Costos Ocultos en Salud Ocasionados Por Transporte

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The HiddenHealth Costsof Transportation


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PREFACE

Our past and current paradigm of transportation investment has created a transportation system

that is focused on road building and the private auto. This system has given our country an

unprecedented level of individual mobility andfacilitatedeconomic growth from coast to coast.As important as these benefits are, they have come at a high pricecosts to our environment and

the healthof our communities.U.S. residentsespeciallyour childrenare more obese and

overweight than ever beforedue in part to sedentary lifestyles and the lack of opportunity for

everyday physicalactivity. Traffic crashes cause close to 40,000 deaths a year, andexposure to

air pollution from traffic results in high rates of asthma andrespiratoryillness. These negative

outcomes have thelargest effect on those who are most vulnerablethe elderly,children, and

traditionally underserved and disadvantaged (low income and non-white/ethnic minority)

communitiesthe most, through greater adverse health impacts and through a relative lack of

access to economic, recreational, and social opportunities.

Thefull costs to public healthof transportation are only beginning to be understood. Although

health impactssuch as not being able to walk safely to school or breathe clean airmay not

seem tangible, they can infact be valued. These costs are as real and in certain instances as

measurable as the costs of steel and concrete. It has often been said that what gets measured

gets done. To date, the costs of public healthimpacts have been externalizedthat is, they are

not accounted for in thecurrent frameworkof planning, funding and building highways,bridges

and public transit.No doubt, different decisions about transportation investments would be

made if health-related costswere incorporatedintothe decision-making process.

A lookat our cities and towns confirmsthat sidewalks, bikeways do not compete wellagainst cars

for lane spaceand transit funding is a fraction of what is spent on roads. For many years, public

transit, bicycle lanes, and trails and sidewalks have suffered from a lack of investment.A more

balanced transportation system is needed, or these costswill continue to grow and undermine the

countrys economic health and quality of life.Fortunately, there are plenty of models illustrating

howto engineer physical activity and safety back into everyday lives, and plenty of opportunities

to create thepolitical support, funding systems andevaluative methods to do so.This document

outlines some of those pathways andopportunities, and the role the public healthcommunitycanplay.

A report prepared forthe AmericanPublic Health Association by Urban Design 4 Health, Inc. March, 2010


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THE HIDDEN HEALTH COSTS OF TRANSPORTATION :: 1

Introduction

How Transportation Investment Impacts Health Costs

Transportation investmentsshape lives and communities. Highways, sidewalks, bikepaths, trains and busservicesconnect people to friends and family, jobs, shopping, school, and countlessother activities. Trans-portation investments, and the transportation systemsthatemerge from those investments, alsoshape thebuildings and neighborhoods thattheylinktogether. The combination of transportation systemsand landusepatternsknown as thebuilt environmentinfluences the relativespeed, out-of-pocket cost, convenience,andcomfort of different travel options. Thesefactors impact how individualschoose to getaroundon a dailybasisandwhether they do so viaactiveor sedentary, polluting or non-polluting modes of travel.

This reportoutlines howtheconnection between healthandthebuiltenvironment impacts thepocketbook;

it also provides a summaryof theprocess of planning, funding andbuildingtransportationsystems, anddiscusses key opportunities forpublic health professionals to get involvedin the process.

The health impacts of transportation investment involve costs andbenefitsthat areoftenunaccounted for inthecurrent system of transportation planningandfunding. These costs andbenefitscanbe personalforexample, the weight loss that occurs when one moves to an area where it is easy and pleasant to walkand bicycleor to take transit to work may mean fewer,andless costly, visits to the doctor. Costscanalso be societalthehealthimpacts of physicalinactivity increase thecosts of healthcare for everyone,notjust those whoarentgetting enough exercise.

HOW TRANSPORTATION IMPACTS HEALTH COSTS.Transportation investmentsimpacthealthdirectly,andalso indirectly through theirimpact on land use. Investments in transit,walking andbicycling facilities

support transit use, walking andbicyclingdirectly;they also supporttheformation of compact, walkable,transit-orientedneighborhoods thatin turnsupport more walking, bicycling and transit and lessdriving.These built environmentshaverepeatedly been associated withmorewalking, bicyclingand transit use,1-3

moreoverall physicalactivity,4-7 andlowerbody weights;8-10 lower ratesof traffic injuries andfatalities,particularly for pedestrians;11-12 lowerrates of airpollution13-14 and greenhouse gas emissions;15 and bettermobility for non-driving populations.16-18 Slower modessuch as walking andbiking canbe integrated withtransit andcreatehealthiertravel options.Increased transit useis associated with greater odds of getting re-quired levels of physicalactivity in turn reducing the chances of chronic disease onset.19

On the other hand, an auto-orientedparadigmof transportation investment leads to auto-oriented landusepatterns, where neighborhoods andbuildings arebuilt to accommodate the car. Notonly is the design of these

places less friendly andefficientfor non-auto travel, butthesheer distances that must be overcome to getfromplaceto placemeans thenear exclusionof transit,bicycling andwalking. Because the people livingin theseauto-oriented places then have little choicebutto continue to drive, a vicious cycle is created: More moneyisspenton roads to ease congestion, which fuels more auto-oriented land development, which then generatesdemandforyetmore roads.Auto-oriented neighborhoodsarethus associated withmore driving,20-22 lessphysical activity,23-26 higher rates of obesity,27-29 chronic diseases30 and traffic injuries/fatalities,31-32 higherrates of airpollution33-34 and the economicand social marginalization of non-driving populations.35-37

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PHYSICAL ACTIVITY AND BODY WEIGHT.Auto-oriented built environmentsnecessitate more timespentdriving, a sedentary(and oftenstressful) activity,while takingaway time that might otherwisebe usedforhealth-promotingactivitiessuch as exercise or time with friendsandfamily. Investments in transit, pedes-trian andbicyclingfacilities allow us to buildmoderate physicalactivity into ourdailylives, by walking, bicy-cling or takingtransit38 to work, school, shopping or other everyday activities. They also help to shape walkable,transit-oriented communities thatessentially allow larger concentrations of people to walk, bicycle and usetransit for more of their trips.

AIR POLLUTION.Because vehicle transportation is polluting, built environmentsthatresult in more drivingwill generatemore airpollution per capita. Depending on thepollutant andthespecificclimate / weather patternsin a region, airpollution impacts canbe global (inthecase of greenhouse gases andclimate change), regional(inthecase of ozone)or local (aswith fine particulatematter).Exposureto airpollution canresultin asthmaand other respiratory illnesses and trigger cardiac eventsparticularly among sensitive populationssuchas

youth and the elderly.Because theyconcentrate people and traffic intosmallerareas, communities thataremore walkable may have more residentswhoare exposed to hazardousairpollution.39 Eventhough residentsin a walkable neighborhoodmay be polluting less per capita, the totalamountof pollutantsmay be higher thanin low-density neighborhoods, especially forlocalized pollutants suchas fineparticulate matter. It is impor-tantto considereachindividual casecarefully, especially where vulnerable populations(children, low-incomegroups, the elderly) are concentratedin medical centers,schools, playfields and senior centers. Additionalmeasuresthatphysically separate vehicle traffic from people and encourage cleaner-burning cars, buses and

trucks(particularly those that runon high-polluting diesel) shouldbe a priorityin high-riskareas.

TRAFFIC SAFETY.Trafficcrashes killed nearly 35,000people in 2008, andover 10 percent of those killedwerepedestrians40an enormoustollon our society. Crashes alsotend to killor disable people at a fairlyyoung agefor Americans underage34 traffic crashes aretheleading causeofdeath.41 Theconnectionbetweenthebuiltenvironment andtraffic safety works in several ways. For example, themore people drive, themorelikely they are to bein a crash.42Wide roads thatare designed to moveas muchtraffic and at the highest speedpossible increaseboth thelikelihood andtheseverityofa crashespecially for cyclistsandpedestrians.43-46 Thepresenceof sidewalks anddesignof streets,intersections andother crossingscanalso supportor undermine

TABLE 1 HOW TRANSPORTATION IMPACTS HEALTH AND EQUITY COSTS

2 :: THE HIDDEN HEALTH COSTS OF TRANSPORTATION


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pedestrian safety. Narrowerstreets withsidewalks, bicycle lanes and prominentcrossings for pedestrianscanslow traffic andreducethe number of severe crashes.47

HOUSEHOLD EXPENSES AND EQUITY.Homebuyers and renters frequently trade off lessexpensivehousing for a longercommute, andthen find themselvestrapped into spendingmore hours behind thewheeland more moneyongasandvehiclemaintenance. For low-income households, accessingjobs andservicesfroma lower-cost home location may mean tryingto getby on thelower quality public transportation in rural orsuburban areas or deferring other household expenses in order to continue to getto work by car. Once theexpensesof vehicle ownership are accounted for, close-in, walkableand transit-orientedneighborhoodsmayactually be less costly than suburbanlocations48-49 because they allow families to reduceauto ownershipor justdriveless.The Center for NeighborhoodTechnologyhascreated a mappingtool that calculates housing andtransportation affordability for some of thelarge US cities, helping to illustrate thisphenomenon.50

Investmentsin improving transit service to neighborhoodsthatare already centrally located and walkable cantherefore benefit low-income households, especially whenthese improvements are made in combination withstrategies to provide affordable housing.

