parks, public health, and partnerships national governors association promoting quality of life...

Parks, Public Health, and Partnerships

National Governors AssociationPromoting Quality of Life Through

ParksWashington, April 22, 2002

Howard Frumkin, M.D., Dr.P.H.Rollins School of Public Health

Emory University

Are parks good for health?

• Evidence for specific health benefits of parks

• Which type of park might promote health?

• What partnerships come to mind?

A health-related typology of parks

• Dense urban parks– Liberty Bell– MLK National Historic Site

• Green (often waterway-related) urban parks– Wissahickon Park– Minneapolis bike trails

• Natural areas near cities– Chattahoochee River greenbelt– C&O Canal

• Large remote natural areas– Yosemite– Smokies

Specific health benefits of parks

1. Direct nature contact2. Physical activity3. Cooling4. Clean air5. Clean water

“Nature matters to people. Big trees and small trees, glistening water, chirping birds, budding bushes, colorful flowers—these are important ingredients in a good life.”

Rachel Kaplan

Nature contact: a health benefit?1.

“Thousands of tired, nerve-shaken, over-civilized people are beginning to find out that going to the mountains is going home; that wilderness is a necessity; and that mountain parks and reservations are useful not only as fountains of timber and irrigating rivers, but as fountains of life.”

John Muir

Health benefits of nature contact

Health benefits of nature contact

Biophilia: “the innately emotional affiliation of human beings to other living organisms”

E.O. Wilson, 1993

Health benefits of nature contact:

Empirical evidence• Animals• Plants• Landscapes• Wilderness experience

Plants and human health

Horticultural Therapyused in:• Acute hospitals• Children’s hospitals• Nursing homes• Psychiatric

hospitals• Hospices

Landscapes and human health

State Prison of Southern Michigan, 1978:

Sick call attendance from inside cells was 24% higher than from outside cells

Moore, J. Env. Systems, 1981-2

Landscapes and human health

Recovery from surgery:• All cholecystectomies in a

Pennsylvania hospital, May-October, 1972-1981

• Exclusions: age <20 or >69; serious complications; history of psychological problems

• Matched pairs: “tree view” patients with “brick wall view” patients

Landscapes and human health

Results: The “tree view” patients had• shorter hospitalizations (8.70 days vs

7.96 days)• less use of analgesic medications• fewer negative nurse notes (e.g.

“needs much encouragement,” “upset and crying”)

Ulrich, Science, 1984

Pain control during bronchoscopy

80 patients undergoing bronchoscopy

40 viewed a pristine meadow scene, heard bubbling brook sounds

40 controls

29.3% with “very good” or “excellent” pain control

20.5% with “very good” or “excellent” pain control

Lechtzin et al., ATS, 2001

Wilderness and human health

Reported benefits of wilderness experiences: • Improved measures of cooperation and trust

among adolescents with depression, substance abuse, or adjustment reactions (Witman, 1987).

• Improved coping ability and locus of control among psychiatric inpatients (Plakun et al., 1981).

• Improved function and greater probability of discharge among inpatients at the Oregon State Mental Hospital (Jerstad and Stelzer, 1973)

Parks, nature contact, and health:

Which kinds of parks might help?• Dense urban parks

– Liberty Bell– MLK National Historic Site

• Green urban parks– Wissahickon Park– Minneapolis bike trails

• Natural areas near cities– Chattahoochee River greenbelt– C&O Canal

• Large remote natural areas– Yellowstone– Tetons

Parks, nature contact, and health:

What partnerships are possible?

• Medical Association• Public Health Association• State and local Health Departments• Mental Health Association• Academy of Pediatrics• Children's health advocates• Rehabilitation medicine specialists• Disease-specific associations

– Autism, Multiple sclerosis, Alzheimer’s, others

Physical activity

• A sedentary lifestyle increases the risk of- overall mortality (2

to 3-fold)- cardiovascular

disease (3 to 5-fold)

• The effect of low physical fitness is comparable to that of hypertension, high cholesterol, diabetes, and even smoking.

