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MedGenMed. 2004; 6(3): 59.
Published online Sep 13, 2004.
PMCID: PMC1435615

Urban Sprawl and Public Health: Designing, Planning, Building for Healthy Communities

Reviewed by Russ Lopez, MCRP, ScD

Urban Sprawl and Public Health: Designing, Planning, and Building for Healthy Communities, By Howard Frumkin, MD, DrPH; Lawrence Frank, PhD; Richard Jackson, MD, MPH, Island Press, Copyright 2004, 338 pages, ISBN: 1-55963-305-0, $30 paperback

Presenting his groundbreaking research on neighborhood characteristics and health at a conference sponsored by the Robert Wood Johnson Foundation in 2004, Larry Frank said, "Thank God for the Pacific Ocean, otherwise Atlanta would keep sprawling forever." Atlanta's (Georgia) sprawl problems illustrate many of the issues in Urban Sprawl and Public Health: Designing, Planning, and Building for Healthy Communities by Howard Frumkin, MD, DrPH; Lawrence Frank, PhD; and Richard Jackson, MD, MPH. It has replaced Los Angeles, California, as the primary example of contemporary US development for good reason. By almost every measure and definition, it is the most sprawled large metropolitan area and its growth seems relentless.

This book provides an excellent summation of the current state of evidence linking the spread of developments (as houses and shopping centers) on undeveloped land near a city and public health. Although it may lack some of the rhetorical flourishes of James Kunstler's The Geography of Nowhere or Jane Holtz Kay's Asphalt Nation, this book is better researched and is more appropriate for policy makers, public health professionals, and urban planners. Unlike those other books, here the authors acknowledge the attractions of sprawl and the benefits of suburban living. It is through reasoned language and careful scholarship that the book documents how this pattern of the built environment has profound impacts, both good and bad, on public health.

At one time, Atlanta was the home of all 3 of the authors. Dr. Frumkin's position as Chair of the Department of Environmental and Occupational Health at Emory University and his expertise as a physician have given him a unique position to analyze how sprawl affects health. Dr. Jackson, also a physician and now State Health Officer of the California Department of Health Services, speaks firsthand about the problems posed to pedestrians by the Buford Highway outside his former offices at the US Centers for Disease Control and Prevention. This commercial strip road lacks sidewalks, has few stoplights to allow pedestrians to cross, and has high-speed traffic. Its dangers put many people at risk; Dr. Jackson spent several years traveling across the United States working to convince public health professionals of the need to become more closely involved in land use and design issues to prevent other areas from making similar types of development decisions. Dr. Frank's contribution to the book derives from his training in transportation and planning. Before moving to the School of Community and Regional Planning at the University of British Columbia, Vancouver, British Columbia, Canada, he was on the faculty of the Georgia Institute of Technology.

Urban Sprawl and Public Health begins with a description and definition of sprawl, a word that can have many different meanings and contexts. The book defines sprawl with 2 land use concepts, density and land use mix, and 2 transportation concepts, automobile dependence and connectivity (the frequency of intersections and proximity of destinations). Following this introduction are chapters on the history of sprawl (relying heavily on Kenneth Jackson's Crabgrass Frontier) and urban health. Next are chapters on specific issues, including air quality, physical activity, mental health, and social capital. Especially important is a chapter on sprawl's health effects on special populations, including the elderly, people of color, the poor, and people with disabilities -- groups often not included in discussions of this suburban-focused issue. The authors conclude with a discussion on alternatives to the current trend of ever increasing sprawl and contemporary development patterns.

The book is strongest where the evidence is greatest: A growing number of studies are showing that urban sprawl reduces physical activity and promotes obesity. It is likely that post-World War II zoning and design guidelines overly separate work and shopping destinations from housing, forcing people to drive rather than walk. Other research shows that streets without sidewalks and large-lot zoning further discourage physical activity. This contributes to the current obesity epidemic in the United States. The book is less convincing where the underlying science is lacking. For example, the authors state a strong logical argument associating sprawl with depression, but ultimately the dearth of actual research on sprawl and mental health forces them to admit the links are currently speculative. The authors do not hesitate to point out where additional research is needed.

Sitting at the intersection of 2 different disciplines, a book of this nature is challenged to present concepts of health to planners, architects, and designers while incorporating the language of planning and architecture in a format understandable to the health professions. The authors succeed on many levels, from its extensive endnotes and bibliography sections (a combined total of 101 pages) that will serve as a resource for researchers to its many charts, graphs, and photos that will assist laypersons to understand the science underlying the book's conclusions. For example, a series of maps illustrating the increase in obesity by state between 1991 and 2002 (page 96) are dramatic. The figure's top text explains how obesity is defined for those unfamiliar with the body mass index, whereas at the bottom of the figure, data sources are clearly cited so that background articles can be researched. The book has numerous photographs, charts, graphs, and text boxes on special side topics.

Americans moved to the suburbs in part because they wanted to escape the pollution and social turmoil of inner cities. A desire for a healthier environment provided a strong motivation for the pattern of development we now call sprawl. But the resulting environment may be less healthy than many now revitalized metropolitan communities left behind. This book should serve as a call to action for those concerned about public health. It certainly assembles evidence to explain why Americans are not as healthy as they could be.

This book is a portrait of the state of science at this time. In less than a decade, the Atlanta metropolitan area will be several hundred square miles larger, and there will be more studies exploring the relationship between sprawl and health. It will then be time for an updated edition.


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