Ensuring Equity in Transportation and Land Use Decisions to Promote Health and Well-Being in Metropolitan Areas

  • Date: Oct 26 2021
  • Policy Number: 202116

Key Words: Transportation, Urban Health, Health Equity, Health Disparities, Racism

Abstract
As social determinants of health, land use design and transportation systems, and the decisions that lead to them, play a significant role in shaping community health. However, “historically excluded” groups — including Black, indigenous, and other people of color; lower-income individuals; immigrants; older adults; people with disabilities; women; and LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, and asexual) individuals — have been marginalized from as well as harmed by decision making in these areas. This policy statement has a particular focus on addressing racial equity in land use and transportation decisions in metropolitan areas (taking into account urban centers and their suburbs); although the recommendations may also benefit other historically excluded groups, the specific needs of each of these groups are deserving of examination in additional policy statements. Equity is examined in the context of five key health impact areas: (1) access to health-promoting resources, (2) social cohesion and mental health, (3) traffic safety, (4) physical activity, and (5) environmental exposures and climate. Cross-cutting evidence-based strategies are proposed with an overarching focus on centering equity in all decision making; these strategies are predicated on an acknowledgment of the history of structural racism in transportation and land use (e.g., redlining), authentic community engagement, and engagement in processes ensuring that decision makers reflect the people and needs of the communities they serve. To operationalize the recommended strategies that provide long-term co-benefits for health, it is essential to center and prioritize a past-present-future health equity and racial lens in built environment planning, decision making, and actions.

Relationship to Existing APHA Policy Statements
The following APHA policy statements support this statement by addressing and advocating on a range of issues and topics related to equity, environment and climate change, transportation, and community engagement. However, none of these policies holistically address transportation and land use decision making as it relates to health equity in metropolitan areas.

  • APHA Policy Statement 20197: Addressing Environmental Justice to Achieve Health Equity 
  • APHA Policy Statement 20196: Addressing the Impacts of Climate Change on Mental Health and Well-Being 
  • APHA Policy Statement 20189: Achieving Health Equity in the United States
  • APHA Policy Statement 20183: The Public Health Impact of Energy Policy in the United States
  • APHA Policy Statement 201711: Public Health Opportunities to Address the Health Effects of Air Pollution
  • APHA Policy Statement 201710: Protecting Children’s Environmental Health: A Comprehensive Framework
  • APHA Policy Statement 20172: Supporting the Updated National Physical Activity Plan
  • APHA Policy Statement 20166: Opportunities for Health Collaboration: Leveraging Community Development Investments to Improve Health in Low-Income Neighborhoods
  • APHA Policy Statement 20157: Public Health Opportunities to Address the Health Effects of Climate Change
  • APHA Policy Statement 20137: Improving Health and Wellness through Access to Nature
  • APHA Policy Statement 20135: Environmental Noise Pollution Control
  • APHA Policy Statement 201210: Promoting Health Impact Assessment to Achieve Health in All Policies
  • APHA Policy Statement 20091: Support for Community Health Workers to Increase Health Access and to Reduce Health Inequities
  • APHA Policy Statement 200712: Toward a Healthy Sustainable Food System
  • APHA Policy Statement 20079: Building a Public Health Infrastructure for Physical Activity Promotion

Problem Statement
Need to address historical inequities in transportation and land use decision making in the context of metropolitan areas: Land use, transportation systems, and related infrastructure shape community access to resources, influence exposure to pollutants, and constrain or facilitate healthy behaviors. Related decisions can therefore strongly promote or detract from health and well-being, affecting equitable access to critical resources including health care, housing, employment, quality education, parks and recreation, and goods and services (e.g., grocery stores) necessary to live a complete and healthy life.[1] Inequities resulting from decisions related to social determinants of health have especially adverse effects on the health of historically excluded groups. In particular, structural racism is a significant feature of U.S. history, acting both implicitly and explicitly through discriminatory policies including segregation, highway planning, and redlining[2] that still negatively affect communities today, such as a historical lack of home ownership opportunities for people of color—especially Black Americans—resulting in a persistent racial wealth gap.[2,3] While these impacts are felt across the nation, given that more than 83% of the U.S. population lives in urban areas, the adverse effects of such inequities deserve specific examination in the context of metropolitan areas (urban cores and suburbs).[4] Groups have been excluded from decision-making processes through inadequate or tokenizing community engagement.[5] To improve health for all, it is critical to consider the needs of those most affected when decisions are made[6] and, even more important, to include decision makers who reflect the racial and social makeup of the communities they serve. For example, the historical dominance of men in urban planning (a profession that is also overwhelmingly White)[7] has produced physical urban characteristics that privilege the life and travel patterns of men.[8,9] Diversifying planning staff and leaders will support the creation of land use and transportation systems that better reflect the needs of their communities.[10] 

