Healthy People, Places and Transport

Chloë Mason

ISSUE ADDRESSED

Transport systems have recently been identified as significant social determinants of health. Because physical activity is extraordinarily effective in protecting physical and mental health, health professionals are beginning to promote 'active transport' (travel by foot, bicycle or public transport) as a sustainable positive lifestyle habit. This paper argues that a convergence of interests in health, environment protection and transport is opportune for securing more livable neighbourhoods and better public health.

This paper takes a composite ecological approach to investigating the links between transport, environment and health, rather than the conventional pollution paradigm. In doing this, three issues are raised:

• the scale of the health-damaging effects of current and projected transport practices;
• the potential for increasing the health-promoting effects of transport; and
• the potential to intervene in practical ways in the harmful trend toward sedentary car travel at the expense of active transport.

CONCLUSIONS

Health promotion professionals implementing the full range of health promotion actions outlined in the World Health Organization's Ottawa Charter could advance and support the movement for health-linked transport practices and policies in Australia.

SO WHAT?

Achieving healthier transport systems will take time but the benefits for health and quality of life will be considerable.

KEY WORDS

physical activity, ecological health, active transport

Introduction

Health status and health inequalities have a complex relation to a whole spectrum of public policies. [1] The World Health Organization (WHO) now identifies transport policy and practice as a social determinant of health and health equity. [2]

Transport systems lead to both health-damaging and health-promoting effects in the localities they serve. They also have regional and global impacts on the environment, for example in relation to habitat loss, greenhouse gas emissions and marine pollution. Over the last 50 years there has been a growing reliance on car use at the expense of walking, cycling and public transport. This has resulted in an increase in the use of cars even for very short trips, such as taking children to and from school, and is jeopardising the quality and livability of our urban areas.

People in the transport sectors in many countries recognise the need for a new direction. This new direction involves integration of urban and transport planning to enable a better balance between sustainable travel modes and car travel. Transport reformers are also attempting to put public transport and cycling on a universal rather than residual footing so that services are available for most people living in towns.

This shift in direction was signaled in Europe when ministers for transport met with ministers for health and for the environment (including urban planning) at a multisectoral summit in London in 1999. This summit resulted in the landmark WHO Charter for Transport, Environment and Health which aims to reduce the use of motorised transport. [3]

It is my view that there is a convergence of interests between this new transport and planning agenda and health. [4] Health workers can play a valuable role in advocating transport policy and practice that is sustainable for health and the environment by collaborating with people across sectors and by amending transport policies within the health sector.

The health effects of transport

The current consensus is that, to protect health, every adult should accumulate 30 minutes or more of moderate-intensity, endurance-type physical activity-such as walking or cycling-on most days of the week. This level or dose of physical activity has major and multiple beneficial effects on mental and physical health. Conversely, physical inactivity is a significant risk factor in all-cause mortality. The Australian Institute of Health and Welfare reported in 2000 that physical inactivity is the second leading cause of years lost to life in Australia. They also reported that the time spent walking by Australian adults fell by 10% over two years. [5]

Interestingly, despite the significant health benefits of physical activity, an analysis of the medical media by Dupen has shown that medical readers are less exposed to research about the benefits of physical activity than other risk factors for cardiovascular disease. [6] In exploring the history of public health interventions for increasing physical activity, Dunn has noted that the 'exercise-training-physical fitness' paradigm has been updated and broadened to include 'lifestyle physical activity' as a means of encouraging sedentary individuals to become active. [7] Lifestyle activity, Dunn shows, is maintained over a longer period than programmed exercise.

In terms of a "new imperative for public health", Sparling and others refer to the need for "re-incorporating a modicum of physical activity into our daily life". [8] During each day, opportunities for physical activity arise from the need to travel for work, shopping and school. Forms of transport that involve incidental physical activity, such as walking, cycling and traveling by public transport, are referred to as 'active transport'. [9]

Active transport policies and programs can be effective in overcoming pervasive sedentariness by changing mobility habits and reducing car use. Existing urban environments can be modified, for example, to develop pathways and cycleways for enjoyable access to schools, sports grounds and shops. New developments can be designed around focal points with good connections to provide the physical structure for 'active community environments'. [10]

From an ecological health perspective, the environmental conditions in localities contribute to the popularity and take up of physical activity, particularly active transport instead of car transport. Health-promoting patterns of travel, such as replacing at least some car trips with active transport, can have a synergistic benefit for public health.

