Open Road Surgery

First came smoke-free bars. Next trans-fat donuts got sent packing. New York City's public health agenda has been making headlines and pushing boundaries. In a city where dangerous roadways are a leading cause of death and disability, could a prescription for healthier streets be the next frontier?

For generations, shovel loads of dirt, not spoonfuls of sugar, have made the medicine go down in the five boroughs. The Croton Aqueduct and the city's sewer system get the credit for conquering the cholera epidemics that once ravaged the city. Tighter building and fire codes for new construction did away with the hazardous, disease-ridden tenements where tuberculosis ravaged thousands.

This is a city where public health officials have actively shaped the landscape since those first bold steps in the Nineteenth Century. Today, health agencies and community coalitions are turning their attention to the city's streets as both the cause and the cure for the great epidemics of the 21st century.

Goodbye, Jane Fonda. Hello, Jane Jacobs.

It is common knowledge that regular physical activity can help prevent the big killers of our age--heart disease, diabetes and obesity--but fewer and fewer people are getting the exercise they need. Less than 42% of New Yorkers meet the recommended amount of weekly physical activity. Between 1960 and 2008, the prevalence of obesity in adults swelled from 13% to more than 30%, with the rate climbing dramatically in recent years. Today's youth may turn out to be the first generation in modern history to live shorter lives than their parents.

Well-intentioned public education campaigns and the proliferation of glamorous facilities like Equinox and David Barton have had no effect on this trend. The Institute of Medicine makes the sad admission:

"It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environment conspire against such change."

For this reason, health professionals are now looking for ways to build physical activity into the routines of our day-to-day lives. They are trying to improve neighborhood streets to make them more pleasant, safe and convenient to walk, and scrutinizing the routes that connect residential areas to daily necessities like transit, shops and schools, as well as to parks and recreational destinations.

This all may sound like the sort of prescription more relevant to unwalkable locales like the exurbs of Atlanta or Phoenix. After all, New York City is high-density and mixed-use, with a street grid that should promote walking. Yet closer scrutiny shows how decades of car-centric planning have eroded the city's walkability. A single roadway like Atlantic Avenue, with its numerous lanes, dangerous intersections, noise and pollution, discourages walking in the dozens of neighborhoods that straddle it. Speeding on residential streets cuts off thousands of children from their historic play space. Seniors are deterred by uneven pavement, lack of curb-cuts, unyielding cars and traffic lights timed only for the fleet of foot. And when an essential corridor like Queens Boulevard is hazardous to cyclists, thousands of would-be bike commuters never get on two wheels.

The NYC Department of Health and Mental Hygiene has been gathering its own evidence: based on a survey of 10,000 New Yorkers, the agency found those who walk or bike to work are 13% more likely to report being in good health than inactive commuters, and 4% less likely to report mental distress.

In a recent interview with T.A. (see page 12), NYC's top doctor, Health Commissioner Tom Farley, makes his agency's interest in this agenda clear: "Getting people out of cars and into active modes of transit like walking and cycling has multiple health benefits: it is beneficial for physical activity, it is beneficial for injury prevention because it reduces the number of car crash injuries and deaths, it is also beneficial in reducing the amount of air pollution."

The Front Lines

Nowhere is the need to make streets walkable and bikeable more urgent than in neighborhoods like the South Bronx, Bedford-Stuyvesant and East Harlem. In those communities the dearth of accessible parks, combined with wide, dangerous streets and high traffic has led to some of the highest rates of asthma, diabetes and heart disease in the city. Children--who are canaries in the coal mine of traffic safety--are particularly affected by these conditions.

"The number one reason students don't ride [bikes] to school or adults to work is traffic safety," says Marina Ortiz, an East Harlem resident who founded the volunteer advocacy organization East Harlem Preservation in 2005. "In East Harlem there are two major north-south thoroughfares, First and Second Avenues. Even though there is a bike lane on First Avenue you have to stop every other block to deal with a double parked car or a truck making a delivery."

