Cities, transport and the health of the citizen

Paper presented at the workshop Environment, traffic and urban planning, European Academy of the Urban Environment, Berlin, Germany 30 Nov – 4 Dec 1992.

Motorised transport in the towns and cities of Europe, as elsewhere, damages the health and well-being of their citizens in a wide variety of ways many of which are poorly recognised in public policy decision-making (Ref: Healthy Transport Policy). Its direct impact can be shown to be detrimental most obviously in its physical manifestation in death and injury in road accidents. But it also has psychological consequences owing not only to distress among those directly affected but also to fear and anxiety about the risk of accidents occurring. There are too pathological effects as the pollution and noise from motor vehicles are a source of disease and mental impairment, and ecological effects as the exhaust emissions from traffic are a major contributor to global warming which is highly deleterious to the planet’s ‘health’.

There are also adverse indirect impacts from the viewpoint of the promotion of individual health. The growing volume and speed of traffic, and associated changes in land-use planning, deter people from using their feet as means of travel and thereby act as a disincentive to most of the population who could maintain their physical fitness in this efficient and effective way. A loss of personal autonomy and self-sufficiency is linked to this as motorised transport diminishes the ability of people without a car of their own to lead independent lives.

Physical injury
Road accidents are among the most widely acknowledged causes of unnecessary suffering from physical injury (Ref: Danger on the Road: the needless scourge). Their reduction is an important area of policy on prevention. Each year, 50,000 people are killed just on the roads of the Member States of the European Community. Statistics show that a further half a million are severely injured – and this horrifying number excludes a disturbingly high proportion of injuries which are not reported to the police but are treated in hospital. Indeed, comparison of the number of victims of road accidents treated in the UK as hospital in-patients and the total of all hospital in-patients suggests that the number of beds they occupy each year is equivalent to the ward capacity of 25 medium-sized hospitals in Britain. In addition, the casualty departments of the UK’s National Health Service treat a further third of a million people who are slightly injured.

Calculations made from official statistics in the UK reveal that, during any one lifetime, there is a 1 in 2 risk of slight injury, a 1 in 8 risk of serious injury, and a 1 in 150 risk of dying in a road accident; and an average life is shortened by three months by death on the roads. A quarter of a million people alive today in the UK are likely to die in a road accident. Accidents causing death and serious injury have been falling generally in most European countries in recent years. However, this has not come about because roads have become safer but because they have become more dangerous. This has led to behavioural changes: a declining proportion of journeys are now made by the modes of travel – walking and cycling – which are most vulnerable to the increase in traffic and, as will be seen later, children’s freedom to get about on their own has been increasingly restricted as a by-product of policy on road safety.

Although pedestrians and cyclists represent a high proportion of all fatal and serious injuries on the road, they typically account for only a very small proportion of all mileage travelled. General links observed between social class and mortality and much morbidity are also apparent in accidents: for instance, whether due to living in a more dangerous environment, that is one with more traffic, to being more dependent on walking, or less likely to be accompanied by an adult, pedestrian fatalities in collisions with motor vehicles are several times higher among children of semi-skilled or unskilled parents than those of professional parents. And a further inequitable outcome is that the relative risk of injury in travel by different modes has not stayed constant: the accident ratio per kilometre for journeys on foot or on a bicycle compared with that by car is higher now than it was ten years ago, and higher still than it was 20 years ago.

Distress and anxiety
The death of a close family member is a ‘life event’ which contributes significantly to survivors’ deterioration in health. The cause of death determines the time it takes for them to become reconciled to their loss, the bereaved finding it particularly difficult to come to terms with an avoidable death. Nor are the effects necessarily short-term: for many recall of the event and grief associated with it can be a source of distress throughout life, contributing to a wide range of medical and psychosomatic disorders. The loss of the substantial number of domestic pets and wild animals killed and injured in road accidents also upsets many people in a way similar to that occasioned in accidents involving human beings.

Thus, it is clear that the full extent of the harm caused by road accidents is not limited to those killed or injured. Other people are affected psychologically: when one considers the relatives and friends of those involved, it is obvious that there are many more victims. Indeed, there are few people who have not had a friend or relative injured in a road accident. Guilt at being responsible for a personal injury is also stressful, particularly if it leads to death or disfigurement or if a child is involved. Witnesses too can be traumatised by their experiences.