Although recognition of the health effects of lifestyle physical activity has helped to highlight how walking and cycling are health-promoting forms of transport, the health-damaging effects of transport are probably more widely known. Traditionally, the areas of greatest attention are road traffic accidents and noise and air pollution. A tri-country study presented at the WHO summit quantified the years lost to life from exposure to motor traffic air pollution. [11] Other effects, not so readily quantified, include loss of independent mobility (for children, the elderly and people without use of a car), loss of green and play space, loss of tranquility, and hostile conditions for walking and cycling that encourage sedentary lifestyles. Further adverse effects are forecast as a result of climate change that will in part result from the growing proportion of carbon dioxide emissions from transport.

A composite ecological approach

The composite ecological approach looks at both the health-promoting and health-damaging aspects of transport. An influential report produced by the British Medical Association in 1997-Road Transport and Health-used this approach to promote debate on transport issues. [12] The report supported a more balanced approach to transport policy that would promote rather than damage health. Its four key aims were to:

• reduce the reliance on, and need for, health-damaging forms of transport;
• increase the use of health-promoting forms of transport;
• increase mobility and access and reduce inequity; and
• reduce the negative effects of modes of transport.

To state the position boldly, Wilkinson and Marmot say "the 21st century must see a reduction in people's dependence on cars". [13]

Based on: SUSTRANS. Safety on the streets for children. Information sheet FF10. Bristol: SUSTRANS; 1996

As can be seen from figure 1, the links between transport, health and the environment become apparent at the local level. In localities where children live, play and go to school, the increase in motor traffic encroaches on space and the freedom of their movement. Rather than addressing issues such as accident prevention, traffic congestion, pollution and physical inactivity in isolation, the composite ecological approach recognises their common contributing causes. Such recognition should lead to a willingness to tackle the fundamental changes needed to enable less reliance on cars.

In this approach the emphasis is on people, places and mobility rather than moving cars. The ecological approach has no need to find and deal with a single 'bad guy' such as is conjured up in the traditional infectious disease (or lead poisoning) model of host-vector-environment. It embraces the complex ways in which health is socially determined.

Converging interests in health and transport

The transport debate

As a result of the negative economic, environmental and social impacts of motor traffic growth, a debate about the assumptions underlying transport planning and policy has commenced. In a short valuable exposition, Hazel explains how concerns are leading to the need to re-think from first principles the way in which we meet transport needs in the future. [14] The 'predict and provide' response to motor traffic growth is not sustainable. [15] Alternatives are possible and in many places have been successfully adopted.

Accounts of Australian urban planning and transport are helpful in understanding the complex relationships that exist in urban transport systems. [16-18] Such an understanding is necessary when developing health-linked transport policies. Transport needs to be viewed as a service function which enables people to take part in activities, rather than a bundle of modes or conveyances and infrastructure projects. Excessive automobile use is not merely an individual behavioural characteristic, but also relates to the structuring of activities within cities, the availability of alternative modes of transport (particularly the network and frequency of public transport services) and economic incentives. The principles and policies needed for achieving a better balance are well articulated by Vuchic in Transportation Policies for Livable Cities. [19]

The WHO Charter on Transport, Environment and Health

The 1999 WHO Charter on Transport, Environment and Health sets out guiding strategies for a fundamental shift in transport-related policy and practice to protect health and the environment. [3]

These strategies are directed at reducing the need for motorised transport. They are informed by a set of principles, including ecological sustainable development, multisectoral integration, equity, efficiency and governance. They are also supported by a statement of evidence and a listing of international agreements relevant to the field, including the United Nations Kyoto Protocol to the Framework Convention on Climate Change to which Australia is a signatory.

Other actions, including the European Union's commitments to sustainable mobility and initiatives on mobility management, and some initiatives in British health facilities, complement those outlined in the WHO Charter. Similarly, major changes have occurred to taxation laws, federal transport planning and funding, and commitments to sustainable mobility in some American cities.

Competing views of transport in everyday life

While a fundamental re-think has led to some bold, cross-sectoral policy declarations and guidance materials on developing health-promoting transport systems, the issue is by no means settled either in concept or practice. New approaches must constantly challenge conventional traffic engineering, which aims to maximise vehicle movements through a network to reduce travel time.