Sources: Wei et al., JAMA 1999; Blair et al., JAMA 1996

2.

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1986

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1987

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1988

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1990

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1991

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1992

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1994

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1995

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1996

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1997

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1998

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1999

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% >20%

Source: Mokdad AH et al. J AMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 2000

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

OverweightIncreasing weight associated with: risk of overall mortality (up to 2.5-fold in

the 30-44 age group, less at older ages) risk of cardiovascular mortality (up to 4-

fold in the 30-44 age group, less at older ages)

risk of diabetes (up to 5-fold) risk of hypertension risk of some cancers risk of gall bladder disease

Source: Willett et al., New Eng J Med, 1999

Diabetes among U.S. adults, 1990

Diabetes among U.S. adults, 1991-92

Diabetes among U.S. adults, 1993-94

Diabetes among U.S. adults, 1995

Diabetes among U.S. adults, 1997-98

Diabetes among U.S. adults, 1999

Send this boy to the park!

Physical activity, parks, and health:

Which kinds of parks might help?• Dense urban parks

– Liberty Bell– MLK National Historic Site

• Green urban parks– Wissahickon Park– Minneapolis bike trails

• Natural areas near cities– Chattahoochee River greenbelt– C&O Canal

• Large remote natural areas– Yellowstone– Tetons

Parks and physical activity:What partnerships are

possible?• Medical Association• Public Health Association• Sports Medicine specialists• Academy of Pediatrics• AARP, Geriatricians• Heart Association• Lung Association• Cancer Society• Diabetes Association• Fitness enthusiasts

Cooling3.

• Urban heat island: On warm days, cities can be warmer than surrounding countryside, by as much as 6-8oF.

• Two major reasons:– Loss of trees leads to loss of

evapotranspiration – Dark surfaces (low albedo) retain and

reradiate heat

Atlanta’s Heat Island

Source: NASA Marshall Space Flight Center

Atlanta’s Heat Island: May 11, 1997

Source: NASA Marshall Space Flight Center

Atlanta’s Heat Island: May 11, 1997

Source: NASA Marshall Space Flight Center

1973 1979

1987 1997

25 Years of Urban Growth in AtlantaSource: Scientific Visualization Studio, Goddard Space Flight

Center

Atlanta’s heat island during sprawl, 1972 - 1993

• Less severe effects:– heat syncope – heat edema– heat tetany– heat cramps

• More severe effects:– heat exhaustion– heat stroke

• Long-term exposure associated with infertility, teratogenesis

Heat-Related Illness and Death

Chicago heat wave, 1995

Source: Whitman et al., AJPH 1007;87:1515-18.

• Elderly, children, chronically ill, urban poor are especially vulnerable

• Mitigating factors:– Adaptation– Decreased cold-related morbidity/mortality

Heat-Related Illness and Death

The cooling effects of parks:Which kinds of parks might

help?• Dense urban parks

– Liberty Bell– MLK National Historic Site

• Green urban parks– Wissahickon Park– Minneapolis bike trails

• Natural areas near cities– Chattahoochee River greenbelt– C&O Canal

• Large remote natural areas– Yellowstone– Tetons

Parks, cooling, and health:What partnerships are

possible?• Medical Association• Emergency medicine• Disaster management agencies• Public Health Association• AARP

Clean AirThe major air pollutants:• CO• SOx (SO2)• NOx (NO, NO2)• Particulates (PM)• Ozone• Lead• Volatile organic compounds (Hydrocarbons)• Air toxics (solvents, pesticides, metals, etc.)• Allergens

secondary pollutants

primary pollutants

4.