Access to health-promoting resources: Health-promoting resources include not only health care facilities but also other foundational social determinants of health such as quality education, employment, parks, and grocery stores. Community access to these resources has often been determined through planning and zoning decisions that predominantly — and inequitably — distribute resources in better-resourced, Whiter communities[11]; exclusionary zoning practices and lack of affordable housing prevent many from living in such neighborhoods.[2] In fact, metropolitan areas are more racially segregated now than 30 years ago.[12] Access to health-promoting resources is influenced by decisions related not only to land use but also to transportation, including structure and quality of transportation systems as well as an individual’s ability to pay for different options (e.g., private car or public transit).[13] Decentralized and segregated development patterns have led to increased distances between residences, employment, schools, and other essential destinations. In a phenomenon labeled spatial mismatch, historically excluded residents have difficulty accessing employment in decentralized metropolitan areas owing to the difficulty and cost of commutes.[14] Other research reframes this problem as a modal mismatch in accessing employment opportunities due to lack of access to a private vehicle.[15] Low-income women are particularly disadvantaged by lack of access to vehicles, as they are more likely to commute over long distances, often outside of peak transit hours, and have household responsibilities that require flexible scheduling and multiple stops.[8,16] Overall, people who depend on transit are more likely to be lower income, people of color, elderly, and people with disabilities.[17] The transportation needs of transit-dependent riders (sometimes called “captive riders”) are often neglected because transit agencies direct their resources to attract “choice” riders to boost ridership numbers and revenues.[17,18] The result has been an overall imbalanced transportation network that poorly serves lower-income individuals.

Today, more people live in poverty in suburban areas than in the urban core.[19] This “suburbanization” of poverty brings about a new set of health equity issues. As urban centers grow, disadvantaged “inner-city” residents are displaced to areas with fewer health-promoting land uses, resources, and transportation options. This trend exacerbates the experiences of households living in poverty, who already spend more of their time and income on transportation and have disproportionately lower rates of private vehicle ownership.[20] Emerging technologies may provide new options, but some populations may not have equal access to these options due to racial discrimination or barriers to using mobile technology.[21,22] 

Social cohesion and mental health: Social cohesion refers to the strength of relationships and sense of solidarity among members of a community, both of which are important for physical and psychosocial health.[23] Rates of social cohesion can predict mortality rates and other health outcomes, and neighborhoods with low social cohesion may have higher rates of depression and smoking and lower rates of walking.[24] Social ties are often a protective factor in health, although the effect can vary.[25] Social cohesion is environmentally mediated, and social networks are in part shaped by place.[26]
Transportation networks can impact mental health and social cohesion by affecting access to mobility and human interactions. By design, some streets can become barriers to access; for example, a lack of sidewalks or crosswalks can physically prevent community members from coming together.[27] In addition, race and gender affect individual experiences in public spaces, with Black and Latino individuals as well as women experiencing higher degrees of fear of policing, crime, and harassment.[9,21,28] 

Historically, highways, airports, truck routes, and other major transportation projects have often been built through or adjacent to low-income communities and communities of color, truncating neighborhoods and displacing residents.[29] Displacement of communities of color related to transit investments continues today, creating an unfortunate tension between a positive community feature (transit) and a negative impact for residents. In particular, the destruction of thriving Black neighborhoods in the name of redevelopment, whether for transportation or housing, has made lack of social cohesion a racial issue.[29] Poor air quality, high traffic volumes, and noise pollution can make it unpleasant or dangerous to be outside, reducing organic opportunities for creating and reinforcing social ties.[21]

In addition to transportation, land use significantly impacts social cohesion and equity. Interactions between land use and transportation influence access to jobs and services, which, outside residential areas, provide most opportunities for people to interact with one another. Access to green space, which tends to be lower in low-income neighborhoods and communities of color, is associated with social cohesion and strongly linked to several health outcomes.[30] The racial segregation created by land use policies damages social cohesion both within and across communities and, once in place, is very difficult to undo.[31] Beyond segregation, housing location is a key factor influencing family stability and also generally determines the schools children attend and the public services available, all of which shape the social fabric and long-term health outcomes.[2] Finally, community design, from buildings to street widths and walking environments, influences social connectivity.[32] Where people organically cross paths outside of cars, and where a variety of uses encourage diverse people to interact with each other, crime rates are lower and social cohesion is higher.[32]

