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To Control Health Costs, Build Sidewalks

2013 August 12
by Brice Maryman

Perhaps the most remarkable thing about the image above is just how unremarkable it is. All around the country there are places that look like this; in fact, this is probably a more common situation than the tree-lined sidewalk that we hold up as our ideal infrastructure.

Public health practitioners look at streets like the one above and have gradually come to the conclusion–based on reams of studies–that exposure to streetscapes like it are one of the causes of Americans’ ever-increasing rise chronic disease. In fact, the New England Health Care Institute estimates that our environments influence as much as 20% of our public health outcomes.


As with contagious diseases, researchers have also found that the more proximate you live to this type of environment, the more likely you are to be negatively affected by it. For example, we take it as a given that residents of tropical regions are more likely to get a variety of mosquito borne illnesses if they live near a fetid pool of water. Similarly, Americans are much more likely to have a harder time avoiding chronic diseases that “account for seven of every 10 deaths and affect the quality of life of 90 million Americans” if they are exposed to streets like the one above. As exposure increases, risk increases.

Dr. David Fleming, the Director of Public Health-Seattle & King County (PHSKC), emphasized these points during testimony to the Robert Wood Johnson Foundation in June:

Most deaths today result from diseases and conditions that are shaped by our social and environmental surroundings. Poor health almost any way you measure it is increasingly concentrated in the same locations, making it easy to identify which communities are making people unhealthy and underscoring the importance of place to health. What makes these neighborhoods unhealthy? While the role of clinical health services is vital, medical care alone accounts for only about 10 percent of premature deaths.

Neighborhoods create ill health because of their intrinsic community characteristics. Houses and rental units are substandard and contaminated with mold and toxins like lead, streets aren’t safe for walking to school or work because of crime or just a lack of  sidewalks, and healthy food isn’t easily available, though high-fat, sugar-loaded processed food is for sale at the corner  convenience store.

All of this evidence begs the question: if the built environment is a significant determinant of our public health outcomes, why aren’t health entities–hospitals, HMO’s and clinics–helping to build a better infrastructure that supports sound health outcomes? While public health agencies like PHSKC and the CDC have been leading the way, the private sector has been generally hesitant to directly intervene in the built environment. Yet, public health indicators will continue to decline unless the built environment is changed and cities are already financially constrained.

Dr. Fleming offers some hope, arguing that the Affordable Care Act may have unlocked a key to force the private sector to recalibrate their own financial calculus and compel them to directly intervene in reducing their patients’ exposure to unwalkable streets, unsafe speeds and overly toxic emissions.

In a future of capitated payment for individual health care, health care systems may find that remaining agnostic to the community from which their patients come weakens their bottom line. Instead, targeted investments in neighborhoods with the poorest health may begin to make both good health and good business sense.

So does that mean that we’ll see Group Health sidewalks, Kaiser Permanente greenways and BlueCross/BlueShield skateboard parks in our communities? As a new business paradigm sets in, the data suggests these interventions may become a cost effective way to control private sector costs and improve public health outcomes, resulting in a win for everyone involved.


Brice Maryman tries to stay exposed to healthy environments in his job as a landscape architect with SvR Design.