In Melbourne, for example, many local governments want residential streets and collector roads to become 50 km/hr zones. [20] Such a speed reduction would reduce the number of road accidents by about 1600 per year (80% of these accidents involve people who are outside the car). The State road authority, however, wants collector roads to remain at 60 km/hr. Conventional network managers state that reduced speed would result in delays to motorists, estimated to be an aggregate of 1.6 million hours a year!

The need for slower speeds in residential streets so they can function better as links to open spaces and as quiet spaces to satisfy children's needs for diverse physical environments is often overlooked by adults, who see the street mainly from a motorist's perspective. [22]

Trams in Melbourne are held up by cars on the tramlines and by lack of priority at traffic lights. The operations director of Swanston Trams recently told an international conference on light rail for livable cities that, in Melbourne:

At traffic lights a tram with 100 people is treated the same as a car with one person because the light sequences are always based on the flow of cars. [21]

Holding up trams and buses in private motor traffic obviously increases the journey times for many travellers and increases the costs of providing reliable, frequent services. The objectives of transport systems should be to move people and goods between places and to enable access to a range of activities and other people for social and economic exchanges. [23] As the BMA stresses:

Ease of access and participation are essential for both the nation's economy and human health and wellbeing. [24]

Including transport in health promotion practice in Australia

People working in the health sector are well placed to support new directions in transport that have the potential to bring benefits for environment protection, health and health equity. There are a number of ways they can do this. [6]

Influencing transport policy

As with other issues in health, such as poverty [25] or smoking, strategic influence is essential. Public health commentators argue that attention to reducing health risk factors (i.e. behaviour) rather than attention to affecting health risk conditions (e.g., unemployment, social exclusion) has limited the effectiveness of efforts to promote population health. [26] Health promotion practitioners can 're-focus upstream to the social determinants of health' to include mobility and healthier transport systems as life conditions heavily influencing patterns of behaviour. Health improvement, therefore, can become more central to public policy development.

To influence policy in sectors beyond health care, Wilkinson and Ziglio suggest that the facts about the need for healthier transport systems should be "boldly stated" and emphasis should be put on the idea of health being an investment. [2, 27] As government income is being earmarked for roads, education and health expenditure, it would be appropriate to allocate funds for public transport that improve the quality of life and livability of towns and cities.

In the 1993 Goals and Targets report, Australian public health policy advisers recognised the sectors of housing and transport as having an impact on health. [28] With the new lifestyle physical activity paradigm, new knowledge and awareness (e.g., about air pollution and greenhouse), and the urgency for stating the 'bold facts' about aspects of social determinants of health, transport again needs to become a key target for health promotion action.

In Australia, there are good signs of new directions in urban transport and landuse policy. The new advisory National Transport Secretariat to the Federal, State and Territory Transport Ministers has been briefed to work on an improved transport planning process and on improving the environmental performance of the transport system. In particular, it is to put forward options to reduce greenhouse emissions and address urban congestion. [29]

Health reasons may serve as leverage in justifying a shift in expenditure within the transport budget. Health reasons can also be marshalled to support the case for reforming the perverse economic and taxation incentives for car use. Within the tight portfolio structure of government, however, these influences may be quite limited. Health advocates have been able to influence the core goals and assumptions of policies in transport, landuse and quality of life in Britain, however. As a result, mobility and healthy transport are being incorporated into health plans and place-based health programs. This is described in Making THE Links, a report on integrating sustainable transport, health and environmental policies prepared for local government and local health authorities. [30] Strategies include reducing the amount of car parking (in areas served by alternative transport) and ensuring provision of recreational facilities and easy access to facilities.

Non-government and professional transport organisations are recommending Australian governments make the fundamental shift to sustainable transport. For example, in late 1999 the Sustainable Energy Transport Taskforce of the Institution of Engineers made some cogent recommendations, such as seed investment funding for infrastructure, that will enable greater public transport provision. [31] We welcome the strong recommendations from the Senate Inquiry into Australia's Response to Global Warming in its recent report. [32]

Managing mobility

Travel Demand Management

In transport, physical infrastructure is the supply of an appropriate mix of public transport services and conditions for walking and cycling. Complementary measures, or 'soft measures', are also needed to promote the efficient utilisation of healthy transport services, particularly where car travel is presumed to be the norm. Travel Demand Management (TDM) consists of measures to:

… modify travel decisions so that more desirable transport, social, economic and/or environmental objectives can be achieved, and the adverse impacts of travel can be reduced. [33]

A wide range of measures are available to the governments, enterprises and transport operators who undertake programs to reduce the use of cars. [34] Since the introduction of TDM in the 1970s, mobility management has developed as a result of a more multi-disciplinary social approach and a stronger emphasis on people's needs and how these can be satisfied in the places where they live, work and play.