Traffic safety: More than 36,000 Americans were killed in traffic crashes in 2018, and about 4.5 million were seriously injured; in addition, urban fatalities per 100 million vehicle miles traveled (VMT) have increased by 18% since 2009.[33] Urban sprawl is a risk factor for fatal traffic crashes, likely as a result of higher speeds on suburban streets.[34] The hierarchical or dendritic street networks often found in suburban areas are associated with higher crash rates than traditional street grids with higher intersection densities.[35] While overall rates of death from traffic crashes decreased in 2018, pedestrian and bicyclist deaths increased to the highest they had been since 1990, representing 20% of traffic fatalities.[33] 

An analysis of fatal pedestrian crash hot spots showed that nearly all were on multi-lane roadways, with 70% requiring pedestrians to cross five or more lanes of traffic.[36] Also, the number of pedestrians killed in crashes involving large trucks increased by 13%.[33] Census tracts with higher concentrations of low-income and Black, indigenous, and people of color (BIPOC) populations have higher levels of vehicle traffic and high-speed arterials.[37] Furthermore, individuals who rely on walking for transportation are disproportionately people of color and low income, even though low-income communities are significantly less likely to have sidewalks and other infrastructure to support safer, slower speeds. This results in crash rates in lower-income communities being much higher than in higher-income areas. BIPOC are also disproportionately represented in traffic injuries and fatalities, and American Indians/Alaska Natives have the highest traffic fatality rate of all racial and ethnic groups.[27,33,37]

Physical activity: Regular physical activity has benefits across the life span, yet 80% of adults in the United States do not get recommended amounts of physical activity, putting them at risk of physical and mental health problems such as high blood pressure, weight gain, and depression.[38] Disparities in physical inactivity exist across racial and ethnic groups, geographic locations, and socioeconomic status levels.[39] The existence of these disparities can be traced largely to decisions made by federal, state, and local governments, including transportation and land use planners, that result in inequitable access to health-supporting community environments and economic opportunities.[27] For instance, physical activity is lower in less “connected” communities that do not provide safe and reliable access to public transportation or other forms of active transportation such as biking and walking (i.e., “obesogenic” environments); in contrast, areas where there are connected street networks with fewer lanes on arterial roads are associated with reduced rates of obesity, diabetes, high blood pressure, and heart disease.[13] Personal security concerns can affect the perceived safety of the environment and may limit opportunities for physical activity as part of daily life,[9] and personal safety issues and discrimination factor into all transportation modes, from walking down the street to choosing to isolate in a personal vehicle. Finally, land use policies also have direct implications for the physical activity options available to children, with the proximity of safe outdoor play spaces close to home being particularly important; physical activity levels are higher among children living in neighborhoods with a higher density of and variety of nonresidential land uses.[40]

Environmental exposures and climate: Environmental exposures related to land use and transportation planning include air pollution, noise, temperature, and green space.[35] Rising air pollution levels from stationary and mobile sources have been linked to poor health outcomes such as cardiovascular and respiratory diseases (e.g., asthma), certain types of cancer, and adverse birth outcomes and childhood development.[41,42] Other hazards, including harmful environmental pollutants and noise pollution, also have substantial adverse effects. Government-backed segregation through housing and other land use policies has produced racial inequities leading to disproportionate exposures to environmental hazards among historically excluded groups. For example, formerly redlined neighborhoods are hotter than non-redlined areas,[43] and low-income neighborhoods and communities of color are more likely to face exposure to environmental pollutants and hazardous waste, an outcome facilitated by a complex system of weak, inadequately enforced environmental laws and regulations.[43,44] 

Climate change is one of the largest threats globally, and older adults, children, low-income communities, and communities of color are disproportionately affected by related health impacts.[45] In 2018, the U.S. transportation sector accounted for 28.2% of total national greenhouse gas (GHG) emissions, with the majority coming from passenger cars, sport utility vehicles, pickup trucks, and minivans.[41] Urban sprawl has increased travel distances to jobs and critical services, increasing VMT and GHG as well as commute times and negatively affecting physical, emotional, and social health. These long distances also increase transit riders’ exposure to extreme weather conditions.[1] Vast areas of paved surfaces, such as surface parking lots, can hinder natural stormwater management and contribute to regular flooding, particularly in lower-income areas.[46] Chronic flooding incurs significant individual- and community-level remediation costs and leads to many negative health outcomes including injury, carbon monoxide poisoning, psychological distress, and respiratory illness.[46]

Evidence-Based Strategies to Address the Problem
Many of the strategies presented here are cross cutting and address multiple health impact areas, illustrating how one intervention can have multiple co-benefits for health. These strategies are grounded first on a review of two key resources: (1) the County Health Rankings & Roadmaps[47] and (2) the Community Guide, with strategies from the Community Preventive Services Task Force.[32] These resources have been further examined in the context of additional supporting literature and with specific adaptations and emphasis to focus on centering equity in transportation and land use decisions. Because evidence hierarchy standards and systematic reviews privilege internal validity over external validity, it becomes even more necessary to engage with community members to understand local conditions, needs, and hopes for the community.[48,49] This is particularly true when working with historically excluded groups wherein “off-the-shelf” planning interventions may be less likely to be effective. Importantly, depending on how the strategies are implemented, their impact could either increase health equity or increase health disparities, so it is important to adequately anticipate and prevent unintended consequences.