Walkable Communities: A Triple Win

Because healthcare costsarea serious policy concern on their own, it becomeseven more importanttorecognizepreventive measures as a solution. Working together, urban planners and public health professionals can helppeople to maintain a higher level of personal health through their everydaysurroundings. Walkable, transit-orientedbuilt environments, especially those thatare centrally located, can be a win-win-win, producingbenefitsto theenvironment, to theefficiency andequity of the transportation system, andto public health.Makinga neighborhood more walkable canalso createa safer,lively andmore interestingplace, give a regionsresidents more housing andlifestylechoices, andreducethepersonal costs of transportation andhousing.In

compactly developed areas, providing essentialinfrastructure suchas water and sewers; garbageand recyclingservices, fireand police services;schools will be more efficientandless expensiveper capitathan in large,sprawling areas.Onestudy estimated that if the U.S. grew in a morecompact waybetween 2000 and 2025,the countrycould save $110 billion in local road costs.51

TheSacramento AreaCouncil of Governmentsestimated thata compactly developed Sacramentoregionwould save the region$9.4 billionininfrastructure costs through 2050, comparedto

continuing witha business-as-usualland usepattern.52

Recent researchhas documented thatmanypeople prefer to livein walkableneighborhoods.Consumersurveys,53-54 demographic trends,55

and construction trends56 indicatea substantialandgrowing marketfor homes in walkable places.Onestudy in Atlanta showedthat many people are


W A L K A B L E C O M M U N I T I E S : A T R I P L E W I N


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currentlylivingin less walkableneighborhoods than they wouldprefer.57 By simply accommodatingthedemandthat existsfor walkable neighborhoods, those people whochooseto live in them canbe more active. This willbenefit healthas well as loweringhealthcare costs for all. Making underserved neighborhoods more walkablecanalso increaseaccessto goods andservices at no cost to residents.

Calculating the Coststo Health

The consequences of inactivity, obesity, exposure to airpollution, and traffic crashes in theU.S. arestaggeringwhen viewedin terms of cost. Tragically,these costs arealso largely preventable. Thecost of obesity/overweighthasbeen estimatedat $142 billion(2008 dollars) in medical expenses,lost wages dueto illness anddisability,andthefutureearnings lost dueto premature death.58A 2002study estimated obesity-related healthcare coststo be as much as 9.1 percent ofthecountrystotal healthcare spending.59 Thehealth costs associated with poor

airquality from transportation are estimated torangefrom$50to $80 billion per year(2008dollars),whenaccountingfor healthcare costs and premature death.60 The cost of traffic crashes reaches about$180billionannually (2008 dollars),including healthcarecosts, lost productivityandwages, property damage, traveldelaysdueto traffic crashes, administrative andlegalcosts,and costsduetopain, sufferingandlost quality of life.61

The Nation al

Health Costsof

$$

(Billions)

Estimate Includes Source

Obesity andoverweight

$142 Healthcare costs

Lost wages due toillness & disability

Future earnings lost bypremature death

National Institutes of Health, National Institute of Diabetesand Digestive and Kidney Diseases. Statistics Related toOverweight and Obesity: The Economic Costs.

Available at: http://win.niddk.nih.gov/statistics/index.htm

Air pollutionfrom traffic

$50-80 Health care costs

Premature deathFederal Highway Administration. 2000. Addendum to the1997 Federal Highway Cost Allocation Study Final Report,May 2000.

Available at: www.fhwa.dot.gov/policy/hcas/addendum.htm

Traffic crash es $180 Healthcare costs Lost wages

Property damage

Travel delay

Legal/administrativecosts

Pain & suffering

Lost quality of life

AAA. Crashes vs. Congestion? Whats the Cost to Society?Cambridge, MD: Cambridge Systematics, Inc.; 2008.

www.aaanewsroom.net/assets/files/20083591910.crashesVscongestionfullreport2.28.08.pdf

All cost estimates adjusted to 2008 dollars.

The conse quenc es o f in acti vity, obesit y, ex posur e to air pollu tion, and traffic crash es in t he U.S. are stagg ering when viewe d in terms

of cost. Fortunately, with certain policy changes, these costs are largely preventable.

THE COST OF TRANSPORTATION-RELATED HEALTH OUTCOMESTABLE 2

Available at:


2


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Morework isneeded todevelop health cost analysisandto ensure thathealthis considered in the cost-benefitanalysisof transportation planning, policy and decisionmaking. Several models havebeen developed and arebeingused, anda large amount ofdataandresearch exists thatcanbeused asthe basis for the analysis. However,there areno standard methods, modelsor specific guidelinesforthese calculations,although federal agenciesfrequently have standardsforimpacts(for example, theClean AirActstandardsarehealthbased)andcosts thatcanbeapplied to a costanalysis. With anyassessment, a number ofassumptionswill need tobemade.

Calculating health costs ofchanges in investment or policy decisionswill require differentsets of data,modelsandconsiderationsfor each scenario.Therearethree basicsteps to a cost analysis:

1 DETERMINE THE POPULATION THAT IS EXPOSED OR AFFECTED.For example, this can bethepercentage of obeseandoverweight individuals in an area; the percentage of people exposed to unsafelevelsof airpollution; or thenumber of deathsor serious injuries dueto traffic crashes.

2 DETERMINE THE HEALTH IMPACT TO THE EXPOSED POPULATION.Todo this requires

determining thehealthimpactassociatedwitha certain environmental conditionor change in conditions.Inthisstepitwill typicallybenecessarytoapply the results obtained byother researchers whohaveexaminedthehealthimpact of thechangebeing considered.

3 DETERMINE THE COSTS ASSOCIATED WITH THAT HEALTH IMPACT.These costs canincludethecosts of medical care or hospitalization, absenteeism from work or school, andcosts due to pain andsuffering, premature deathor disability.The costs that areincluded in theanalysis will vary depending onthe typeofimpact being estimated. Intangible costs such aspain and suffering and value oflife may or maynotbe appropriate to includehowever, documenting these costs mayactually be themore conservativeapproach. Again,in this step it will be necessary to apply thework of otherresearchers;governmentagencies alsomay publishrecommendations on coststandards. Wheneverpossible, costs should beadjusted so that they reflect local cost of living andinflation.

The following examplesareconceptual andshow howhealth costs or benefitscanbe calculated for changes inpedestriansafety, airpollutionand physical activity. These examples aredrawn fromwork of other researchers,detailing the methods andapproaches they used to arriveat theestimates.

CASE STUDY :: TrafficSafety

The SanFrancisco Departmentof PublicHealth estimatedhow plansfor growthin five SanFrancisconeighborhoods would impact pedestrian injuries from motor vehicle collisions.62-63

Method:

1 DETERMINING AFFECTED POPULATION:The population in five San Francisco neighborhoodswhichwerebeing studied forincreased residential development.

2 DETERMINING HEALTH IMPACTS:A citywide analysis wasused to determine which factors weremosthighly correlated withpedestrian-vehicle injury collisions.64 These factors includedtraffic volume,proportion of arterial streets without public transit service,land area, proportion of households withoutcars, proportion of residents commuting viawalking or public transit, andtotal numberof residents.