With the growing commitment to 'sustainable mobility' in Europe, the European Commission has funded a series of applied research projects in mobility management. Generally, these projects entail partnerships between local governments, transport operators and organisations and are continuing to generate transferable principles and models. Information sharing is encouraged through conferences and a network supported by the European Platform on Mobility Management (EPOMM). [35]

Influencing individual and household decisions

As part of a major initiative to help create healthy communities, research on the effectiveness of information and publicity about public transport, cycling and walking was undertaken through INPHORMM-Information and Publicity Helping the Objective of Reducing Motorised Mobility. This project resulted in the sharing of good practice across Europe, the United States and Australia. The INPHORMM project demonstrated that the provision of user-friendly, passenger-oriented information about public transport not only led to increased use of services but also influenced understanding about transport policy proposals to reduce car reliance.

Large-scale individualised marketing in areas such as south Perth in Western Australia, using methods developed by Broeg, produced dramatic and lasting reductions in car use and increases in cycling and public transport use where services were previously under-utilised. These results are encouraging. The method used characterises the travel taken by an individual or by household members as a bundle of trips taken during a year, and disconnects trip making from a pre-determined mode of transport. It provides the potential for more people to reduce at least some of the trips they would previously have taken by car.

Promoting organisational travel plans

Information about transport can also be produced and distributed through organisations that are 'trip generators', that is they attract staff, clients, customers and visitors. As INPHORMM has shown, simply providing information can be very effective in reducing the number of car trips generated. In Sydney, the NSW Sustainable Energy Development Authority developed a brochure advising organisations about producing and using transport access guides. [36] Such guides provide a concise presentation of how to reach a site or venue using public transport or by walking or cycling.

Transport access guides are a cost-effective measure and a first step toward organisation-based plans. Typically, employer mobility plans offer staff incentives to use healthy transport and take effective measures about subsidies to parking. They can reduce the share of car journeys from 5 to 20% depending upon the specific characteristics and services available.

In Australia, a number of organisations have adopted mobility management or TDM plans. [37] For example, the University of New South Wales introduced a transport program in 1998 to improve accessibility to the campus while reducing car use. While such programs are typical of universities in Europe and North America, this program was the first of its kind in Australia. The size of the university, generating 25 000 trips daily, together with the comprehensive nature of the program and its advocacy of systemic reforms, are leading to improvements in the transport system not only for the university but also for people living in the region.

Health promotion workers can encourage and enable other organisations to take action towards more healthy transport practices. Organisations influence the internal and external environment and provide the setting within which health can be influenced. Efforts in health promotion can link personal health to the values and goals of the organisation.

Re-orienting health services

One of the important ways people in the health sector can encourage active transport and a healthier transport agenda is by looking at their own organisations and programs.

The WHO Charter on Transport, Environment and Health committed signatories to ensuring that:

… health authorities take full account of the impact on transport of their own policies. [IV Goal achievement-integration] [3]

Clearly the functioning of health services themselves impacts on transport. Health services can be major trip generators and major employers. They can also be served by public transport and offer health programs in which active transport can be incorporated.

As a starting point in healthy transport, the Canterbury Hospital in conjunction with the Health Promotion Unit, Central Sydney Area Service produced a map showing public transport access and the health benefits of walking from the station.

The map shown in figure 2 is incorporated into a brochure about the Canterbury Child, Adolescent and Family Health Service that is produced for clients and referral agencies. Such information enables visitors and clients to plan their journey without using a car.

As employers, health service agencies can also offer healthy travel plans. While little is known about practices in the Australian health services, in the United Kingdom the National Health Service, with the support of Transport 2000 Trust, a non-government organisation, produces the Healthy Transport Newsletter. This newsletter reports on the many hospitals that are now adopting healthy transport plans with measures to ease congestion by moving from 'free for all' to 'fair for all' transport policies. Most recently, a new standard was announced requiring organisations to demonstrate a reduction in the environmental and other risks associated with transport and implementation of healthy transport plans.

