Complete streets promoting health equity in communities: Supporting transportation for all users
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* Julia Haskins

*Second in a series on health equity, which ties into the theme of APHA’s 2018 Annual Meeting and Expo: “Creating the Healthiest Nation: Health Equity Now.”*

Transportation says a lot about community equity. The options available for people to get around reflect a community’s values and how it supports its most vulnerable members. If driving is the primary — or only — means of transportation, people who are already disadvantaged suffer from a lack of mobility.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/48/6/1.3/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/48/6/1.3/F1)

Children and adults travel in a Baltimore neighborhood in April 2015. Advocates are working to pass a new, stronger complete streets ordinance that will address disparities and improve health equity in the city.

Photo by Mark Makela, courtesy Getty Images

A community that promotes health equity provides adequate modes of transportation for all users. Pedestrians, public transit riders, bicyclists and others can all get around safely and easily in such an environment. A “complete streets” approach ensures that such mobility conditions are met, making for more liveable communities.

Under the complete streets model, all forms of transportation are considered in street design and policy. People of all ages, abilities and income levels can get where they need to go when complete streets are implemented. Depending on the community, features of a complete streets project could include widened sidewalks, road shoulders or bicycle lanes.

“Improvements in the built environment for walking and biking reduce health disparities,” APHA member Emiko Atherton, MPA, director of the National Complete Streets Coalition at Smart Growth America, told *The Nation’s Health.*

Comprehensive street design measures, including complete streets, are among the Centers for Disease Control and Prevention’s recommendations for improving transportation policy. Complete streets also align with recommendations from the U.S. Community Preventive Services Task Force that call for built environment strategies to increase physical activity through improved bicycle and pedestrian transportation systems.

The implications for complete streets are far-reaching. When streets are easily navigable, people do not need to rely on cars as their only mode of transportation. That eases traffic, cuts emissions and, in turn, leads to a smaller carbon footprint.

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[Figure2](http://www.thenationshealth.org/content/48/6/1.3/F2)

Pedestrians walk through a park in New Orleans in April. The city is one of many communities around the nation with a complete streets policy. The city’s ordinance supports balancing the access, mobility, health and safety needs of all residents.

Photo by Mario Tama, courtesy Getty Images

“We need everyone to understand that transportation, and to a greater degree, the built environment, is serving as a conduit to…the environmental health and economic factors that we all struggle with,” Charles Brown, MPA, senior researcher at Rutgers University’s Alan M. Voorhees Transportation Center and adjunct professor at the Edward J. Bloustein School of Planning and Public Policy, told *The Nation’s Health.*

Brown is based in New Jersey, which is a leader in complete streets policies. The state has adopted more than 140 municipal and nearly 80 county policies in addition to an internal policy from the New Jersey Department of Transportation. The top-down support has been critical to passing complete streets policies in New Jersey, Brown said. He commended the state transportation department for its education efforts — including the creation of a guidance manual — which have inspired more county and local governments to consider their own complete streets policies.

The New Jersey Bicycle and Pedestrian Resource Center in 2017 released a series of complete streets case studies showcasing accomplishments throughout New Jersey. Cherry Hill Township, for example, retrofitted its suburban roadways to allow easier access for all users. In the Borough of Somerville, the Division Street pedestrian mall has revitalized the downtown retail landscape and also serves as a meeting space. In Passiac County, improvements to the Morris Canal Greenway are connecting districts downtown to trails.

New Jersey joins a host of communities nationwide that are embracing complete streets. The movement has been driven in recent years by advocates in fields ranging from environmental health to transportation. More than 1,140 agencies at the local, regional and state levels have adopted complete streets policies, with more than 1,200 policies in the U.S., according to Smart Growth America.

Missouri is one such state, with almost 40 policies in place. The push for complete streets has come from multiple levels of government as well as advocacy groups focused on pedestrian and bicycle safety, said Brent Hugh, executive director at the Missouri Bicycle and Pedestrian Federation.

Columbia was the first city in Missouri to adopt a complete streets policy in 2004, and the early investment has paid off. Policies have since spread throughout the state, thanks in large part to the Missouri Department of Health and Senior Services, Hugh said. The health department, PedNet Coalition, TrailNet and University of Missouri lead the Missouri Livable Streets project, which offers resources and support to communities investing in complete streets initiatives.