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Findings were applied to projected increases in population andtraffic in each of the neighborhoodplansin order to estimatethechangein pedestrianinjurycollisions,resulting in a projected increase of 17percent,or 32 additional collisions in those five neighborhoods each year. These results were largely dueto high existingtraffic volumes andhigh pedestriancrash rates in thefive neighborhoods, exacerbated bythe planned increasesin residential population.To estimatethe health impactsof these pedestrian injurycrashes, thedistribution of pedestrian collisions by severity for the city of SanFrancisco over a five-yearperiod wasapplied to theadditional projected crashes (see first column in Table 3).65

3 DETERMINING HEALTH COSTS: California Highway Patrol estimatesof traffic injury costs were thebasis ofthe healthcosts calculation, as shownin the tables second column. The cost factorswhichincludedcost of propertydamage, lost earnings, medical andlegal expenses, and costs of pain andlost quality oflife, wereadjustedfor inflation.66 The estimatesareconservative in that they assume only onepedestrianis injured pervehicle collision.

The potentialcosts ofthese healthimpactsare nearly $3.5million per yearon top ofthe more than $116million

in existing pedestrian injury costs. Thismakes additional public investment in pedestrian safety measures,suchas traffic calming and reducinglocal vehicle traffic volumes, seemexceptionally prudent.

CASE STUDY :: AirQualityandExposure toAir Pollution

Researchers fromCalifornia State UniversityFullertoncalculated the health costsavings of meeting federalstandardsfor fine particulates andozone in Californias South Coast andSan Joaquin Valley regions.67

Method:

1 DETERMINING AFFECTED POPULATION:Researchers used a computermodelto estimate thepopulation currently exposed to unsafelevels of airpollution in both regions.

CitywideCrash

Distribution(5 year

average)

CHP valueper accident

Estimatedexistingcrashes

Estimated cost ofexisting crashes

Projectedadditional

crasheswith new

development

Estimated costof additional

crashes with newdevelopment

Fatalities 3% $ 2,709,000 28.3 $ 76,664,700 0.96 $ 2,600,640

Severe injuries 10% $ 180,000 94.2 $ 16,956,000 3.2 $ 576,000

Visible injuries 36% $ 38,000 339.1 $ 12,885,800 11.52 $ 437,760

Pain complaints 51% $ 20,000 480.4 $ 9,608,000 16.32 $ 326,400

Total 100% -- 942 $ 11 6,114 ,500 32 $ 3, 422,4 00

TABLE 3 THE COST OF TRAFFIC CRASHES IN FIVE SAN FRANCISCO NEIGHBORHOODS



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2 DETERMINING HEALTH IMPACTS:Researchresultsfrom the scientific literature on air pollutionwereusedto estimatethe health impactson the affected population. The researchers calculated impactsboth for current conditions andfor a scenario in which airquality standards were met.

3 DETERMINING HEALTH COSTS:In the cost estimating step, other research findingsandfederalstandards were used to calculatethecost of premature death,medical expenses due to illness andhospitalization, andlost wages andthevalue of avoided illness (wherepossible, theserates were adjusted forCalifornia income levels and current year [2007]dollars). These rates were applied to each of thehealthimpacts that would be avoided by meeting thestandards.

The study did notseparateoutthe impactsof motorvehicle airpollution from other sources of airpollutionhowever,we know vehicles contribute significantly to airpollution.In theSanJoaquin Valley, on-road motor

vehiclesmakeup 58 percent of oxides of nitrogen(NOx) emissions, one of the major contributors to ozone,and11 percent of fine particulates. In theSouth Coastregion, on-road motorvehicles make up 53 percent ofNOxemissions andabout 15 percent of fine particulates.68 Both regions have severeairquality problems, and

so meeting theairpollution standardswill require a significant andcoordinatedeffort. However, the analysisclearly establishes thevalue of doing so.

CASE STUDY :: PhysicalActivityandBodyWeight

Researchers fromthe University of California-Irvine, University of Wisconsin-Milwaukeeand University ofTexas-Austincalculated costsavings fromreductions in coronary heart disease deaths and overall mortalitydue to increases in walking inspiredby more pedestrian urbandesign.

Method:

1 DETERMINING AFFECTED POPULATION:Portland, Oregon metro region

2 DETERMINING HEALTH IMPACTS: Usingtraveldiarydata for thePortland, Oregonregion, researchersfirst determined which of thefollowingurban designcharacteristics were significantpredictors of physicalactivity: street connectivity, retail employment density, total employment density, population density andproximity to downtownPortland. Theanalysisaccounted forsociodemographic traits (age,race, gender,income and housing tenure) and potential self-selection bias(i.e., personswho weremore predisposed

San Joaquin South Coast (Los Angeles, Orange,

Riverside and San Bernardino counties)

Costs of air pollution (per year) $1,600 per person $1,250 per person

Savings if air quality standards

are met (per year) $6 billion regionwide $22 billion regionwide

HEALTH SAVINGS FROM MEETING AIR QUALITY STANDARDSTABLE 4



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to walking would chooseto live in more walkable neighborhoods), making the results more conservative.The findingsof the analysiswere applied to twoscenarios: a low change scenario increasing each urbandesign value from theregional median to the 75th percentile,anda high change scenario that increasedeachto the95th percentile. To calculatehealthbenefits,researchers assumed that a change in urban design

would impact 5,000 peopleasignificant but not unusual change roughly the sizeof a transit station areaor a neighborhood. Existing research on theimpact of physical activity on mortalityrates69was usedtocalculate the number of lives saved per year for each scenario andeach design characteristic.

3 DETERMINING HEALTH COSTS:To estimate the health cost savings,monetized valuesof humanlife from previously published sources were applied. The lower value ofhuman life ($2.47million70)wasapplied to thelow change scenario,whereas thehigher value ($7.98million71) was applied to the highchange scenario.Thefinal valuesthereforehada wide distributionbecause they reflected both thedifferingassumptions for value of life andthe differencesin lives saved for each scenario.

In additionto demonstrating thatthere are substantial monetarybenefitsdue to additional physical activity

associated with more walkable urban form, the results show thepotential value of changing a singleurban formcharacteristic (forinstance,a regulation thatincreases allowable developmentdensities), or making a combi-nation of changes (forexample, adding the benefitsof increasing street connectivity and retail developmenttogether). Theseresults canthereforebe useful for policy analysis by incorporating thepotential benefit fromreduced mortality intoexistingmethodsforbenefit/cost analysis.

Land Use/Urban Change in Amount Number of Persons Annual Lives Present Discounted

Design Characteristics of Walking (Miles, Who Will Move from Saved Value (in Dollars)

Over a Two-Day Period) First to Second Tertile

of Physical Activity

Low High(median75th (median95th Low High Low High Low High

percentile) percenti le)

Street connectivity0.3816 1.1844 22.79 78.59 0.0456 0.1572 $2,255,107 $23,205,007

(intersection density)

Retail employment

density (retail jobs/ 0.0652 0.9734 4.72 62.09 0.0094 0.1242 $466,574 $18,331,955

0.0652 square mile

Total employment

density (jobs/1.0648 0.0019 1.0648 1.57 66.02 0.0031 0.1320 $155,525 $19,492,206

square mile)

Population density0.2581 0.549 15.72 28.29 0.0314 0.0566 $1,555,247 $8,353,802

(persons/square mile)

Distance to central0.8108 2.5054 45.58 209.05 0.0912 0.4181 $4,510,215 $61,725,318

business district (miles)

ESTIMATED COST SAVINGS FROM WALKABLE URBAN DESIGNTABLE 5



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CASE STUDY :: HousingandTransportationCosts

People whoareable to live in close-in,walkable andtransit-oriented communitiescanrealize savings from

transportation. Researchers recentlydocumented these costs forthe Atlanta region. Based on researchresultsfrom the SMARTRAQ study,an average two-car household in a highly walkable neighborhoodwasestimated touse25%less gasolineper year than a similar householdin oneof theregions least walkable neighborhoods.

At a costof $3 pergallon, thisis an estimated savings of $786per yearin gasolinecosts alone. If a household isalso able to reducecarownership, itssavings increase to $4,600peryear, even when factoringin the addi-tional costof public transportation.72 There also maybe health benefits from reduced carownership, as foundin one study on youth that was based on the same Atlanta region data set.73

The Transportation InvestmentProcessThe Current Paradigm

Withallof thehealth andenvironmental benefitsthey offer, whyisit sodifficult tomake large-scaleinvestmentsin sidewalks, transit,and bicycle facilities? Our current paradigmof transportation planningand investmenthasbeen a tremendously successful system for buildingstreets, roads andhighways,but works less well forexpandingandimproving other modesof travel. This paradigmis slowly changing in many urban areas,butcurrent planningand funding practicesarestillbiasedtoward carmobility androad expansionmaking itdifficultto implement a larger shift toward investment in transit,pedestrian and bicycling infrastructure.