Healthy transport can also be promoted to clients attending the health service, and can be part of a healthy lifestyle program in clinical practice, such as in programs for cardiac rehabilitation or management of anxiety. The physical activity programs supported by Active Australia could readily incorporate active transport, for example.

Creating supportive environments for healthy transport

While we can borrow many good ideas and programs from other countries, the conditions and commitment to healthy, sustainable transport have to be established here too. At the time of writing, Australia has significant perverse economic incentives that encourage car use and the under-provision of public transport and safe cycling routes. Organisation-based or locality-based travel plans hold great potential for promoting and achieving healthier travel patterns. The incentives for car use, however, create a hostile climate, both economic and cultural, for such plans and a disincentive for healthy transport. Making the transport system itself more ecologically sustainable is a necessary foundation for generalising the practice of organisation-based travel plans.

Work on travel behaviour change is drawing upon behaviour change models used in health promotion. The Institute for European Environmental Policy drew attention to how issues in health-related behaviour have implications for changing travel behaviour. [38] Its summary of lessons from health promotion, however, construes health promotion to relate only to individual behaviour, rather than the breadth of actions under the Ottawa Charter or the urgency for addressing the actual environments within which people live. The Institute's paper does refer to the relevance of car-free housing schemes and car sharing schemes, however, which could conceivably be part of a health promotion strategy pursued through organisations and advocacy. In developing any inter-sectoral collaboration, we need to be careful not to locate the problem merely at the level of individual behaviour.

Communicating and consulting across sectoral borders

Those addressing the need for healthier transport systems and their use can probably learn from the evaluation of the National Youth Suicide Prevention Strategy. [39] One identified strength of this strategy was its focus on building the capacity of health and welfare services to respond to young people's needs generally rather than creating structures and processes focusing specifically on suicide. The evaluation supported the idea of a general principle of capacity building health promotion for a wide variety of goals. Inclusion of transport in health promotion by addressing comprehensive systemic processes, rather than adding a new priority to the list, would undoubtedly strengthen the collective capacity to deal with this social determinant of health and health inequalities.

Learning strategies for organisations to support health development would also be desirable. The Californian Department of Health Services, for example, supported the US Centre for Livable Communities to produce a series of fact sheets to demonstrate the strong connections and design, economic activity and health-linked transport. [40]

Fundamental shifts in transport will take time to achieve, and affected communities need to be engaged in policy development through a wide range of discussion methods. Strategies such as deliberative conferencing or citizen juries could be used. [41, 42]

Issues of evaluation and performance monitoring need attention too. To assess performance on environment and transport, the European Environment Agency produced Are we moving in the right direction? in which indicators of societal responses to the transport impacts are reported. [43]

Conclusion

Health-linked transport is every bit as essential for improved public health as smoking cessation. It also is a long-term project.

Health education researchers understandably find the task awesome. Sparling et al. ask, for example,

Will environmental and social-change solutions which go against the prevailing economic and technological trends be achievable? [44]

If we can bring together people working in health and environment protection, we will have between us a wealth of experience in addressing the problems that arise when unrestricted individual behaviour collides with socially optimal behaviour. This is the basic problem we are now witnessing in regard to travel in cities. [45]

There is scope for action at both the micro and macro levels. Small, modest actions can be easily taken that will enable and encourage people to increase their mobility by foot, cycling or public transport with relatively little effort and cost. The combined effect of small steps taken by many organisations will also help to change expectations about travel being dependent upon car use.

Conventional expectations about car travel are embedded in the policies and communications of most organisations, including health services. One immediate first step, therefore, is to begin the process of reviewing communications about transport access exemplified so well by the Canterbury Hospital case.

The links between transport, environment and health are so extensive that not only are there opportunities for increasing mobility and access using health-promoting means of transport, but also for reducing inequity and the reliance on and over-use of cars.

Achieving healthier transport systems involves fundamental shifts in mindsets, legislation and policy. These changes will take time, and influencing governments to take action will require all our collective experience, imagination and tenacity.

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Author

Chloë Mason
PO Box A973
Sydney South NSW 1235
Phone: 02 9281 1751
Fax: 02 9281 9501
Email: Chloemason@bigpond.com

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