Centering equity in all decision making: Equity cannot be viewed as a side effort; it must be integrated throughout the entire life cycle of any decision-making process, from preparatory and planning stages to implementation and evaluation. Racial equity tools, such as the toolkit proposed by the Government Alliance on Race and Equity, can help decision makers explicitly consider racial equity in policies, practices, programs, and budgets.[50] All phases must also include a focus on authentic community engagement, with many scientifically supported policies and programs recommending that community members serve as collaborators to guide interventions.[47] While transportation and land use decisions do not start from scratch (built environment interventions often inherently have a strong equity component aimed toward increasing access), situationally this strategy can be difficult to implement.[32,47] Well-intended interventions, such as transit-oriented development, streetscape improvements, and better green space access, can result in adverse health outcomes if equity and engagement are not centered in the process.[51–53]

Implementing complete neighborhoods through an equity and health in all policies approach:  Transportation and land use policies can effectively encourage active transportation. The Community Guide recommends combining “one or more interventions to improve pedestrian or bicycle transportation systems with one or more land use and environmental design interventions” to promote community-wide physical activity.[32] Neighborhood-scale design features that improve physical activity include higher residential densities, interconnected street networks, diverse land uses, and access to transit. In addition, having good regional access to destinations can reduce VMT and GHG.[32,47,54] Researchers often call such neighborhood design features the 5 “Ds” (density, diversity, design, destination accessibility, and distance to transit).[54] In practice, neighborhoods with these features are often described as complete, walkable, traditional, compact, or 20-minute neighborhoods.[32,47] Decision makers need to consider diverse approaches and strategies, along with potential impacts, in order to best promote walking and walkability, as well as mobility, for people of all backgrounds, abilities, and incomes.[47]

Designing multimodal streets in ways that prioritize health for historically excluded communities: Municipalities should look to “The Three As of Equity” to advance more equitable outcomes in pedestrian planning: acknowledgment of transportation inequities, accountability to equity measures, and application of interventions (implementation).[55] A starting point can be focusing on policies determining street network connectivity and adopting the Complete Streets approach, which prescribes that streets be designed and operated to support safe mobility for all users while also balancing the needs of different transport modes and supporting local land uses, economies, cultures, and natural environments.[32,47,56] Such policies and plans have been shown to reduce vehicle speeds, increase active transportation, increase physical activity,[32] and reduce VMT and therefore GHG.[47] Specific interventions to improve safety and access include dedicated paths, protected bicycle lanes, smart intersection designs, traffic calming measures, and dedicated street lighting.[32,47,50] 

Using the “Vision Zero”/Safe Systems Approach: Vision Zero uses a comprehensive set of design and policy tools to take action for improving the safety of the entire transportation system by targeting zero traffic-related deaths or serious injuries.[56] The related Safe Systems Approach has been preferred more recently, as it recognizes that humans are not perfect and therefore roadway systems should be designed such that human mistakes do not have fatal consequences. Both approaches ignore more traditional cost-benefit models of road safety and instead place human health and life first, encouraging greater use of safer, active modes of travel such as public transport, walking, and cycling.[57] 

Supporting transit-oriented cities: Because most people walk to bus stops or transit stations, transit is a recommended strategy for increasing physical activity.[32,47] Transit is also a climate change mitigation strategy, as a typical public transit trip emits 55% fewer GHG emissions than driving or ride hailing.[58] Designing cities to be transit oriented rather than auto-centric increases transit’s feasibility while making efficient use of limited transportation right of way.[17] Efforts to create walkable neighborhoods help residents connect actively to transit and access essential destinations in other parts of the city. Designing transit systems to serve additional trip types beyond “9 to 5” central city commutes (e.g., for shopping, health care, retail destinations) will better serve historically excluded groups. Recommended changes for serving all types of trips include better suburb-to-suburb transit routes, increases in the frequency of transit, and extension of service hours.[17,18] The structure of transit fares should also be examined with respect to equity impacts because low-income transit riders travel differently than higher-income riders.[17] 

Providing transportation demand management programs and incentives: Transportation demand management aims to maximize the efficiency of urban transport systems through a wide range of measures. For example, active travel to school programs, such as Safe Routes to School and walking school buses, help shift trips from cars or buses to walking and bicycling, increasing physical activity while reducing vehicle traffic and improving traffic safety around schools.[32,47] Multicomponent workplace programs (e.g., bicycle parking, employer-based incentive programs for biking and public transportation) have also been shown to increase physical activity[47] and reduce VMT and GHG.[59] In addition to incentivizing active transportation, road user pricing strategies can cut traffic volumes and may reduce VMT and GHG, particularly for those living near highways.[47] However, these types of policies can also have disproportionately negative impacts on workers who rely on private vehicles as a primary form of transport for reasons such as lack of adequate access to safe, reliable, and timely public transportation. 