Current practices frequently emphasize reductions in congestion or travel time, and the movementof vehiclesover the movementof people.A supply-side, capacity-orientedapproach hasbeen the norm, andonlyrecentlyhavedemand-sideor behavioral approaches to transportation investment beenconsidered more

seriously. While there are manyinstances where transit investments are prioritized, our current system tendsto favor investmentsthat show near term gains in congestion. Most often, that meansmore roadway capacity.

Todayssystem of planningandfunding is a holdoverfrom theinitial structuresetup to implementtheU.S.interstate highway systemin the Eisenhower era. Thissystemestablishedthe current systemof statedepartmentsof transportation (DOTs) andgave these agencies thefunding, andbroaddiscretion, to buildwhat is nowtheinterstate system. The federal government also setup theHighway Aid Trust Fund (knownas theHTF or TitleI) andthefederal gastaxwasestablishedas a funding stream for the HTF. AlthoughHTF funding hasrecentlydriedup dueto declinesin driving andincreases in fuel efficiency, until recentlyit provided a consistent,dedicated funding stream fortransportation investments.Project funding is blendedbetweenfederal andlocal sources. For most majorprojects, thefederal matchis 80 percent andthe local matchis 20 percent.Thelocal share is often derived from thegastaxas well; many state constitutions require that gastaxfunds be spent

only on roads and bridges. Other transportation modes do nothave as much, if anydedicated funding. TheFederal Transit Administration, foundedin 1964by President Lyndon Johnson,has no dedicated fundingsource and is reliant on yearly congressionalappropriations, guided by the federal transportation bill. Federalinvestmentsin bicycle and pedestrian facilities are similarly reliant on congressional appropriations.

Additionally, under the current paradigm, the analytical methodsusedto select and prioritize projectsforfundingare limited in scope andsimply donot account for many ofthe costs ofroad building. The methods usedto select transportation projects typically provide, at best, an incomplete accounting of a projects potentialhealth costs andbenefits. A Government Accountability Officesurvey of state DOTs andtransit agencies found


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that althoughassessmentsof costs andbenefitsoftenplay some role in thedecision-making process, formalcost-benefit analysis is rare, andnot necessarily themost important factor in project selection.74Althoughthereport includes no data on howfrequently healthcosts andbenefitsareincorporated into cost benefitanalysis,itsresults indicate that more thorough accounting systems areneededto bringhealth into thedecision-making process.

Althoughthe methodsusedin the transportation planning processvarya great dealfrom place to place, theytypically relyon similaranalytical processes to weigh and prioritize potential projects: alternativesanalysis,cost-benefitanalysisand environmental impact assessment. We discuss eachof these processes in moredetailbelow. For publichealthprofessionals, participating in theseprocesses canbe another important wayto makesurepublic health is properly considered in decisionmaking.

Alternatives Analysis.The coreof the transportation planningprocess is the alternativesanalysis. Alternativesanalysis,also known as scenario planning, is used to identify thebest set of transportation investmentswithina given corridor or area. An alternativesanalysis canbe triggeredby specific deficiencies or complaints (for

example,high rates of pedestrian accidents or growing vehicle congestion),by a long-range planningprocess,or by a desire to revitalize or further develop an area. Alternatives analysis typically includes public inputthroughout theprocess,especiallyfor largeror federally funded projects. Whether it is large or small, an alter-natives analysisgenerally involvesthe following steps.

1 DEFINE THE PURPOSE AND NEED FOR THE STUDY(reducecongestion; improve safety, stream-line freight traffic, etc.). The purposeandneed statement will frame allsubsequent partsof theanalysis,so healthconcerns shouldbe included at this stage to ensurethat healthconcerns areconsidered asappropriate.

2 DEFINE THE SCOPE OF THE ALTERNATIVES TO BE MEASURED (Will the project considermass-transitalternativesor onlyroadway alternatives?Will all or someofthealternativesbe multimodal?).From a publichealthperspective, alternatives shouldbe explicitlymulti-modal or focused on active modesof transportation.

3 FURTHER DEFINE THE SPECIFICS OF EACH ALTERNATIVE.Typically, alternativesare refinedin an iterativeprocess with the subsequent stepasimpactsareestimated, the alternatives arerefined tobetter supportthe projects goals.

4 MEASURE THE IMPACT OF EACH ALTERNATIVE.Numerousmethodsareused toweightherelativeimpacts(positive and negative) of eachalternative,includingtransportation and landuse modeling,cost-benefitanalysis, and environmental impact assessment.Transportation plannersrelyheavily ontransportationandland usemodelsto understand howan alternative will impacttraffic congestion and

travel overall. However, these models can have numerouslimitations, particularly in howthey react tobicycle and pedestrian improvements.

5 SELECT AN ALTERNATIVE AS THE PREFERRED ALTERNATIVE.

Environmental and Health Impact Analysis. TheNational Environmental Policy Act (NEPA) requiresdocu-mentation of the environmental impactsof federal actions or projectsreceiving federal funding. TheresultingEnvironmental Impact Statement (EIS) is presented to Congress when related funding or legislation is sought,


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andthe impact statement ismadeavailable tothe public.Although the findings ofan EISare not legally binding,they canhave a majorimpact on a projects ability to be funded or receive othermeans of legislative support.

Whenthe requirementsof NEPA are readthrough a lensof public health and welfare, its intent is clear.Promoting health andwelfare is part of theActs statedpurpose.75 NEPAs language and requirementsconsistentlyextend beyond non-human environmental impactsto social, cultural, and health concernsdirect, indirectand cumulative in scope.76 Since 1996, NEPA has requiredEISs to address environmental

justice impactspotentially disproportionate human health and environmental effects on low-income orminoritypopulations.77 However, the explicitconsideration of healthis often left outof theEISprocess.

Since federal funding is frequently used for transportation projects, EISs canbe an important opportunity tointegrate health intoan existingdecision-making process. Again, systematic considerations of public healthimpacts in EISs have been rare,78-79 and limited in scope.80 The growing interestin Health Impact Assessment(HIA) in theU.S. has, however, ledto some recent successful examples of HIAs used to evaluate transportationprojectsin theSanFrancisco BayArea81-82 andthe Seattle region,83 among others.84An HIA can and should be

conducted as a part of theEISprocess, or as a stand-alone analysis.

Many states also have environmental reviewstatutes that essentially parallelNEPA for projectsthat mayhavean environmental impact but arenotsubject to NEPAreview. Projectsgoverned by these so-called littleNEPAs canrange from infrastructure facility citingto private development proposals. In some states, such asCalifornia, health impactsmay already be explicitly requiredas partof state-levelenvironmental review. Inothers, requirements may be less clear or nonexistent, and health professionals may need to advocate for theinclusionof health as part of an environmental review.

Cost-Benefit Analysis.Cost-benefit (also referredto as benefit-cost) analysisattemptsto translate bothhard andsoftproject costs andbenefitsinto monetaryterms, and is frequently used during theanalysis ofpotential project alternatives. The scope of costs andbenefits measuredin the process varies, but typically alarge array of impacts areleft outoftheanalysis,or externalized. These externalized costs arelargeand, inthecase of healthcare costs, aregrowing at a rapid rate. Cost-benefit analysis is by naturea flawedand incom-pleteanalytical method, particularlyif oneconsidersthedifficulty of assigninga monetaryvalue to intangiblebenefitssuch as clean airor safe streets. However, an effort to monetizeandquantify anyof thefollowingimpacts will have great value,even if theeffortmust remainqualitative or at an order-of-magnitudelevel.

The scope andprocess for cost-benefitanalysis andproject selectionwill vary widelydependingon theprojectand its location. Typicallyany cost-benefit analysisfor transportation will include the costs of construction,right of wayacquisition, operation andmaintenance,travel time savings, andanyrevenues generated such astolls or fares.The monetarycosts andbenefits to safety, airpollution andnoise aresometimes included.However, farmore health-related costs arenotevaluated. The decisionto leaveoutanysingleimpact may be

made because of budgetandtime constraints, because those impactsaredifficult to measure,or because evi-denceis newor limited. However, these decisions have theresultof inflatingthebenefitsof auto-orientedprojectsandunderestimatingthe benefitsof transit, bicycle andpedestrian projects. It is safe to assume that ifeven some of thecosts listedbelowwere to be internalized into the transportation planningprocess, the deci-sions we make would be very different.

