Parks, Public Health, and Partnerships National Governors Association Promoting Quality of Life Through Parks Washington, April 22, 2002

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Parks, Public Health, and PartnershipsNational
Governors AssociationPromoting Quality of Life
Through ParksWashington, April 22, 2002

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

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Are parks good for health?

• Evidence for specific health benefits of parks
• Which type of park might promote health?
• What partnerships come to mind?

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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
• CO Canal
• Large remote natural areas
• Yosemite
• Smokies

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Specific health benefits of parks

1. Direct nature contact
2. Physical activity
3. Cooling
4. Clean air
5. Clean water

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Nature contact a health benefit?
1.

• Nature matters to people. Big trees and small
  trees, glistening water, chirping birds, budding
  bushes, colorful flowersthese are important
  ingredients in a good life.
• Rachel Kaplan

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Health benefits of nature contact

• 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

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Health benefits of nature contact
Biophilia the innately emotional affiliation of
human beings to other living organisms E.O.
Wilson, 1993
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Health benefits of nature contact Empirical
evidence

• Animals
• Plants
• Landscapes
• Wilderness experience

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Plants and human health

• Horticultural Therapy
• used in
• Acute hospitals
• Childrens hospitals
• Nursing homes
• Psychiatric hospitals
• Hospices

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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

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Landscapes and human health

• Recovery from surgery
• All cholecystectomies in a Pennsylvania hospital,
  May-October, 1972-1981
• Exclusions age lt20 or gt69 serious
  complications history of psychological problems
• Matched pairs tree view patients with brick
  wall view patients

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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

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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
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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)

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Parks, nature contact, and healthWhich 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
• CO Canal
• Large remote natural areas
• Yellowstone
• Tetons

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Parks, nature contact, and healthWhat
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, Alzheimers, others

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Physical activity
2.

• 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
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Overweight
Source Kuczmarski et al., JAMA 1994
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Obesity Trends Among U.S. AdultsBRFSS,
1985(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
21
Obesity Trends Among U.S. AdultsBRFSS,
1986(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
22
Obesity Trends Among U.S. AdultsBRFSS,
1987(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
23
Obesity Trends Among U.S. AdultsBRFSS,
1988(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
24
Obesity Trends Among U.S. AdultsBRFSS,
1990(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
25
Obesity Trends Among U.S. AdultsBRFSS,
1991(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
26
Obesity Trends Among U.S. AdultsBRFSS,
1992(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
27
Obesity Trends Among U.S. AdultsBRFSS,
1994(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
28
Obesity Trends Among U.S. AdultsBRFSS,
1995(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
29
Obesity Trends Among U.S. AdultsBRFSS,
1996(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
30
Obesity Trends Among U.S. AdultsBRFSS,
1997(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
31
Obesity Trends Among U.S. AdultsBRFSS,
1998(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
32
Obesity Trends Among U.S. AdultsBRFSS,
1999(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
33
Obesity Trends Among U.S. AdultsBRFSS,
2000(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad AH et al. J AMA 199928216,
200128610.
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Overweight

• Increasing 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

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Diabetes among U.S. adults, 1990
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Diabetes among U.S. adults, 1991-92
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Diabetes among U.S. adults, 1993-94
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Diabetes among U.S. adults, 1995
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Diabetes among U.S. adults, 1997-98
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Diabetes among U.S. adults, 1999
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Send this boy to the park!
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Physical activity, parks, and healthWhich 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
• CO Canal
• Large remote natural areas
• Yellowstone
• Tetons

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Parks and physical activityWhat 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

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Cooling
3.

• 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

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Atlantas Heat Island
Source NASA Marshall Space Flight Center
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Atlantas Heat Island May 11, 1997
Source NASA Marshall Space Flight Center
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Atlantas Heat Island May 11, 1997
Source NASA Marshall Space Flight Center
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1973
1979
1987
1997
25 Years of Urban Growth in Atlanta
Source Scientific Visualization Studio, Goddard
Space Flight Center
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Atlantas heat island during sprawl, 1972 - 1993
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Heat-Related Illness and Death

• 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

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Chicago heat wave, 1995
Source Whitman et al., AJPH 1007871515-18.
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Heat-Related Illness and Death

• Elderly, children, chronically ill, urban poor
  are especially vulnerable
• Mitigating factors
• Adaptation
• Decreased cold-related morbidity/mortality

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The cooling effects of parksWhich 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
• CO Canal
• Large remote natural areas
• Yellowstone
• Tetons

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Parks, cooling, and healthWhat partnerships are
possible?

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

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Clean Air
4.

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

primary pollutants
secondary pollutants
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Ozone health effects

• Respiratory effects (ozone gt PM)
• Airway inflammation
• Decreased air flow
• Increased symptoms, ER visits, medication use,
  hospitalizations
• Cardiovascular effects (PM gt ozone)
• Increased mortality
• Immune effects
• Increased susceptibility to infection

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Ozone health effects

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

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Particulates

• Mixture of solid and liquid particles
• Natural sources dust from soil, evaporation of
  sea water
• Combustion and metallurgical processes (e.g fly
  ash from coal diesel exhaust)
• Secondary formation oxidation of atmospheric
  gases (e.g. SO2?H2SO4), aerosol formation through
  condensation and accumulation

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Particulates

• Chemical composition may vary widely carbon,
  metals, acids, salts, organics
• Size distribution
• TSP Total Suspended Particulates
• PM10 Diameter ? 10 ?m
• PM2.5 Diameter ? 2.5 ?m
• Finer particles more likely to penetrate deep,
  more closely associated with adverse health
  effects

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Particulate air pollution and mortality the Six
Cities Study

• All-cause mortality by
• pollution levels
• RR ? 1.3 for most polluted vs least polluted city
• Excess was lung cancer and cardiopulmonary
  disease
• Unaffected by other variables

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Particulate air pollution and and acute health
effects

• Several 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

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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

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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
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Ozone
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Ozone Season in Atlanta
Unhealthful
Source M. Chang, Ph.D., Georgia Tech
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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
• CO Canal
• Large remote natural areas
• Yellowstone
• Tetons

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Parks, clean air, and healthWhat partnerships
are possible?

• Medical Society
• Lung Association
• Heart Association
• Thoracic Society
• Public Health Association
• Asthma patients

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Clean water
5.
Source Center for Watershed Protection
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Water quantity
Source Center for Watershed Protection
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Source Center for Watershed Protection
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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

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Source water protection is public health
protection. R. Jackson, CDC
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Clean waterWhich 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
• CO Canal
• Large remote natural areas
• Yellowstone
• Tetons

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Clean water, parks, and health What partnerships
are possible?

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

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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 ? ? ?
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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)

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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.

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Thank you!
Doc who likes parks
Dog who agrees