There are few statistics on changes over time in public anxiety and fear about road accidents. However, the current traffic environment in which a child’s perfectly normal momentary lapse of attention can have such an horrific outcome as an ‘accidental’ death or serious injury does appear to have increasingly encouraged parents to feel that it is unwise to allow their children to travel unaccompanied.

Fear and loss of autonomy
Parents’ worry about the dangers of their children being involved in an accident or of being molested has led to a situation in which children are far less likely to be allowed to get about on their own or to play in the street than were the children of a generation ago (Ref: One False Move… a study of children’s independent mobility). Nowadays, most young children are denied that degree of autonomy during an important stage in their social development to adulthood because they have to be confined to the home or taken to their destinations in a manner which seldom provides them with opportunities to develop coping skills in an unsupervised environment, to take initiatives and learn from the consequences, and to enjoy the equivalent freedom and exposure to unpredictable experiences of their parents or even more of their grandparents when they were children.

The consequent loss of this basic freedom for a higher number of their years at this crucial stage of their lives is reflected in our surveys of children and their parents over the last two decades. These have shown a marked rise in the incidence of ‘escort’ journeys reflecting parents’ changing perception of a traffic environment which is increasingly translated in practice into mothers taking on the additional responsibility of child-rearing so that it now encompasses that of accompanier on foot or part-time chauffeur for all the trips children have to make and many of those that the children want to make.

Able-bodied mothers accompanying their able-bodied children to and from school and other places because of fear is one of the more disturbing and wasteful by-products of the motorised society. It is particularly wasteful as most of these journeys are time-consuming as they are duplicated in order to both take and collect the children. A mother with two children is forced into this tied and potentially unnecessary pattern of activity until the younger child can be granted the parental ‘licence’ – typically now in the UK at the age of ten – to travel independently.

Fear is apparent too among a growing proportion of the population, especially women. They are usually more dependent on walking as their transport mode but the environment for this has become more unpleasant and inconvenient over the years. Surveys have shown that women are increasingly deterred from going out because of a fear of being molested. A recent Home Office Crime Survey in the UK has recorded that three in five female pensioners, and two in five younger women feel very unsafe walking alone in the dark.

When compared with their parents, many old people too can be seen to have sustained a decline in their capacity to meet their daily travel needs conveniently and safely. Obviously, their well-being is influenced by their ability to maintain social contacts and take part in leisure activities. But only a minority have use of a car, whilst for the rest, there are now greater demands made on their declining faculties to cope with the speed, ubiquity and severance effects of high volumes of traffic. Our studies have shown that old people frequently cite difficulty in crossing roads and fear of traffic as factors influencing their choice of destinations and how they travel, even to the extent of limiting their activity outside the home (Ref: Transport Realities and Planning Policy). To compound their problems, their independence has also been reduced as many of the places they need to reach in their daily lives, such as shops, surgeries and clubs, are no longer within reasonable walking distance. Thus, in common with other people without a car of their own, pensioners are unnecessarily cast in the role of dependants and have to rely on being given a lift to and from their destination or use a public transport system, albeit at free or concessionary rates, which may not run as conveniently and frequently as they would wish and which, in any case, usually entails walking at either end of the trip in that less pleasant pedestrian environment.

Lack of exercise
Considerable evidence links low levels of physical exertion with respiratory and heart diseases. For most people, brisk walking and especially cycling are ideal methods of keeping physically fit. These methods encourage the natural use of limbs and lungs and can be associated with varying degrees of effort; they can form part of the daily routine, in contrast to other means health promotion and are therefore less likely to be abandoned. (Ref: Cycling: Towards Health and Safety.)

However, in most European towns and cities, existing patterns of travel and land use militate against people using their legs to get about – on foot or bicycle. Activity based around the use of cars not only directly discourages their owners from taking these forms of exercise, but indirectly discourages others from doing so owing to the perceived risk of a road accident and the lowered quality of the environment from the noise and pollution of traffic. The adverse consequences of this can be seen in the decisions noted earlier that parents take in forbidding their children from cycling on public roads. They are also apparent when older people fail to maintain their fitness because their travel becomes organised around motorised transport.

There are no European published statistics on the physical fitness of each country’s citizens, but analysis of data from travel surveys shows that, in most countries, walking and cycling are declining as travel methods (Ref: Walking is Transport). Although cycle ownership is relatively high in many European countries, cycling, with few exceptions, accounts for only a small proportion of all journeys and an even smaller proportion of all mileage. This is no doubt partly explained by the low expenditure by governments on safe and convenient pedestrian and cycle networks as compared with expenditure on roads and public transport.