Ozone health effects

• Respiratory effects (ozone > PM): Airway inflammation Decreased air flow Increased symptoms, ER visits, medication

use, hospitalizations

• Cardiovascular effects (PM > ozone) Increased mortality

• Immune effects Increased susceptibility to infection

Ozone health effects

Susceptible subgroups include:• Asthmatics• Children• The elderly• Those with certain underlying

diseases

Particulate air pollution and mortality: the Six Cities Study

All-cause mortality bypollution levels:• RR 1.3 for most

polluted vs least polluted city

• Excess was lung cancer and cardiopulmonary disease

• Unaffected by other variables

Particulate air pollution and and acute health

effectsSeveral dozen time-series studies in

– asthmatics, COPD patients, and healthy individuals

– children and adults– European and U.S. cities

show associations between PM and symptoms, ER visits,

hospitalizations lung function

Do parks clean the air?

• Olmsted: Parks as the “lungs of the city”

• Benefits of parks for air quality:

– Direct removal of pollutants

– Cooling effect ozone formation

– Cooling effect energy demand

Direct removal of pollutants

• Leaves directly resorb CO, SO2, NO2, ozone, particulates.

• Chicago: Urban tree canopy removes 15 metric tons of CO, 84 metric tons of SO2, 89 metric tons of NO2, 191 metric tons of ozone and 212 metric tons of particulates each year. David Nowak, project leader, USFS Urban

Forest Ecosystem Research Unit, quoted in Emagazine, Vol XII, No 6, Nov-Dec 2001

Ozone

0.00

0.04

0.08

0.12

0.16

0.20

Apr May Jun Jul Aug Sep Oct

O3

(pp

m)

Ozone Season in Atlanta

Unhealthful

Source: M. Chang, Ph.D., Georgia Tech

Clean air: Which kinds of parks might

help?• Dense urban parks

– Liberty Bell– MLK National Historic Site

• Green urban parks– Wissahickon Park– Minneapolis bike trails

• Natural areas near cities– Chattahoochee River greenbelt– C&O Canal

• Large remote natural areas– Yellowstone– Tetons

Parks, clean air, and health:What partnerships are

possible?• Medical Society• Lung Association• Heart Association• Thoracic Society• Public Health

Association• Asthma patients

Clean water5.

Source: Center for Watershed Protection

Relationship Between Watershed Imperviousness (I)and the Storm Runoff Coefficient (Rv)

(Source: Schueler, 1987)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 10 20 30 40 50 60 70 80 90 100Watershed Imperviousness (%)

Run

off C

oeff

icie

nt (R

v)

Source: Center for Watershed Protection

Water quantity

Source: Center for Watershed Protection

Water quality non-point source pollution

Well documented for PAHs, zinc, organic waste, nutrients (nitrogen, phosphorus)

Likely for pesticides, other metals, bacteria

siltation, potentially compromising water treatment

“Source water protection is public health protection.”

R. Jackson, CDC

Clean water:Which kinds of parks might

help?• Dense urban parks

– Liberty Bell– MLK National Historic Site

• Green urban parks, especially those on waterways– Wissahickon Park– Minneapolis bike trails

• Natural areas near cities– Chattahoochee River greenbelt– C&O Canal

• Large remote natural areas– Yellowstone– Tetons

Clean water, parks, and health: What partnerships

are possible?• Medical Association• Public Health Association• State and local health departments• Infectious disease specialists

Summary: Parks and health

DENSE URBAN PARKS

GREEN URBAN PARKS

NATURAL AREAS

NEAR CITIES

LARGE REMOTE NATURAL

AREAS

1.DIRECT NATURE CONTACT

2.PHYSICAL ACTIVITY

3. COOLING 4.

CLEAN AIR

5.CLEAN WATER

Summary: Potential health partners for park

advocates• Medical Associations• Medical specialist groups: pediatrics,

geriatrics, rehabilitation medicine, sports medicine, pulmonary medicine

• Disease advocacy groups: Heart Association, Lung Association, etc.

• Public Health Associations• State and local Health Departments• Medical research agencies (NIEHS, CDC,

IOM)• Health payors (insurers, HMOs, MCOs)

Parks, public health, and partnerships: an agenda

• Understand more fully the health benefits of parks.

• Publicize these benefits.• Form partnerships with potential

allies based on shared goals.• Advocate for park-friendly policies.

Thank you!

Doc who likes parks

Dog who

agrees