– Set operational goals and indicators in a transparent and non-sectorial manner

– Have strict legislation for integrated transport planning with land-use

– Clear policy and guidance to transport professionals to include health in the

development and transport agenda

“This is difficult to ask to people

who are already under pressure

to do their job as fast as

possible and whose boss does

not recognise the importance of

integrating health impact”

Changing perspectives?■ “Economic investment in roads is seen as an important determinant of economic growth. It is

important to break this cycle and think about economic development rather than growth”

■ “It might be worth a quick thought experiment around what a health oriented approach to

transport planning might look like. Stated differently, from an engineer’s perspective,

accounting for black spots and reducing fatalities is health. From an urban designer

perspective, designing places for human interaction is health. From an urban planning

perspective (at least land use), separating land uses like residential from commercial or

industry (like pig slaughter houses) is health. As such, contemporary urban planning reflects

a variety of different perspectives and aims, which are often tied to specific pots of monies

and constrained and constituted via specific professional remit and duties”

■ “As my focus is more on design, I don’t think I’m the best person to contribute to the sections

about policy. In my role as policy advisor for the ministry I am of course involved in policy, but

this papers helps me realize how lucky road safety experts are”

■ “Neoliberalism and CBAs as wrong instruments at two levels: technical and fundamental”

■ “Yes CBAs are based on reducing travel time see article you sent me. While increasing travel

time may be beneficial in case of active transportation”

Conclusions

“Citing Frank and Engelke's 2001 literature review, the very first sentence in Northridge et

al. (2003) article is "While it has been stated before, it nonetheless bears repeating that the

connections between urban planning and public health are not new. Clearly, though such

connections are not new, they have been inadequate to generate consensus towards a more

sustainable, healthy and ethical urban and transport systems. There is probably several

articles you can point to which have sought to make similar points and cross disciplinary

boundaries. That being said, whereas such examples evidence Karen's point, I remain

unconvinced they evidence practice. There remains a gap between the academic and

professional circles. Again, this is not to pick on professionals or civil servants, who for the

most part do or at least strive to do a good job, but if things were different, you wouldn't

have a paper. They're aren't different, and thus, you still have valid points and a paper”

A few learning experiences

■ “The big questions will only be answered by cooperation of multiple disciplines”

■ “Transport and Health seem to have quite different histories, experiences and (vested)

interests and we need to develop a common narrative and close collaboration to tackle

the transport and health problems”

■ “Collaboratively writing this paper helps me to put my own discipline (road safety in my

case) in the broader context of health. For instance, some safety measures are helpful

for road safety only while other measures contribute to other health benefits as well.

This stimulates thinking”

■ “The one major lesson learnt is that although health has made significant advances in

demonstrating effects from car-oriented planning (which I was not aware of), such work

has yet to contribute to a more evidence-based approach to urban policy and practice”

■ “Collaborative efforts of both sectors are needed to provide healthy and sustainable

transport policies”

■ “…How to combine both interest in a sustainable manner will be the challenge of the

near future”

A few learning experiences?■ “It will take a lot of time and effort to develop

principles for designing the road system that are helpful for all important health aspects. And even more difficult (or impossible), principles that work in different contexts. Having such principles (e.g. the Sustainable Safety principles in the Netherlands) were extremely helpful for road safety policy. It would be great to have such principles for transport and health in general. It seems we have a long way to go to develop such principles”

■ “What a pleasant surprise to realise we were so many, with so different backgrounds, thinking that health should be taken into account while planning transport systems. Joining our forces is definitely a promising avenue towards a more integrated way of thinking transport issues”

Health & Medicine

Hk icth2016 13th_june2016_website version