Local pollution and climate change
Traffic is a major source of noise widely regarded as disturbing. Noise can reduce concentration and exacerbate psychiatric disorders. For many people, especially poorer ones living on main roads or on flight paths close to airports, it can lead to interrupted sleep. There are adverse effects either if the traffic is continuous as it then interrupts REM sleep and is subjectively disturbing or, if it is intermittent, as it induces lighter and therefore less restorative sleep. The dramatic rise in the number of motor vehicles on the roads in every European country in the last few decades, and their spread by area and hour of day and night, strongly suggest that levels of traffic noise, and therefore the harm caused, have increased.

Exhaust fumes from motor vehicles, too, have adverse effects. They contain harmful pollutants which impair efficiency, cause lethargy and headaches, and aggravate some existing medical conditions. They can represent a health risk especially for pregnant women, young children and old people, all groups in the population which are more sensitive to lower oxygen levels. It is worth noting too that those who are worst-off in society are again also more likely to live on main roads subject to higher levels of noise and pollution. Indeed, studies have demonstrated that the planned environment, including the proximity of traffic, can be causally implicated in the aetiology of mental illness.

The incidence of cancer has been known for many years to be associated with leaded petrol, particularly when combined with other carcinogenic substances in vehicle exhaust fumes. However, the effects of EC legislation to reduce the lead content will take several years before safe levels are reached. Moreover, whilst the amounts of lead and sulphur dioxide from vehicle exhausts are being reduced, those of carbon monoxide, hydrocarbons and nitrogen oxide continue to rise largely in line with the growth of traffic. The benefits of the change in the law requiring new cars in EC countries to be fitted with catalytic converters from the beginning of next year to reduce these harmful gases will only become markedly apparent later in the decade. And it needs to be borne in mind that the CAT is only efficient on car journeys in excess of about 8 kilometres.

Finally, in discussing the hazards of noise and local air pollution associated with traffic growth, it is important to highlight what is likely to be the central issue facing policy makers in the very near future: the consensus of expert scientific opinion points to the use of fossil fuels as being likely to lead, within a generation or two, to a destabilising of the balance of weather and climate patterns which have evolved over tens of thousands of years. Transport is a major contributor to greenhouse gases from fuel combustion and, moreover, its share of the ecological harm is rising steadily.

Transport policy with a health dimension
It is apparent that current transport policy is deficient in terms of a recognition both of its impact on health and its social context. Motorised traffic increases apparently inexorably. And, ironically, people who walk or cycle – the modes most favourable to public health – have to do so in an environment which in the main has been rendered progressively unpleasant and unsafe. Moreover, far more motor traffic growth is forecast. This can only make matters worse.

A policy incorporating consideration of the promotion of well-being would not have such undesirable outcomes which so clearly stem from the growing use of the transport modes most prejudicial to public health. This use has been encouraged in almost all European countries by the transport policies of the last few decades which have been formulated on the premise that the rising ownership of motorised vehicles, and especially cars, and increases in the capacity of the road network to cater for their use, are indicators of progress.

Three sets of practical measures can be taken in our towns and cities to give policy a positive health dimension (Ref: Reviving the City: towards sustainable urban development). The first entails reducing the need for motorised travel rather than, as at present, generating more demand for it. This could be encouraged by planning, land use and location policies specifically directed towards minimising the distances that have to be travelled to reach shops, schools, sports facilities and so on, and to bring more of the quality of the natural environment into urban areas so that people do not feel so much of a need to get out to the country for fresh air and tranquillity. In addition, policies affecting personal decisions on how and how far to travel need to be framed in such a way as to ensure that proper regard is paid to the wider social and environmental costs of those decisions: at present, they are almost wholly disregarded.

The second set consists of reversing the spiral of increasingly car-dependant activity by encouraging use of those transport modes for personal travel which have the lesser undesirable attributes. Safe and convenient networks need to be established for pedestrians, uninterrupted at every road intersection, and for cyclists, either exclusive to them, or shared with motor vehicles which are subject to low speed limits. In addition, public transport needs to be promoted for those journeys that cannot be conveniently be made by the non-motorised modes.