Prioritizing green infrastructure: Increasing access to green space improves health outcomes by reducing harm from environmental stressors, restoring capacities (e.g., stress recovery), and building capacities (e.g., facilitating physical activity and social cohesion).[60] Parks specifically can facilitate an increase in physical activity.[47] They can also buffer the effects of traffic noise, reducing the psychological effects of the stress response to noise.[60] Trees and green infrastructure can mitigate against the increased heat island effect and rainfall resulting from climate change.[45] Systems designed to manage rainwater (e.g., stormwater best management practices, green infrastructure, sustainable drainage systems) minimize the risk of flooding and sewage overflows to water bodies,[61] and a methodological environmental justice framework can be used to address the health and community impacts associated with flooding while managing risks within the environmental justice community.[62]

Opposing Arguments/Evidence
Embedding equity in transportation and land use decision making directly confronts the notion that equity has not been adequately considered and addressed in the past. One broad opposing argument against this confrontation is that current conditions are acceptable and justifiable, and inequities with regard to transportation and land use are a result of individual behaviors, responsibilities, and choices alone rather than stemming from system-level influences. However, as also highlighted in APHA Policy Statement 20197 on environmental justice,[63] government actions (e.g., redlining) and inaction (e.g., lack of violation enforcement) have created disproportionate inequities in already-vulnerable communities, justifying the need to step in to provide adequate and just responses. 

A second area of opposing arguments relates to criticisms of community engagement processes, with the assertion that community members may be overburdened by too many engagement requests and that authentic engagement processes add resource burdens. However, many of the largest built environment inequities stem from inadequate engagement. The problem is more often a lack of adequate engagement and true community ownership of decision making, and ultimately buy-in, rather than an overburden of engagement.[6] The challenge for planning and transportation staff and elected officials is to find more creative engagement strategies and meet people where they are, using careful planning and consultation where necessary to avoid overburdening community members, such as by incorporating new engagement processes into existing activities and community structures that fit their time and resource availability.

Another related argument is that actions toward a healthy community can unintentionally exacerbate problems through gentrification and de facto segregation as transportation and land use improvements increase the attractiveness of an area and create involuntary displacement. However, authentic engagement efforts can prevent some of these issues, and others can be addressed through actions and policies that help keep long-standing residents in their homes via legal protections and prevention of overinflated rental prices.[32,47] While resources (time, money, human capital) are certainly necessary and this can often be complex work, prioritizing strategies and actions aimed at ensuring equity in land use and transportation decisions ultimately benefits entire communities in terms of both health outcomes and spending.

Action Steps
To achieve the goals of the evidence-based strategies described here, APHA offers the following recommendations:

1. At all levels, from planners to artists and public servants, and institutionally from governments and academics to nonprofits and private companies, centering a past-present-future health equity and racial lens in built environment planning and decision making must be a priority.

  • Community residents and other stakeholders, including the nongovernmental organizations serving these residents, must be authentically engaged in transportation and land use policy and planning through participatory co-creation processes that are nonperformative and need driven. These engagement processes should extend through the entire cycle of planning, implementation, and evaluation, leading toward greater scientific legitimacy and public accountability in decisions.
  • At state and local levels, project plans and budgets should include sufficient time and money for adequate and authentic engagement to take place.
  • At all levels of government, transportation and planning agencies should diversify their staff to include people from historically excluded groups, such as BIPOC, women, and LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, and asexual) individuals, who reflect the identities of their communities.
  • Data analysis and collection in neighborhood and transportation planning and design must include and benefit historically excluded communities. Public health officials and agencies should work with transportation and city planners to identify and continuously monitor health indicators and performance measures to evaluate how policies and decisions influence health.
  • Planning and public health practitioners should engage with each other to ensure that planning, health, and equity goals are aligned in their work. One avenue for collaboration is sharing data to understand health disparities. Community health workers, who engage with community members to improve health, may also serve as engagement partners.

2. At all levels of government, fair land use policies and actions must be pursued to ensure equitable and safe access to public and private spaces that promote health and opportunity.