INDIRECT IMPACTS AND INDUCED TRAFFIC.Thelonger term, indirect impactsof transportationinvestment on land development(for example,a newroad that fuels development on thefringes of anurban area) and transportation (induced traffic)are typically externalized. Short-term indirect impacts



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arealso typically externalized. Often when a newroadway is built, travelerswill changetheir drivingbehaviorto take advantageof what they mightperceiveas a benefit,such as a shorter driveto commercialservices.However, short-termeffects, thepositivebenefit will be limited because as more people takeadvantageoftheroadway, anybenefitsrealized bythenewroad will likelybeoffsetby increasedcongestion,air pollution and other outcomes. For roadway constructionand expansion projects, impactswill likelybe quantified as negative,sincethey result in more auto oriented fringedevelopmentandmore driving.Fortransit projects, indirect impacts are more likely (butnot certain)to generatebenefitsreductionsin driving and,potentially, infill and/or transit-oriented developmentaround transit stations.

The exclusion of indirect land useandtraffic costs also meansthe exclusionof a number of other costs:theimpacts of indirect land development on physical activity andobesity; the cost of the additionalinfrastructure (local roads, water and sewers, schools,fire, police services) necessary to serve indirectland development; andtheimpact of induced traffic on healthandtheenvironment(incremental airpollution, noise, climate change and water pollution costs).

SCOPE OF COSTS ESTIMATED. The scope of costs that areincluded in estimates may be limited.For example,the costs of pain andsufferingandother intangible costs arefrequently left outof cost-benefit analyses due to thedesire for a more conservative approach. However, an approachthat usesthe precautionary principleto avoidharmful action85and thereforeaccountsforall potentialcostsofanaction may actuallybe the most conservativeand health-protective approach.86

OBESITY AND PHYSICAL ACTIVITY IMPACTS, COSTS AND BENEFITS.Becausethe researchon the linkbetweentransportation, the built environment and physical activity/obesity is relatively new,there have been limited opportunitiesto integrate it intocurrenttransportation planning processes,andthere areno requirementswithin the planning processtodoso. However, there isa large and growing bodyof available evidencelinking transportation andland use patternsto physical activity andobesity, andphysicalactivity andobesity to costs.

OTHER HEALTH IMPACTS, COSTS AND BENEFITS.Other health impactsof transportationinvestment caninclude noise, water quality,mentalhealth and/orstress, equity andsocialcapital orsocial cohesion. Noise and water quality impactsare typically documented in a projects environmentalimpactassessment,but impacts on healthin particular,andthecosts/benefits of thoseimpacts arenotusually calculated. Thelinkbetweentransportation investment and mental health, stress and socialcohesionimpacts is less-established, with littleresearch on which to base cost estimates. It may bereasonable to recognize and discuss potential impactsqualitatively while continuingto perform researchanddevelop best practiceson which impacts andcosts can be based. In termsof equity impacts, analyticalandaccounting methodsshould examine thepopulation directly affected by the investment,as well as thepotentialfordifferential impactson differentvulnerable subgroups within thelarger study areapopulation.

Evaluations shouldconsider impacts, costs andbenefits with respectto notonly low-income andethnicminority groups, butto young, elderly anddisabled peoplewhoaretypically left outof impactassessments.

TRAFFIC CRASHES AND AIR POLLUTION EXPOSURE. Althoughthe analytical methodsandtools exist to measure the impactsandcosts of traffic crashes andairpollution exposure,these factorsarenotalwaysaccountedfor in cost-benefit analysis.The stronger the evidenceof theneed andfor thebenefits/costs of a particular investment,andthe more that plannersareable to conceive,articulate, andpromote investmentsthat address an array of established concerns, thegreater thechancethat health-promoting projectswill be funded.


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EXAMPLES & OPPORTUNITIESINTEGRATING HEALTH INTO TRANSPORTATION

INVESTMENT PLANNING & PRACTICE

Therearea number of examples where public healthhasbeen linked to transportation-related legislation,funding or planningprocesses. Thissection discusses those examples, highlightingopportunities to furtherintegrate health impacts intotransportation decisionmaking and support a transportation system thatis morebalanced, sustainable and health promoting.

Federal Level

CLEAN AIR ACT AMENDMENTS OF 1990.Originallypassed byCongressin 1970, theClean AirActdirectstheEPA in itsefforts to protect thenations airquality. The 1990 amendments to the CleanAir Actsetstringent

limits on the majorcomponents of urban airpollution: ozone, carbon monoxide andparticulate matter(PM10particulates of 10 microns or smaller). Theselimits, known as the National Ambient AirQualityStandards (NAAQS)aredeveloped bytheEPA andexpresslylinked tothelevelneeded to protecthuman health,particularly for sensitive populationssuchas asthmatics, the elderlyand children. Urban areas thatdo notmeet the standards for one ormoreofthese pollutants are required totake steps toreduce pollutant levelsandeventually comply with thestandards. Thosethat fail to take those steps aresubject to sanctions.

The CleanAirActforced regions to reconsider theirtransportation decisions, andin some cases to take aserious look at theinteraction between transportation andland use. If an area is in non-attainment status,transportation plans andprograms must notincrease theseverity of pollutionin thearea (bycreating violationsforadditional pollutants, increasing the frequencyof non-attainmentinstances, or increasing the timeneededto comply with thestandards).The Atlanta regionhaditsfederal transportation funding frozenin thelate

1990sbecause it failedto produce a TransportationImprovementPlan (TIP)that wouldresultin compliancewiththe Clean Air Act.

By tying transportation funding to health-based standards, the CleanAirActsets a potentiallyintriguingprecedent forpublic health professionals. Where the evidence is sufficient, future legislation could includeadditional outcomes,such asphysical activity orclimate change. For example,in regions whoseaverage residentgets belowtherecommended dailyamount of physical activity,federal transportation funding could be madecontingent on plansandinvestmentsestimated to increase that amount.

THE FEDERAL TRANSPORTATION BILL.The federal transportation bill is reauthorizedapproximatelyevery five toseven years, andis one ofthe largest potsofdiscretionary funding the federalgovernmentdebates.

The next bill, which will be negotiated over the next year or two, is estimated to designate close to $500 billionforour transportation systems.

Historically, the share of funding for transit,bicycling and pedestrian improvements in transportation hasbeen smallcomparedto thefundingforroadway maintenance andexpansion. Although thelastseveral iterationsof thefederal transportation bill (ISTEA,TEA-21and SAFETEA-LU) have devoted vastlylargersharesof federaldollars to mass transit,pedestrian andbicycle investmentsthan previous bills, dollars for these modes remaina fractionofwhat is spenton highways.The current transportationbill, SAFETEA-LU designatesaboutone-fifthof its$244 billionbudget to transit andsafety programs.

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FEDERAL TRANSPORTATION GRANT PROGRAMS.In addition to thediscussions of major transporta-tion reform, a numberof successful programs exist under currentfederal transportation legislation that directlybenefit publichealthandsafety goals - includingthe Highway Safety Improvement Program ($5.1 billion), theCongestion Mitigation and Air Quality Improvement Program (CMAQ; $8.6billion), the TransportationEnhancements Program,andthe Safe Routes to Schools program ($612 million).87 Funding in these programsadds up to only a smallpercentage of the total federal transportation spending, andall of theseprograms wouldbenefit from additionalfunding. For example, themost recent federal transportation bill designated$612 mil-lionfor the Safe Routesto Schools program. Once that total amount is divided bythe five year timeframe ofthelegislation and byall 50 states, it is enough only to fill small gapsin the networknot to fund the largerscaleretrofits that areneeded in many areas.

FederalLevel PolicyRecommendations

Refocus the planning and funding prioritization processtoward transit,bicycle and pedestrianinvestments,safety improvements, and maintenance/repair of existingroadways.

Require multimodal planning and programmingforany new project receiving federal funding. Incentivize HIAsfor any projectreceivingfederal transportation funding. Require all federally funded projects to accommodate all modes, users and physical abilities

(Complete Streets). Require integrated regional transportation / land useplanning(USDOT / HUD). The recently created

SustainableCommunities partnership between DOT, HUD and EPA is a crucial steptowards encouragingmore holistic, data-driven regional planning. To more fully ensurethat healthis considered, HHSshouldbe a partner in this effort.

Adopt physical activity and safety objectives fortransportation projects receiving federal funding similarto what exists in the Clean Air Act (the NAAQS).