"Safety is the main issue," Ortiz continues. "Streets need to be redesigned to reduce motorized traffic. As the City regulates trans-fat and salt and access to healthy food, the City should also regulate what cars have access to."

Overcoming the safety obstacles on First and Second Avenues--a major priority for T.A.--would open the way for thousands of residents to bike or walk to work and school. And the chances of success are good thanks to growing public awareness.

Recognizing the challenges facing neighborhoods like Harlem, the South Bronx and Bedford-Stuyvesant that bear huge environmental burdens, the Health Department has reorganized its District Public Health Offices to focus on communities suffering from the greatest health disparities and is initiating programs tailored to neighborhood-specific needs. Transportation Alternatives began working with the District Offices in 2007 through the W.K. Kellogg Foundation's Food and Fitness Partnership. With this coalition of healthy food and active living organizations, T.A. built support for transportation projects that increase opportunities for physical activity, such as safer pedestrian access to the East Harlem River Park, and for community-driven traffic calming initiatives to make streets safer for pedestrians and cyclists.

Street Carnage: Its Own Health Crisis

In 2006, the Health Department produced a landmark interagency study on a decade of bicyclist crashes and fatalities--a first-ever in the field of epidemiology. The report revealed that only one of more than 200 cycling deaths had occurred in a designated bike lane, and it identified major crash clusters in several parts of the city. The report underpinned the rapid rollout of bike lanes that followed--200 miles in three years--as well as the "Look" safety campaign, distribution of thousands of bike helmets, and the inauguration of the city's first physically-separated bike lanes. The goal of these efforts was not just to increase bicycle usage, but to reduce road injuries and fatalities for their own sake.

Similarly, a soon-to-be released Department of Health report on pedestrian injuries and fatalities could serve as the catalyst for a new generation of safety enhancements to the city's walking environment. Being struck by a car is the number one cause of accidental death for New York City children and the second- leading cause of injury-related death among senior citizens. Communities with high annual driving mileage tend to have higher traffic death rates than communities where people drive less.

These kinds of reports give the Health Department the rationale and the moral authority to make change. A movement is already taking shape among both public and private health professionals. Trauma center staffers are collecting data to show that improving pedestrian safety can significantly reduce the number of admissions to the Emergency Room, saving lives and reducing overall costs. According to Commissioner Farley, "Encouraging people to drive less is certainly going to be one way of reducing the amount of car-crash fatalities."

The Prescription

Given that the Department of Transportation has jurisdiction over the roadways, where do public health officials fit in the grand vision for safer, more livable streets? There is a key role waiting for them as advocates for, and underwriters of, the progressive work already underway in many parts of the city.

To help make New York City streets safer, the Health Department should continue to carry out studies that demonstrate how environmental and infrastructure changes can turn healthy choices into easy choices. Events like Summer Streets and neighborhood play streets are an untapped resource in the battle against obesity and inactivity. In addition, health professionals should speak out in support of local transportation projects that increase opportunities for physical activity, reduce vehicle congestion and make streets safer – especially projects in neighborhoods in need. There has already been some movement in this direction: the Health Department recently backed the Bike Access to Buildings bill because it promised to increase bike commuting. And the Department's

Active Living Design Guidelines, which prescribe strategies to help New Yorker's live more actively, is another step in the right direction. And there's potential beyond simply supporting positive efforts that are already underway. The Health Department is the ideal City agency to spearhead an overarching strategy to end roadway deaths and serious injuries altogether. Vision Zero--a project adopted by several European countries to eliminate traffic fatalities through a mix of design, education and enforcement--is the sort of ambitious program that Department of Health could import, adopt and oversee.

The introduction of such a project in New York City could end up improving public health on the same scale as the legendary initiatives of the past. Just as a handful of deaths from cholera or tuberculosiswould set off alarm bells among health officials today, it is not unthinkable that a single pedestrian being killed in a crash would do the same for the health officials of tomorrow.