  • All levels of governments should officially recognize the impact of and take actions to address the history of redlining and persistent racial wealth gaps, such as expanding access to wealth-building creators (e.g., homeownership and business ownership) and dedicating specific funds to improve infrastructure and resources in areas most affected by redlining. 
  • The federal government should establish funding to help states better connect residents who have been segregated and cut off from resources by highways, as well as seek to establish community land trusts.
  • Local governments should pursue policies and decisions that seek to advance racial equity in land use and promote inclusive access to public space, including removing symbols of racism.
  • Local and state governments should protect streets and public spaces as safe places for peaceful protest and public gathering, implementing policies and measures that protect historically excluded groups, especially BIPOC community members, from unnecessary violence.
  • State and local governments should design spaces and streets for all ages and abilities that meet or exceed the standards of the American Disabilities Act. 
  • At all levels of government, principles of gender mainstreaming should be used to ensure that plans, projects, and ultimately built environments are designed to meet the needs of women, older adults, and other historically excluded groups. 

3. At all levels of government, land use and transportation agencies should coordinate on policies and actions to create neighborhoods that promote health equity.

  • Land use and transportation agencies and partners at all levels of government should work to expand linkages and options with respect to housing, employment hubs, health care facilities, healthy food retailers, and schools, particularly in low-income and BIPOC communities. 
  • Local governments should implement transit-oriented development planning and design policies and strategies to promote urban development that is compact, mixed use, pedestrian and bicycle friendly, and closely integrated with public transportation.
  • Local governments should prioritize funding and space for green infrastructure to support health and promote equity, including green spaces, particularly in areas historically lacking this infrastructure.
4. At all levels of government, planning, design, and implementation of policies, plans, and programs should prioritize making roadways safe for all users.
  • At all levels of government, the Safe Systems Approach should guide transportation planning and design. Specific actions consistent with this approach include reducing speed limits, designing roadways to meet posted speeds (rather than operating speeds), and implementing traffic calming interventions.
  • State and local governments should plan and design streets to be used by all modes of transportation. Supportive actions include Complete Streets policies, pedestrian-first policies, context-based street typologies, and right sizing of roadways.
  • Federal, state, and local funding budgets should allocate a greater share of funds to expanding and investing in safe facilities for active transportation (including transit operating funds).
  • Federal and state transportation agencies should promote safer, multimodal streets by reforming their adopted design guidance. At the federal level, this effort could focus on the Policy on Geometric Design of Highways and Streets (the “Green Book”) and the Manual on Uniform Traffic Control Devices (these guidelines often also inform state agency efforts).
  • Racial inequity and injustice in traffic safety must be studied to ensure that traffic fees and fines, enforcement, and other initiatives do not exacerbate or create new inequities.
  • Community design must focus on place and not just infrastructure, meaning that building places with and for the needs of all community members should be at the forefront, using context-sensitive design principles along with community input.
  • Transportation funding should require evaluation of transportation investments toward community goals and dedicate funding for data management and project evaluation.

5. Transportation policies and subsequent implementation at all levels of government must prioritize reducing the transportation sector’s contributions to air pollution and global climate change.

  • Environmental justice goals to reduce disparate exposures to harmful emissions should be honored and advanced in transportation and land use activities.
  • Planners should prioritize reducing adverse health impacts of freight transport and movement of goods on low-income, historically excluded communities and workers.
  • The Department of Transportation should partner with the Environmental Protection Agency to require states, metropolitan planning organizations, and localities to set and track performance targets for GHG and other harmful emissions.
  • Local governments should eliminate the use of level-of-service standards for assessing traffic impact, which favor auto-centric infrastructure investment and discourage infill development, and instead explore development standards such as VMT to reduce GHG emissions. 
  • All levels of government should promote electric bicycles and the electrification of private vehicles and transit as well as clean electricity generation. State departments of transportation and cities can provide charging stations, and local transportation agencies can provide infrastructure that favors electric vehicles. 
  • At the federal level, more funding must be allocated for transit. Local-level planners must advocate for infrastructure that supports transit use, such as better transit stops and priority bus lanes. Transit agencies should implement services and schedules that better serve the needs of shift workers (e.g., decentering peak transit service to downtowns and extending evening and weekend hours). 