The third set of measures is concerned with minimising the adverse impacts of motorised travel, in all instances requiring a much higher degree of political commitment to the health-related and social aspects of transport policy than is apparent at present. To reduce accidents and to reduce the fear of accidents – the two objectives are complementary, not synonymous – vehicle speeds must be lowered substantially by using improved enforcement techniques and by imposing more severe penalties; and stricter legislation on noise and air pollution needs to be enacted.

Not only would the adoption of these sets of measures lead to healthier and longer lives for the population of our towns and cities but also, consequently, to savings in health and welfare services. It is clear that traffic growth is damaging public health and steadily eroding the quality of life. It will not be improved unless fewer journeys are made by car and people are encouraged to lead more local lives that do not entail long distance commuting for the consequent adverse effects can neither be relieved by pouring money into public transport nor by palliative measures. But it is not simply that limits on traffic growth will soon have to be recognised. Those limits have long been passed. The principal policy agenda for the 1990s is very likely to be set by the ecological imperative that production of carbon dioxide from man-made processes is drastically cut. Responding to that imperative will inevitably not only restore health to the planet but also to people.

Main sources for the paper
– Hillman, Mayer, Henderson, Irwin, and Whalley, Anne (1976), Transport Realities and Planning Policy, Political and Economic Planning (now Policy Studies Institute).
– Hillman, Mayer, and Whalley, Anne (1979), Walking is Transport, Policy Studies Institute.
– Plowden, Stephen and Hillman, Mayer (1984), Danger on the Road: the Needless Scourge, Policy Studies Institute.
– Hillman, Mayer (1991), ‘Healthy transport policy’ in Health through Public Policy: the greening of public health, (ed. Peter Draper), Greenprint.
– Elkin, Tim, McLaren, Duncan, and Hillman, Mayer (1991), Reviving the City: towards sustainable urban development, London, Friends of the Earth.
– Hillman, Mayer, Adams, John, and Whitelegg, John (1991), One False Move… a study of children’s independent mobility, Policy Studies Institute.
– Hillman, Mayer, and Cleary, Johanna (1991), ‘A Prominent Role for Walking and Cycling in Future Transport Policy’, in J. Roberts et al (eds.), Travel sickness: the need for a sustainable transport policy for Britain, Lawrence and Wishart, pp.214-242.
– Hillman, Mayer (1992), Cycling: towards health and safety, A Report from the British Medical Association, Oxford University Press.
– Hillman, Mayer (1992), ‘Global Warming and the Sustainable City’, Conference Report on The Sustainable City: a European Forum, Streetwise, Summer.

Other references
– Blumer, W., and Reich, T. (1980), ‘Leaded gasoline – a cause of cancer”, Environment International, Vol.3, pp.465-471.
– Department of Transport (1991), Road Accidents Great Britain, 1990: The Casualty Report, HMSO.
– Department of Transport (1992), Transport Statistics Great Britain, 1991, HMSO.
– Eberhardt, J. and Akselsson, K.R. (1987), ‘The influences of continuous and intermittent traffic noise on sleep’, Journal of Sound and Vibration, Vol.114, pp.417-434.
– Halpern, David (1992), The Relationship between Mental Illness and the Planned Environment, unpublished PhD dissertation, St. Johns College, Cambridge.
– Hoinville, Gerald and Prescott-Clarke, Patricia (1978), Traffic Disturbance and Amenity Values, Social Community and Planning Research.
– Hough, Mike and Mayhew, Pat (1988), Taking account of crime: key findings from the Second British Crime Survey, Home Office Research Study No. 85, p.71.
– Jensen, R.A., and Laxen, D.P.H. (1987), ‘The effect of the phase-down of lead in petrol on levels of lead in air’, The Science of the Total Environment, Vol.59.
– Lave, Lester and Seskin, Eugene (1977), Air Pollution and Human Health, John Hopkins University Press. – Morris, J.N., Everitt, M.G. and Semence, A.M. (1987), ‘Coronary Heart Disease and Exercise’, Health Trends, Vol.19, pp.13-16.
– Parkes, Colin Murray (1972), Bereavement: studies of grief in adult life, Tavistock Publications.
– Selye, Hans (1957), Stress of Life, Longmans Green and Co.
– Tarnopolsky, Alex, Watkins, Gareth, and Hand, David (1980), ‘Aircraft noise and mental health: prevalence of individual symptoms’, Psychological Medicine, Vol.10, pp.683-698.
– Whitehead, M. (1987), The Health Divide; inequalities in health in the 1980s, Health Education Council.

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