State, Regional and Local Levels

TRANSPORTATION PLANNING AND PROGRAMMING CRITERIA.Federal transportation flows outacross the U.S. through state departmentsof transportation and metropolitan planningorganizations(MPOs,made up of local government representatives,direct transportation planningforregions of 50,000 people ormore). Long-range plansbased on a 20-year time frame setthebroadmenu of potential transportationprojectsin a state, metropolitan region or local government.These plansareimplemented through thestate orregional TIP (Transportation Improvement Program), a short-range(3-5year), frequentlyupdated shortlistof high-priorityprojects. The TIPgenerally signifiesthe intentto fund andbuild a project.Projects arenominated by stateandlocal jurisdictions for inclusionin the TIP, andmust be consistent with thestateorregional longrangeplan to be eligible. Once funding is obligatedfor a project,it rolls off theTIP.

Like stateandregional agencies,local governmentstypically compile their ownlong range plansandshorterrange CIPs, or capitalimprovement programs. Local governmentscan compete for federal grant funding or uselocally generated revenuesfortransportation improvements. Localfunding is particularly important forsmall-scale improvementssuch as bike lanes, sidewalks, andlocal streets,since these projectsareless likelytoreceive federal funding.


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State,regionalandlocal governmentsandfederal grant programsallhave theirownsets ofcriteria that determinewhichprojects willbe put intothe TIP/CIP or selectedfor funding. Theprocessand criteria thatdetermineshowtheseagencies prioritize their transportation funding cantherefore be quite important to review from apublichealthperspective, andthepublichealthcommunityshouldbe involved in theprocess ofdeterminingTIPcriteria. TIP andCIPcriteriaarerevised periodically,often at thebeginning of the yearlyTIPprocess.

STREET DESIGN, COMPLETE STREETS POLICIES AND CONTEXT-SENSITIVE DESIGN.Standardsfor streetwidths, turning radii,on-streetparking, andother roadway design elements may be determinedbylocal transportation plannersbut are frequently adopted wholesale fromnational guidelines, resulting in solu-tions that may notbe appropriate for theparticular context. Context-sensitivedesign, therefore, is theoppo-sitestreet design that carefully considers thecontext of the surrounding builtenvironmentin order toimplement a solutionrather thanimposing one-size-fits-all standards. Complete Streetspoliciesexplicitlyrequire road projectsto accommodate access by allmodes of transportation,ages andabilities. State andlocalgovernmentsfrom every part of thecountry have recently adopted Complete Streets policies, amongthemFlorida,South Carolina, Hawaii, and California and suchcities as Jackson,Mississippi and Chicago, Illinois.

DEVELOPMENT PROPOSAL REVIEW. Cities use zoning anddevelopment regulations to control sitedesign, density, mass or bulk of buildings, land uses permitted withina given area, parking requirements, andany other requirements forbuildingdesign, amenities or affordable housing. Through developmentfeesandtaxes, citiesalso have thepower to encourageor discouragedevelopmentwith certain features or in certainplaces.Citiesalso control thereview process aswell,meaning they canalso chooseto expedite reviews orprovideincentives in exchange for other featuresfor instance,allowing a developer to buildat a higher density inexchange forbuildingaffordable housing. Health professionals should be includedin the review process forcertain proposals, particularlylarge-scale developmentor developmentof key parcels.In some cases, it maybe appropriateto work with planners to conduct an HIAof a proposal.

USE OF EXISTING TOOLS FOR EVALUATIVE PURPOSES. Standard tools in the planningfield canbeused to test exposure to airpollution, measure changes in land development andtransportation, andunder-stand the population potentially impactedby an action. These instruments include landuse and transportationmodels,and tools thatmeasure air pollution generation, dispersion and exposure.

In addition, a couple of tools have been developed recently specifically to measure impactson health. TheHealthy DevelopmentMeasurementTool (www.thehdmt.org) was producedby the cityof San FranciscosDepartmentof PublicHealthallowstheuser to evaluatehow a project performs along an extensivesetof indi-cators. The I-PLACE3S scenario planningtool wasrecentlyenhanced as part of the King CountyHealthscapeproject so that it canassess the impactsof land development andtransit changes on airpollution andgreen-house gas emissions, physical activity and obesity,and transportation (see www.http://www.kingcounty.gov/transportation/HealthScape.aspx, or http://places.energy.ca.gov/places).

MEASUREMENT OF PROGRESS.Good measurement is a key to trackingsuccess. In theabsence of de-tailed health information, existingplanning indicators of the built environment and transportation can beused. Because theindicators have been linked to healthoutcomes (shownin Table 6),they canbe effectiveproxy measuresforsuchoutcomes.



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Road width

Traffic volumes

Transit modeshare, number oftrips, or distance

Auto mode share,number of trips ordistance (VMT)

Walk / bicycle modeshare, number oftrips or distance

Parks withinwalking distance(about 1 km)

Sidewalks, bicyclelanes or trails

Transit stop withinwalking distance

Mixed landuse pattern

Streetconnectivity

Retail floor arearatio/pedestrianfriendly site design

If you cannot measure it, you can not improve it. Lord Kelvin

P LA N NI N G I N DI CAT O R R E LAT IO N SH I P T O 4 H E ALT H O UT CO M ES

TABLE 6 THE COST OF TRAFFIC CRASHES IN FIVE SAN FRANCISCO NEIGHBORHOODS


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State,Regional&Local Level PolicyRecommendations EnactCompleteStreets legislation. Require theinclusionof health care costs from physical inactivity, obesity,airpollution andtraffic

crashes in cost-benefitanalysis. Adopt transportation programmingcriteria thatspecificallyaddresshealth, safety, equity and

environmental issues. Include health as an explicit requirementin state level environmental impact assessment. Connect existingplanningindicators to healthoutcomes as a way to gauge progress. Include public health professionals in the processof developing and revisingTIP/CIP criteria.

SUMMARY ANDCONCLUSION

The current process by which transportation funding decisions aremade generally does little to consider thelong-term costs and benefits to health. Advocating health-supportive planning, design and funding can helpto createhealthier builtenvironmentsfor generations to come. Success will mean designingapproachesandpractices thatresult in health-supportive decisions, and creating systems thatmeasure,trackand account forhealth outcomes.

Opportunities exist at every level of government to encouragetransportation investmentsthatbenefit health.Negotiationsoverthefederal highway transportation billwillshape transportation spendingfromtopto bottom,and every indication is that the bill is a key opportunity not just to get more funding for health and safetyprograms, but to rethink the transportation funding process.

At the state and locallevels, health-based funding criteriashould include an evaluation of the health impactsofindividual projects. Impactscanbe analyzed as part of theenvironmental reviewprocess or as a stand-aloneHIA. Costsof theseimpacts shouldbe included in cost-benefit analysis.In many cases,existinglegislation oroperating procedures can be strengthenedto make requirements clear and ensure thathealth considerationsarea part of everyday business. Participation in long-range planningprocesses andthereviewof large-scaledevelopment proposalswillhelp produce more health-supportive outcome andwillalso serve to educateothersabout the importanceof health in the planningprocess.

Whenanactivity raises threats ofharmtohumanhealthor the

environment,precautionarymeasures shouldbe takeneven ifsome causeandeffect relationships arenot fully established

scientifically. In this context theproponentof anactivity, rather

than the public, should bear the burdenofproof.

Wingspread Conference on the Precautionary Principle, 1998.

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1. Ewing R, CerveroR (2001). Traveland the Built Environment-A Synthesis. TransportationResearch Record 1780. TRB, National Research Council, Washington D.C., pp. 87114.

2. Holtzclaw J, Clear R, Dittmar H, Goldstein D, & Haas P. (2002). Location efficiency:Neighborhood and socio-economic characteristics determine auto ownership anduse; Studies in Chicago, Los Angeles and San Francisco. Transportation Planning andTechnology, 25 (1), 127.

3. Frank LD, Bradley M, Kavage S, Chapman J and Lawton TK (2007c). Urban form, traveltime, and cost relationships with tour complexity and mode choice. Transportation,35(1): 3754.

4. Saelens BE, Sallis JF, Black JB and Chen D (2003a). Neighborhood-based differences inphysical activity: An environment scale evaluation. American Journal of Public Health,93: 15521558.

5. TRB/IOM Committee on Physical Activity, Health, Transportation, and Land Use (2005).Does the Built Environment Influence Physical Activity? Examining the Evidence. TRBSpecial Report 282, Transportation Research Board/Institute of Medicine.