A riverfront trails project in Warsaw, Missouri, was named one of 2017’s best complete streets initiatives by Smart Growth America. The comprehensive trail network connects the city’s downtown to waterfront parks as well as historic sites and recreational facilities, providing opportunities for physical fitness.

“We’ve created a sense of pride here for the community,” city administrator and planner Randy Pogue said in the report highlighting top complete streets intiatives. “When people come here, they’re amazed with what we have.”

Indiana is another state with extensive complete streets policies. Similar to Missouri, the success of complete streets projects in Indiana can be attributed to the many public and private partners involved, said Kate Riordan, MUP, active living program manager at the Indianapolis-based Health by Design. The group has supported initiatives such as Indy Walk-Ways, which developed a pedestrian master plan for Indianapolis and Marion County that creates a long-term strategy for improvements in walkability in the area.

Riordan leads technical assistance workshops for communities that are interested in complete streets projects. It is critical that communities looking into complete streets have a strong foundation for their plans, going beyond simply installing a few bicycle racks in a neighborhood. Just as important as the physical attributes of a complete streets project is a framework that will ensure its longevity.

Smart Growth America has laid out 10 elements of a complete streets policy, which include a community’s vision for completing its streets, promoting street connectivity and creating performance standards that can be measured. One element, however, has eluded many communities — determining next steps to actually get policies implemented.

Getting a policy off the ground comes with a host of new challenges, particularly for historically disadvantaged communities. For example, many underserved communities cannot access the technical assistance needed to develop policies and move their projects forward. It can be a labor-intensive process, and must be tailored to each community.

Even if underserved communities do have access to technical assistance provided by organizations such as Health By Design, implementing complete streets may be far down the list of priorities, as Riordan has found. She noted that some of the communities where she holds workshops are struggling to access resources as fundamental as grocery stores. It is a problem that Brown has encountered in New Jersey as well.

“We’ve also come up against municipalities where they don’t see improvements to the built environment being their No. 1 priority because they’re dealing with other issues such as affordable housing, crime and other variables outside of the transportation network,” he said.

While it is understandable that communities with few resources could be hesitant to dive into a seemingly expensive and complex project, research from groups including Smart Growth America has found that complete streets initiatives are not often costly and do not necessarily require a total overhaul of street networks. In fact, comprehensive street design measures may save communities money in the long run.

Complete streets can also alleviate some of the public health crises overrepresented in marginalized communities, such as pedestrian and bicyclist deaths. There were nearly 6,000 pedestrian fatalities in 2017, according to the Governors Highway Safety Association. The organization also found that bicyclist deaths increased more than 12 percent in 2015 from the year before, marking the greatest percentage increase of any other group on the road that year. Such fatalities are indicative of the health disparities resulting from unsafe streets, as minorities, low-income people and seniors have higher rates of traffic-related deaths, research shows.

Lack of political will is another often-cited barrier to implementing complete streets, and is a challenge that Baltimore has been dealing with for years.

The city has had a complete streets resolution in place since 2010, but it is nonbinding. To bolster it, City Councilman Ryan Dorsey and advocacy group Bikemore have drafted a new complete streets resolution with an emphasis on health equity.

The new resolution would hold Baltimore decisionmakers accountable for implementing complete streets measures. It also seeks to address the structural racism inherent in Baltimore’s streets networks, demonstrated by disparities such as the high rate of minority residents who lack reliable transportation options and the siloing of communities of color.

Bikemore Executive Director Liz Cornish, MEd, said that she does not want just bicycling advocates to rally around complete streets. Instead, she wants complete streets to be recognized as a public health priority that affects people from all backgrounds and walks of life.

“If we start to frame the conversation as a public health issue, then I really do believe that you’re going to start to include more people in that advocacy environment,” Cornish told *The Nation’s Health.*

Discussions at APHA’s 2018 Annual Meeting and Expo in San Diego in November will focus on the built environment and health, including a lessons-from-the-experts session, 3102, on Monday, Nov. 12, and a walkable communities session, 5005, on Wednesday, Nov. 14.

For more information on complete streets policies, visit [www.smartgrowthamerica.org](http://www.smartgrowthamerica.org).

*APHA’s 2018 Annual Meeting and Expo will focus on “Creating the Healthiest Nation: Health Equity Now.” Registration is now open at* [www.apha.org/annualmeeting](http://www.apha.org/annualmeeting).

*   Copyright The Nation’s Health, American Public Health Association