What role for environmental public health practitioners in promoting healthy built environments?

W hile the built environment (BE) has long been of interest to public health practitioners, widespread reengagement of public health agencies in community planning is a phenomenon of the last decade. In 1854, John Snow identified the Broad Street water pump as the source of a cholera outbreak in London.1 Since then, public health authorities have championed introduction of sanitary and safe water infrastructures to control infectious disease.2 Early efforts to separate urban residents from industrial pollution culminated in modern zoning bylaws.2–4 To address the roots of chronic diseases, many public health agencies now seek to reduce negative and augment positive attributes of our human-built physical surroundings through greater social connectedness, more physical activity, and improved access to affordable healthy food. While some agencies have partnered with and funded community organizations to initiate BE projects, most focus on advocacy and support for local government initiatives. Doing so involves injecting a population health focus into local government planning based on an understanding of how the BE influences health. Historically, public health agencies sought to protect people from hazards in the BE, but increasingly they promote healthier BEs as a way to support healthy behaviours. A 2003 commentary in the Journal of Law, Medicine and Ethics reviewed the historical links between public health and urban planning and advocated for increased public health intervention in the built environment as a tool to both prevent illness and promote well-being.2 Although the authors noted the value of BE interventions to protect communities from environmental toxins, they did not specify a role for environmental public health (EPH) practitioners per se. EPH practitioners in North America have clear mandates to protect people from infectious or toxic agents in food, water and other environmental sources, including those mediated by the BE. They are thus well situated to take a lead in advocating for – and implementing interventions in – BEs that both protect and promote health. With strong evidence for the influence of BE features on behavioural risk factors for non-communicable diseases (e.g., walkable communities reduce physical inactivity5 ), the time is right to explore the role of EPH and other public health professionals in supporting healthier built environments. In this paper, we use examples from the authors’ experiences in British Columbia (BC) and New York City to show how EPH practitioners have begun to incorporate BE initiatives into their practice and suggest ways to expand this role across health departments in Canada. Existing intersections between environmental public health and the built environment Some environmental health agencies have integrated a BE focus into traditional mandates and practices of EPH; some have created parallel teams to promote healthier BEs; and others work with health promotion professionals on BE issues. Although not always framed specifically as BE work, their efforts fall into three main areas of practice. First, typical EPH roles include food premises Author Affiliations 1. Environmental Health Services, BC Centre for Disease Control, Vancouver, BC 2. National Collaborating Centre for Environmental Health, Vancouver, BC 3. School of Population and Public Health, University of British Columbia, Vancouver, BC 4. Dr. Karen Lee Health + Built Environment + Social Determinants Consulting, New York, NY Correspondence: Karen Rideout, PhD, Environmental Health Services, BC Centre for Disease Control, 0073-655 West 12th Avenue, Vancouver, BC V5Z 4R4, Tel: 604-829- 2544, E-mail: Acknowledgements: The authors thank Sandra Gill, Claire Gram and Dr. Lisa Mu for clarifying how built environment teams were integrated into regional health authorities, and Tina Chen and Emily Peterson for comments on an earlier version of this manuscript. Conflict of Interest: None to declare. COMMENTARY e126 REVUE CANADIENNE DE SANTÉ PUBLIQUE • VOL. 107, NO. 1 © 2016 Canadian Public Health Association or its licensor. inspection and permitting, waste management, safe housing, and oversight of air and water, all of which impact the quality of the built environment. Second, EPH practitioners assess and respond to innovative local-level BE interventions that flag concerns for health protection, such as backyard poultry by-laws, standards for siting community gardens, active transportation networks and mixed land use zones. Third, some EPH professionals participate in community planning processes around land use and transportation, allowing them to raise awareness of the links between the BE and chronic disease prevention.6 In some jurisdictions, approval of local public health authorities is required for land-use plans,7 a powerful tool to ensure that both acute and chronic health considerations are incorporated into BE planning. Expanding the scope of environmental health Many public health agencies have tasked EPH professionals with using BE initiatives (e.g., active and sustainable transportation, mixed-use neighbourhoods, green space, community gardens, safe and accessible housing) as a tool to support their ongoing role in health protection while contributing to chronic disease prevention.6 This is aligned with public health’s increasing focus on the determinants of health and healthy communities,8 along with a recognition that hypertension, physical inactivity and overweight/obesity are the leading risk factors for mortality today (responsible for 7.5, 3.2 and 2.8 million annual deaths globally).9 In addition to support from health system management, assumption of this expanded responsibility demands that practitioners reimagine their roles, develop competency on BE issues related to chronic diseases, strengthen relationships with other public health professionals, and collaborate with other sectors. We see four areas where EPH practitioners could leverage their skills and authority to operationalize a BE focus (see Table 1 for additional details and examples): • Inspections and/or Permitting. BE interventions could be added to existing functions without requiring significant resource requirements. In BC and New York City, oversight of menu labelling and trans-fat restriction has been incorporated into routine restaurant inspections (Table 1). A similar application of public health authority could require building features that reduce pollutant and noise exposure (for example, through building permits and during inspections in response to health and safety complaints) as well as promote minimum physical activity time allotments in daycare licences. • Oversight of Land Use Planning. Many health authorities review community or regional land use and transportation plans (Table 1).7 EPH professionals could further develop relationships with planners and leverage this opportunity to promote, or even require, healthy development that includes amenities for active transportation, gardening and healthy food access. Similarly, they could advocate for zoning bylaws or land development policies that ensure access to green space or healthier food options. • Health Hazards Legislation. Public health officials have legal authority to enact special measures to safeguard the public from health hazards. These measures typically address immediate or acute hazards associated with drinking water or the spread of communicable disease, but could be used to control hazards in the BE that lead to chronic disease outcomes. The BC Public He