6. Frank LD, Schmid T, Sallis JF, Chapman J, Saelens B (2005). Linking Objective PhysicalActivity Data with Objective Measures of Urban Form. American Journal of Preventive

Medicine. 28, (Suppl 2): 117 25.7. Frank L, Sallis JF, Conway T, Chapman J, Saelens B, Bachman W (2006). Multiple

Pathways from Land Use to Health: Walkability Associations with ActiveTransportation, Body Mass Index, and Air Quality. Journal of the American PlanningAssociation, 72(1): 7587.

8. Ewing R, Schmid T, Killingsworth R, Zlot A, Raudenbush S (2003a). Relationshipbetween Urban Sprawl and Physical Activity, Obesity, and Morbidity. AmericanJournal of Health Promotion, 18(1): 4757.

9. Frank L, Andresen M and Schmid T (2004). Obesity Relationships With CommunityDesign, Physical Activity, and Time Spent in Cars. American Journal of PreventiveMedicine, 27(2): 8797.

10. Lopez R (2004). Urban Sprawl and Risk for Being Overweight or Obese. AmericanJournal of Public Health, 94(9): 5741579.

11. Ewing R, Schieber R and Zegeer CV (2003b). Urban Sprawl as A Risk Factor in MotorVehicle Occupant and Pedestrian Fatalities. American Journal of Public Health,

Vol. 9 3, No. 9, pp. 1541-1545.

12. Dumbaugh, E (2005). Safe Streets, Livable Streets. Journal of the American PlanningAssociation, 71 (3): 283300.

13. Frank L, Stone B and Bachman W (2000). Linking Land Use with Household VehicleEmissions in the Central Puget Sound: Methodological Framework and Findings.Transportation Research Part D 5, 3: 173196.

14. Frank L, Sallis JF, Conway T, Chapman J, Saelens B, Bachman W (2006). MultiplePathways from Land Use to Health: Walkability Associations with ActiveTransportation, Body Mass Index, and Air Quality. Journal of the American PlanningAssociation, 72(1): 7587.

15. Ewing R, Bartholomew K, Winkelman S, Walters J, Chen D, McCann B and Goldberg D.(2007) Growing Cooler: The Evidence on Urban Development and Climate Change.Chicago: Urban Land Institute. p 93.

16. Robert D. Bullard and Glenn S. Johnson. Just Transportation: Dismantling Race andClass Barriers to Mobility. Gabriola Islands, British Columbia, Canada: New SocietyPublishers, 1997.

17. Robert D. Bullard, Glenn S. Johnson, and Angel O. Torres. Highway Robbery:Transportation Racism & New Routes to Equity. Cambridge, MA: South End Press, 2004.

18. K. H. Schaeffer, Elliott Sclar. Access for All: Transportation and Urban Growth.New York, NY: Columbia University Press, 1980

19. LaChapelle U, Frank LD (2009). Transit and health: Mode of transport, employer-sponsored public transit pass programs, and physical activity. Journal of PublicHealth Policy 30 Suppl 1; 573-594.

20. Ewing R, Cervero R (2001). Travel and the Built Environment-A Synthesis.Transportation Research Record 1780. TRB, National Research Council, WashingtonD.C., pp. 87-114.

21. Holtzclaw J, Clear R, Dittmar H, Goldstein D, & Haas P. (2002). Location efficiency:Neighborhood and socio-economic characteristics determine auto ownership and

use; Studies in Chicago, Los Angeles and San Francisco. Transportation Planning andTechnology, 25 (1), 127.

22. Frank LD, Bradley M, Kavage S, Chapman J and Lawton TK (2007c). Urban form, traveltime, and cost relationships with tour complexity and mode choice. Transportation,35(1): 3754.

23. Saelens BE, Sallis JF, Black JB and Chen D (2003a). Neighborhood-based differences inphysical activity: An environment scale evaluation. American Journal of Public Health,93: 15521558.

24. TRB/IOM Committee on Physical Activity, Health, Transportation, and Land Use (2005).Does the Built Environment Influence Physical Activity? Examining the Evidence. TRBSpecial Report 282, Transportation Research Board/Institute of Medicine.

25. Frank LD, Schmid T, Sallis JF, Chapman J, Saelens B (2005). Linking Objective PhysicalActivity Data with Objective Measures of Urban Form. American Journal of PreventiveMedicine. 28, (Suppl 2): 117 25.

26. Frank L, Sallis JF, Conway T, Chapman J, Saelens B, Bachman W (2006). Multiple

Pathways from Land Use to Health: Walkability Associations with ActiveTransportation, Body Mass Index, and Air Quality. Journal of the American PlanningAssociation, 72(1): 7587.

27. Ewing R, Schmid T, Killingsworth R, Zlot A, Raudenbush S (2003a). Relationshipbetween Urban Sprawl and Physical Activity, Obesity, and Morbidity, American Journalof Health Promotion, 18(1): 4757.

28. Frank L, Andresen M and Schmid T (2004). Obesity Relationships With CommunityDesign, Physical Activity, and Time Spent in Cars. American Journal of PreventiveMedicine, 27(2): 8797.

29. Lopez R (2004). Urban Sprawl and Risk for Being Overweight or Obese. AmericanJournal of Public Health, 94(9): 5741579.

30.Sturm, R and Cohen, DA (2004). Suburban Sprawl and Physical and Mental Health.Public Health, Journal of the Royal Institute of Public Health, 118(7): 488-496.

31. Ewing R, Schieber R and Zegeer CV (2003b). Urban Sprawl As a Risk Factor in MotorVehicle Occupant and Pedestrian Fatalities. American Journal of Public Health, Vol. 9

3, No. 9, pp. 1541-1545.

32. Dumbaugh, E (2005). Safe Streets, Livable Streets. Journal of the American PlanningAssociation, 71 (3): 283300.

33. Frank L, Stone B and Bachman W (2000). Linking Land Use with Household VehicleEmissions in the Central Puget Sound: Methodological Framework andFindings.Transportation Research Part D 5, 3: 173-96.

34. Frank L, Sallis JF, Conway T, Chapman J, Saelens B, Bachman W (2006). MultiplePathways from Land Use to Health: Walkability Associations with ActiveTransportation, Body Mass Index, and Air Quality. Journal of the American PlanningAssociation, 72(1): 7587.

35. Robert D. Bullard and Glenn S. Johnson. Just Transportation: Dismantling Race andClass Barriers to Mobility. Gabriola Islands, British Columbia, Canada: New SocietyPublishers, 1997.

36. Robert D. Bullard, Glenn S. Johnson, and Angel O. Torres. Highway Robbery:Transportation Racism & New Routes to Equity. Cambridge, MA: South End Press, 2004.

37. K. H. Schaeffer, Elliott Sclar. Access for All: Transportation and Urban Growth. NewYork, NY: Columbia University Press, 1980

38. Besser LM and Dannenberg AL (2005). Walking to public transit: Steps to help meetphysical activity recommendations. American Journal of Preventive Medicine, 29(4),273 280.

39. Frank L and Engelke P (2005). Multiple Impacts of the Built Environment on PublicHealth: Walkable Places and the Exposure to Air Pollution. International RegionalScience Review, 28: 193 216.

40.US Department Of Transportation. Fatality Accident Recording System Encyclopedia.Accessed February 18, 2010 at http://www-fars.nhtsa.dot.gov/Main/index.aspx

41. U.S. Centers for Disease Control & Prevention. Motor Vehicle Safety. AccessedFebruary 18, 2010 at http://www.cdc.gov/Motorvehiclesafety/index.html

REFERENCES



21/22

42. Jovanis P, Chang H (1986). Modeling the Relationship of Accidents to Miles Traveled.Transportation Research Record 1068: 42-51.

43. Grder P (2004). The impact of speed and other variables on pedestrian safety inMaine. Accident Analysis & Prevention 36 (4): 533-542.

44. National Highway Traffic Safety Administration. Literature Review on Vehicle Travel

Speeds and Pedestrian Injuries. Washington, DC: USDOT, 1999.

45. LaScala EA, Gerber D, Gruenewald PJ. 2000. Demographic and environmentalcorrelates of pedestrian injury collisions: a spatial analysis. Accident Analysis andPrevention 32:651-658.

46. Swift P (1998). Residential Street Typology and Injury Accident Frequency.Presentation at the Congress for the New Urbanism VI, Denver CO, June 1998.

47. Jacobsen, P., Anderson, C.L., Winn, D.G., Moffat, J., Agran, P.F. and Sarkar, S. (2000).Child Pedestrian Injuries on Residential Streets: Implications for Traffic Engineering.ITE Journal on the Web, February: 71-75.

