This week on Talking Headways we’re joined by Dr. Lawrence Frank to talk about how the built environment and the way we get around connect to public health outcomes. We also discuss the work that led to Walk Score, the shortcomings of transportation cost benefit analysis, and the systematic externalization of health benefits.
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Partial edited section:
Jeff Wood: I’m wondering what’s changed since you started working on this stuff in the 1980s.
Lawrence Frank: What’s changed? Over the last three decades, we have learned that our notions about the connections. When Urban Sprawl and Public Health was written, I’d already been working on the topic for a decade when folks in public health. Especially environmental health and CDC started really focusing on it. So it was really wonderful to see others join the bandwagon and start to really get interested.
Jeff Wood: This is your book from 2004?
Lawrence Frank: I was working on this for 15 years by the time 2004 came around. Where we started actually doing basic research on the topic in physical activity. The physical activity, exercise, science and behavior and nutrition part of CDC, that whole chronic disease branch, they were in earlier. Environmental health came a little later and then took it on fully. Different parts of the public health arena slowly engaged in the built environment as it became topical.
As it became topical, it attracted people who were interested, obviously, in environments and environmental health, and clearly interested in the fact that this topic attracts a lot of attention, and it’s a way to potentially influence the wellness of the public.
The evolution you asked over the last 30 years, what’s changed? Lots of different groups, as we’ve seen slowly have come on board. As it becomes clearer and clearer through the evidence side. Causal evidence exists.
We started with notions, testing hypotheses. Associations were established with lots of conjecture, that it’s self-selection and the things you’re observing aren’t really the environment, it’s just masking the underlying attitudes and values. I’ve always viewed that as a wasteful use of energy because what better situation than to have an unmet demand for something that people want to do that’s good for them and good for the environment?
So even if it is, the mechanism is only enabling the underlying attitudes, if that even were the case, which it’s not, it would still make sense to provide more of that.
All the more reason than if you had a situation where you were trying to promote something that underlying attitudes were the opposite. But in this case, we have coherence, we have adherence, we have synergy. We have everything we need. And so getting on with building and actively shifting the funding within the transportation.
We talk, "What are we building and how is that changing?" We’re doing a very poor job of that. We keep making terrible decisions. The economics underneath the decisions, the cost benefit analysis, the methodologies are so warped and so distorted. We systematically continue to externalize the economically derived health-based benefits that we get from investing in active transportation.
Most of my work in the last decade has been on this topic. I’ve been a professor my whole career. And then throughout my whole career, I’ve been working on this scientifically, but at the same time, I’ve run a company called Urban Design for Health. It started in 1997. And that company has taken the evidence and applied it directly to one project after another with decision-makers, end users, NGOs like the Houston Air Alliance, trying to fight widening of the highway system in downtown Houston. Or it could be the Los Angeles area, Southern California Association of Governments, our biggest MPO, where we monetize the health benefits of active transportation infrastructure investments.
They had a $13-billion set-aside, and we got hired to demonstrate the economic benefits. Lo and behold, when we ran the cost-benefit model, we measured directly the health-related benefits that would be derived from this investment. We calculated an $8.41 return on that investment, conservatively, not even including chronic disease of the elderly (where most chronic disease exists), and we ended up showing a $100-billion return on investment through the life of the plan.
It’s shocking the degree of distortion that we’ve been able to allow happen. Of course, looking at the way the world is, I suppose this isn’t shocking at all. We should expect it. But we’re excluding costs bigger than the infrastructure costs that are even being considered by excluding the health impacts, the health related economic impacts, because it’s not just reduction in cost of illness by avoided disease. It’s the lack of engagement in workforce participation, workforce productivity — the fact that infrastructure, active transportation, infrastructure and transit, both give money back to people, who spend money in the economy that give you bigger multiplier rather than material oriented investment in highways and roads. Concrete doesn’t spend money. People do.