References
1. Frank LD, Iroz-Elardo N, MacLeod K, Hong A. Pathways from built environment to health: a conceptual framework linking behavior and exposure-based impacts. J Transport Health. 2019;12:319–335. 
2. Hilovsky K, Lim K, Willian TT. Creating the healthiest nation: health and housing equity. Available at: https://www.apha.org/-/media/files/pdf/topics/equity/health_and_housing_equity.ashx. Accessed August 6, 2021.
3. Shapiro T, Meschede T, Osoro S. The Roots of the Widening Racial Wealth Gap: Explaining the Black-White Economic Divide. Waltham, MA: Braindeis University; 2013.
4. Center for Sustainable Systems, University of Michigan. U.S. cities factsheet. Available at: https://css.umich.edu/factsheets/us-cities-factsheet. Accessed August 6, 2021.
5. Arnstein SR. A ladder of citizen participation. J Am Plann Assoc. 2019;85:24–34. 
6. Policylink. Regional planning for health equity. Available at: https://www.policylink.org/sites/default/files/Regional-Planning-for-Health-Equity_FINAL.pdf. Accessed August 6, 2021.
7. U.S. Census Bureau. American Community Survey, 2021. Available at: https://www.census.gov/programs-surveys/acs. Accessed August 6, 2021.
8. Wachs M. Men, women, and wheels: the historical basis of sex differences in travel patterns. Transport Res Rec. 1987;1135:10–16.
9. Sethi S, Velez-Duque J. Walk with Women: Gendered Perceptions of Safety in Urban Spaces. Boston: Leading Cities; 2021.
10. Thomas JM. The minority-race planner in the quest for a just city. Plann Theory. 2008;7:227–247.
11. Arnold CA. Fair and Healthy Land Use: Environmental Justice and Planning. Chicago: American Planning Association; 2007.
12. Menendian S, Gailes A, Gambhir S. The Roots of Structural Racism Project: Twenty-First Century Racial Residential Segregation in the United States. Berkeley: Othering & Belonging Institute, University of California; 2021.
13. Marshall WE, Piatkowski PE, Garrick NW. Community design, street networks, and public health. J Transport Health. 2014;1:326–340. 
14. Kain JF. Housing segregation, Negro employment, and metropolitan decentralization. Q J Econ. 1968;82:175–197. 
15. Fan Y. The planners’ war against spatial mismatch: lessons learned and ways forward. J Plann Literature. 2012;27:153–169. 
16. Blumenberg E, Pierce. Multimodal travel and the poor: evidence from the 2009 National Household Travel Survey. Transport Lett. 2014;6:36–45. 
17. Lubitow A, Rainer J, Bassett S. Exclusion and vulnerability on public transit: experiences of transit dependent riders in Portland, Oregon. Mobilities. 2017;12:924–937. 
18. Higashide S. Who’s on Board 2016: What Today’s Riders Teach Us About Transit That Works. New York: TransitCenter; 2016.
19. Allard SW. Places in Need: The Changing Geography of Poverty. New York: Russell Sage Foundation; 2017. 
20. FHWA National Household Travel Survey. Sterling, VA: U.S. Federal Highway Administration; 2014.
21. Ge Y, Knittle C, MacKenzie D, Zoepf S. Racial and Gender Discrimination in Transportation Network Companies. Cambridge, MA: National Bureau of Economic Research; 2016. 
22. Dillahunt T, Kameswaran V, Li L, Rosenblat T. Uncovering the Values and Constraints of Real-Time Ridesharing for Low-Resource Populations. Denver, CO: CHI Conference on Human Factors in Computing Systems; 2017. 
23. Thoits PA. Mechanisms linking social ties and support to physical and mental health. J Health Soc Behav. 2011;52:145–161. 
24. Echeverría S. Associations of neighborhood problems and neighborhood social cohesion with mental health and health behaviors: the Multi-Ethnic Study of Atherosclerosis. Health Place. 2008;14:853–865. 
25. Granovetter M. The strength of weak ties: a network theory revisited. Sociol Theory. 1983;1:201–233. 
26. Berkman LF, Clark C. Neighborhoods and Networks: The Construction of Safe Places and Bridges. Oxford, England: Oxford University Press; 2003. 
27. National Complete Streets Coalition, Smart Growth America. Dangerous by design 2021. Available at: https://smartgrowthamerica.org/dangerous-by-design/. Accessed August 6, 2021.
28. Pollard TM, Wagnild JM. Gender differences in walking (for leisure, transport and in total) across adult life: a systematic review. BMC Health. 2017;17:341. 
29. Chapple K, Loukaitou-Sideris A. Transit-Oriented Displacement or Community Dividends? Understanding the Effects of Smarter Growth on Communities. Cambridge, MA: MIT Press; 2019. 
30. Rigolan A. A complex landscape of inequity in access to urban parks: A literature review. Landscape Urban Plann. 2016;153:160–169. 
31. Geronimus AT, Thompson JP. To denigrate, ignore, or disrupt: racial inequality in health and the impact of a policy-induced breakdown of African American communities. Soc Sci Res Race. 2004 [Epub ahead of print]. 
32. Community Preventive Services Task Force. The community guide. Available at: https://www.thecommunityguide.org/findings/physical-activity-built-environment-approaches. Accessed August 6, 2021.