48. Urban Land Institute, Center for Neighborhood Technology and the Center forHousing Policy (2009). Beltway Burden: The Combined Cost of Housing andTransportation in the Greater Washington, D.C. Metropolitan Area. Washington, DC:Urban Land Institute.

49. Bernstein S, Makarewicz C,McCarty K. Driven to Spend: Pumping Dollars Out of ourHouseholds and Communities. Center for Neighborhood Technology and the SurfaceTransportation Policy Project 2005.

50. The Center for Neighborhood Technology. Housing and Transportation AffordabilityIndex. Available at http://htaindex.cnt.org/

51. Burchell, R et al. The Costs of Sprawl 2000. Transit Cooperative Research ProgramTCRP Report 74. Report for the Transportation Research Board / National ResearchCouncil. Washington, D.C.: National Academy Press. 2002.

52. Sacramento Area Council of Governments. Sacramento Regional Blueprint. Availableat: http://www.sacregionblueprint.org/sacregionblueprint/home.cfm

53. Belden Russonello & Stewart (2004). American Community Survey National Surveyon Communities. Washington, D.C.: Smart Growth America and National Associationof Realtors.

54. Levine J, Frank LD (2007). Transportation and land-use preferences and residentsneighborhood choices: The sufficiency of compact development in the Atlanta region.Transportation 34(2): 255-274.

55. J. Thomas (2009). Residential Construction Trends in Americas Metropolitan Regions.Washington, DC: U.S. Environmental Protection Agency.

56. A.C. Nelson (2006). Leadership in a New Era. Journal of the American PlanningAssociation 72(4): 393-407.

57. Levine J, Frank LD (2007). Transportation and land-use preferences and residentsneighborhood choices: The sufficiency of compact development in the Atlanta region.Transportation 34(2): 255-274.

58. National Institutes of Health, National Institute of Diabetes, Digestive and KidneyDiseases. Statistics Related to Overweight and Obesity: The Economic Costs. AccessedMay 13, 2008 at: http://win.niddk.nih.gov/statistics/index.htm. Adjusted to 2008dollars. Includes health care costs, lost wages due to illness / disability and value offuture earnings lost by premature death. Direct medical costs = $61B.

59. Finkelstein EA, Fiebelkorn IC, Wang G. (2003) National medical spending attributableto overweight and obesity: How much, and who's paying? Health Affairs Web ExclusiveW3:219-226. Available at http://content.healthaffairs.org/cgi/content/full/hlthaff.w3.219v1/DC1

60.Federal Highway Administration (2000). Addendum to the 1997 Federal Highway CostAllocation Study Final Report, May 2000. Accessed May 12, 2008 at:www.fhwa.dot.gov/policy/hcas/addendum.htm; Adjusted to 2008 dollars.

61. AAA (2008). Crashes vs. Congestion Report. Whats the Cost to Society? Cambridge,MD: Cambridge Systematics, Inc.; 2008. Accessed May 14, 2009 at:www.aaanewsroom.net/assets/files/20083591910.crashesVscongestionfullreport2.28.08.pdf.Adjusted to 2008 dollars.

62. Wier M, Bhatia R, Weintraub J (2007). Predicting Pedestrian Injury Collisions in SanFrancisco, California: An Area-level Model. San Francisco, CA: San FranciscoDepartment of Public Health.

63. Bhatia R, Wier M, Weintraub J (2007). Impacts of Urban Land Use Development onPedestrian-Motor Vehicle Collisions: An Application of the San Francisco PedestrianInjury Model to Five Neighborhood Plans. San Francisco, CA: San FranciscoDepartment of Public Health.

64.Wier M, Weintraub J, Humphreys E, Seto E, Bhatia R (2009). An area-level model ofvehicle-pedestrian injury collisions with implications for land use and transportationplanning. Accident Analysis & Prevention 41:137-145.

65. Ragland DR, Markowitz F, MacLeod KE (2003). An Intensive Pedestrian SafetyEngineering Study Using Computerized Crash Analysis. Institute of Transportation

Studies: UC Berkeley Traffic Safety Center publication UCB-TSC-RR-2003-12.66.U.S. Department of Transportation, Federal Highway Administration. Motor Vehicle

Accident Costs. Technical Advisory T 7570.2. Washington, DC: USDOT; October 31,1994. Accessed June 22. 2009 at: http://www.fhwa.dot.gov/legsregs/directives/techadvs/t75702.htm

67. Hall J, Brajer V (2008). The Benefits of Meeting Clean Air Standards in the SouthCoast and San Joaquin Valley Air Basins. Fullerton, CA: California State University-Fullerton Institute for Economic and Environmental Studies

68.California Air Resources Board (2006). Emissions Inventory for the San Joaquin ValleyAir District California Emissions Forecasting System (CEFS) Emissions by SummaryCategory. Web query accessed May 15, 2009 at: http://www.arb.ca.gov/app/emsinv/fcemssumcat2007.php

69.Leon, A. S., J. Connett, D. R.Jacobs, and R. Rauramaa (1987). Leisure-time physicalactivity levels and risk of coronary heart disease and death: The Multiple Risk FactorIntervention Trial. Journal of the American Medical Association 258 (17): 2388-95.

70. Mrozek, Janusz R., and Laura O. Taylor (2002). What determines the value of life? Ameta-analysis. Journal of Policy Analysis and Management 21 (2): 253-70.

71. U.S. Environmental Protection Agency (2000). Guidelines for preparing economicsanalyses. Washington, DC: U.S. Environmental Protection Agency.

72. Kats, G (2009) Greening Buildings and Communities: Costs and Benefits. Washington,DC: Good Energies.

73. Frank LD, Kerr J, Sallis J (2007). Urban Form Relationships with Walk Trip Frequencyand Distance among Youth. American Journal of Health Promotion 21(I4 S): 305.

74. United States Government Accountability Office (2008). Surface Transportation.Restructured Federal Approach Needed for Focused, Performance-Based, andSustainable Programs GAO-08-400. Washington, DC: US GAO.

75. National Environmental Policy Act of 1969 Sec. 2 [42 USC 4321]

76. NEPA, the Environmental Quality Improvement Act of 1970 40 C.F.R. 1508.8, 40 C.F.R.Sec. 1508.14; see quotes in Bhatia, Kavage & Frank briefing paper 2007

77. Executive Order 12898, Environmental Justice Executive Order 12898. Federal Actionsto Address Environmental Justice in Minority Populations and Low-IncomePopulations, 1994. Amended by EO 12948 (1/30/95)

78. Davies K, Sadler B. Environmental Assessment and human health: perspectives,approaches, and future directions. Ottawa: Health Canada; 1997

79. A. Steinemann (2000). Rethinking human health impact assessment. EnvironmentalImpact Assessment Review 20: 627-645

80.Corburn J. Confronting the challenges in reconnecting urban planning and publichealth. American Journal of Public Health. 2004; 94: 541-546.

81. Bhatia R, Wier M, Weintraub J (2007). Impacts of Urban Land Use Development onPedestrian-Motor Vehicle Collisions: An Application of the San Francisco PedestrianInjury Model to Five Neighborhood Plans. San Francisco, CA: San FranciscoDepartment of Public Health.

82. Cole BL, Fielding JE. Health impact assessment: a tool to help policymakersunderstand health beyond health care. Annu Rev Public Health. 2007;28:393-412.

83. Carr P, West J and Wright B. "SR 520 Health Impact Assessment." Seattle: PugetSound Clean Air Agency / Seattle King County Public Health, 2008.

84.Dannenberg AL, Bhatia R, Cole BL, Heaton SK, Feldman JD, Rutt CD (2008). Use ofhealth impact assessment in the U.S.: 27 case studies, 1999-2007. Am J Prev Med.34(3):241-56.

85. Frank and Kavage (2008). Urban Planning and Public Health: A Story of Separationand Reconnection. Journal of Public Health Management & Practice 14(3), 214220.

86.Litman, Todd. Transportation Cost and Benefit Analysis II. Victoria Transport PolicyInstitute 2009. p. 8-3. Accessed May 14, 2009 at http://www.vtpi.org/tca/tca08.pdf

87. See a complete list of federal health and safety related programs and funding levelsin APHAs first Transportation Policy Brief, At the Intersection of Public Health andTransportation.



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Costos Ocultos en Salud Ocasionados Por Transporte