33. Fatal Motor Vehicle Crashes: Overview. Washington, DC: National Highway Traffic Safety Administration; 2019.
34. Ewing R, Hamidi S, Grace J. Urban sprawl as a risk factor in motor vehicle crashes. Urban Stud. 2016;53:247–266. 
35. Mueller N. Urban and transport related exposures and mortality: a health impact assessment for cities. Environ Health Perspect. 2017;125:89–96. 
36. Scheider RJ, Sanders R, Proulx F, Moayyed H. United States fatal pedestrian crash hot spot locations and characteristics. J Transport Land Use. 2021;14:1–23.
37. An Analysis of Traffic Fatalities by Race and Ethnicity. Washington, DC: Governors Highway Safety Association; 2021.
38. Physical Activity Guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services; 2018.
39. Wang Y, Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev. 2007;29:6–28.
40. Sallis JF, Floyd MF, Rodríguez DA, Saelens BE. Role of built environments in physical activity, obesity, and cardiovascular disease. Circulation. 2012;125:729–737. 
41. Our Nation’s Air 2020. Washington, DC: U.S. Environmental Protection Agency; 2020.
42. Clay K, Muller NZ. Recent Increases in Air Pollution: Evidence and Implications for Mortality. Washington, DC: National Bureau of Economic Research; 2019.
43. Hoffman J, Shandas V, Pendelton N. The effects of historical housing policies on resident exposure to intra-urban heat: a study of 108 US urban areas. Climate. 2020;8:12. 
44. Countering the Production of Inequities to Achieve an Equitable Culture of Health: Extended Summary. Washington, DC: Prevention Institute; 2016.
45. U.S. Global Change Research Program. Impacts, Risks, and Adaptation in the United States: Fourth National Climate Assessment, Volume II. Washington, DC: U.S. Government Publishing Office; 2018.
46. Sampson NR. “We’re just sitting ducks”: recurrent household flooding as an underreported environmental health threat in Detroit’s changing climate. Int J Environ Res Public Health. 2019;16:1. 
47. County Health Rankings and Roadmaps. Strategies 2020. Available at: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/strategies. Accessed August 6, 2021.
48. Green LW, Glasgow RE. Evaluating the relevance, generalization, and applicability of research: issues in external validation and translation methodology. Eval Health Professions. 2006;29:126–153.
49. Welch VA, Petticrew M, O’Neill J, et al. Health equity: evidence synthesis and knowledge translation methods. Syst Rev. 2013;2:43. 
50. Nelson J, Brooks L. Racial Equity Toolkit: An Opportunity to Operationalize Equity. Richmond, CA: Government Alliance on Race and Equity; 2015.
51. Mehdipanah R, Manzano A, Borrell C, et al. Exploring complex causal pathways between urban renewal, health and health inequality using a theory-driven realist approach. Soc Sci Med. 2015;124:266–274. 
52. Cole H, Lamarca MG, Connolly J, Anguelovski I. Are green cities healthy and equitable? Unpacking the relationship between health, green space and gentrification. Epidemiol Community Health. 2017;71:11. 
53. Padeiro M, Louro A, Marques de Costa N. Transit-oriented development and gentrification: a systematic review. Transport Rev. 2019;29:733–754. 
54. Ewing R, Cervero R. Travel and the built environment: a meta-analysis. J Am Plann Assoc. 2010;76:264–294. 
55. Berg A, Newmark GL. Incorporating equity into pedestrian master plans. Transport Res Rec. 2020;2674:764–780. 
56. Hanzlik M. The State of Transportation and Health Equity. Washington, DC: Smart Growth America; 2019.
57. Moving Beyond Zero. Vision Zero and the safe systems approach. Available at: https://movingbeyondzero.com/the-safe-systems-approach/. Accessed August 6, 2021.
58. National Academies of Sciences, Engineering, and Medicine. An Update on Public Transportation’s Impacts on Greenhouse Gas Emissions. Washington, DC: National Academies Press; 2021.
59. Boarnet MG, Hsu HP, Handy S. Impacts of Employer-Based Trip Reduction Programs and Vanpools on Passenger Vehicle Use and Greenhouse Gas Emissions. Sacramento, CA: California Environmental Protection Agency Air Resources Board; 2014.
60. Markevych I. Exploring pathways linking greenspace to health: theoretical and methodological guidance. Environ Res. 2017;158:301–317.
61. Venkataramanana V, Packman A, Peters DR, et al. A systematic review of the human health and social well-being outcomes of green infrastructure for stormwater and flood management. J Environ Manage. 2019;246:868–880. 
62. Meenar M, Fromuth R, Soro M. Planning for watershed-wide flood-mitigation and stormwater management using an environmental justice framework. Environ Pract. 2018;20:55–67.
63. American Public Health Association. Addressing environmental justice to achieve health equity. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2020/01/14/addressing-environmental-justice-to-achieve-health-equity. Accessed August 6, 2021.