As a community pediatrician, I have had the privilege to provide high-quality care to low-income and vulnerable populations. Despite the administration of vaccines, medical treatments and screenings, many of my patients continued to suffer high levels of chronic disease and often could not comply with prescribed treatments. Inadequate housing, failing schools, lack of access to affordable and healthy foods in addition to inaccessibility to transportation collectively created a milieu that challenged their ability to be healthy.
Maslow’s Hierarchy of Needs illuminates the idea that the most basic levels of need (safety, shelter and food) must be met before an individual can reach his or her full potential. A prescription alone does not have the breadth of power to supply these needs nor deter the impact of lack of access and resources. In order to truly improve health outcomes and tackle health inequity, upstream interventions and cross-sector engagement are critical.
Growing income inequality and poverty is plaguing many communities across the country, with a person’s zip code having a greater impact on health and overall success than any other demographic factor. We know that place matters. A recent Harvard University study by economist Raj Chetty showed that where a child grows up has significant effects on his or her prospects of upward mobility.
Growing up in communities that limit a child’s physical, economic and educational potential contributes to and perpetuates poor health and incidence of chronic disease, among other public health metrics. Out of the many neighborhood characteristics examined by Chetty, the relationship between commute time and social mobility proved to be stronger than the relationship to crime, elementary-school test scores or the percentage of two-parent families and social mobility.
Understanding the role that transportation infrastructure plays in creating economic mobility and access to opportunity is directly tied to ensuring healthy and livable communities. Under the leadership of Secretary Anthony Foxx, the United States Department of Transportation (USDOT) has embraced this unsettling statistic and is changing the way it approaches transportation policy, moving the conversation from building infrastructure to building pathways to opportunity.
In a recent interview with the American Public Health Association’s publication Nation’s Health, Secretary Foxx commented that “…transportation is place-making.” Transportation does not just take you to a place, it can create a place. Depending on how transportation infrastructure is developed and implemented, it can close off communities and create divide, or it can revitalize and mobilize. This is captured in Secretary Foxx’s Ladders of Opportunity initiative, a body of work and policy interventions that provide access to opportunity and economic mobility for all Americans.
Centered on three principles, Ladders of Opportunity is more than just a program or project, it is a new way of thinking:
- Work – infrastructure investment creates jobs and paves the way for businesses, particularly small and disadvantage enterprises.
- Connect – a multimodal transportation system provides Americans with safe, reliable, and affordable connections to employment, education, healthcare and other essential services.
- Revitalize – transportation infrastructure can lift up neighborhoods and regions by attracting new opportunities, jobs and housing.
These three simple concepts underscore the ubiquitous influence transportation infrastructure has on daily life. Instilling these principles into the U.S. Department of Transportation’s DNA is the key to using transportation policy to create economic opportunity.
Changing the way a governing body, agency or department thinks is no easy task. Culture shifts in industries often come as a result of a tipping point, when a hand is forced to do things differently as a result of external forces. Being proactive about culture change so that it allows an organization to actualize its true potential requires a savvy strategy and strong leadership that not only spurs top-down change, but also invigorates an upward momentum. This is the approach that Secretary Foxx has implemented to ensure that well beyond his tenure as Secretary of Transportation, decision-makers within the Department as well as across the country are held accountable for ensuring pathways to opportunity are seamlessly integrated into transportation policies and programming.
Utilizing the bully pulpit, Secretary Foxx has created a Ted Talk-style presentation that he will conduct to stakeholders and decision-makers across the country. Orated through his personal story of how a highway entrapped the Charlotte, North Carolina, neighborhood he grew up in, while illustrating the impact of poor urban planning through vignettes, Secretary Foxx eloquently sheds light on the transgressions of historic policies that shaped communities for generations and perpetuated economic divide, inequity and poor outcomes. In doing so, he amplifies the notion that place matters, and that it is the responsibility of current policy- and decision-makers to be mindful of all implications of building a new road or highway, including its impact on health.
It is not only in the presence of action behind transportation policy that communities and neighborhoods are impacted, but it is also the absence of consideration of vulnerable populations that builds walls to opportunity instead of roads. Walls to opportunity can present themselves through a variety of mechanisms, one of which can be demonstrated through the story of Raquel Nelson.
Raquel Nelson is like many other Americans across the country. A single mother of three, 30- year-old Raquel attended Kennesaw State University in Georgia while providing for her children. Unable to afford a car, she utilized public transportation to connect her from her suburban home to school, work and the grocery store. On the night of April 10, 2010, Raquel disembarked the bus with her children at a stop across the street from her apartment complex in Marietta. Eager to get home, she walked her family across the busy four-lane state road, as most of her neighbors did daily.
But as they crossed the street on this day, Raquel and her family were struck by a van, wounding her and her two daughters while fatally injuring her 4-year-old son. While grieving the loss of her child, Raquel was charged with second-degree vehicular homicide, failure to cross at a cross-walk and reckless conduct. The jury’s heavy-handed verdict reflected the lack of insight into what truly caused this horrific event. This was not a failure of Raquel’s judgement, but a failure of urban planning – the closest crosswalk was three-tenths of a mile away from the bus stop.
Raquel’s case sparked outrage in both the civil rights community as well as among urban planning and public transportation organizations, bringing to light how lack of pedestrian considerations in urban planning can negatively impact vulnerable populations. As the income inequality gap widens, many Americans with lower incomes are forced to move out of gentrified urban neighborhoods to more affordable, inner-suburban areas where the infrastructure is more suitable for driving than utilizing public transportation.
The inability to afford a vehicle puts you at a disadvantage, and coupled with the lack of pedestrian-friendly infrastructure creates an environment that many Americans like Raquel have to endure in order to have access to education, jobs and healthcare. Public health advocates understand the detrimental impact of poverty and income inequality on health, however situations such as Raquel’s highlight how transportation infrastructure serves a critical role in bridging the gap to access and directly impacts outcomes.
This is just one of the stories Secretary Foxx uses to illustrate the impact of transportation policies on everyday Americans. Raquel’s ability to provide for her children while pursuing her education to create a better life for her family was greatly dependent on transportation and urban planning decisions. This is what Secretary Foxx wants to ingrain into decision-makers – it is more than just a road, bridge or highway, it is a conduit to opportunity.
Through discretionary grant programs, technical assistance efforts and innovation, USDOT is translating Secretary Foxx’s Ladders of Opportunity presentation into real work, leveraging its regulatory power to spur revitalization in distressed communities and encourage local and state decision-makers to think differently about transportation policy and projects. From Richmond to Phoenix, neighborhoods across the country are using transportation as a way to connect Americans to opportunity. Initiatives such as the LadderSTEP program help cities advance transportation projects that revitalize and support access to opportunity, while the Transportation Investment Generating Economic Recovery (TIGER) competitive grant program invests in projects that more reliably, safely and affordably connect communities to centers of employment, education and other services.
Acknowledging the role that health plays in access to opportunity and equity, initiatives are not restricted to just roads and bridges. USDOT’s Rides to Wellness program is a strategic initiative to build partnerships, stimulate investment and drive change in the health and transportation sectors by supporting innovative solutions to healthcare access for vulnerable populations. Over 3 million Americans miss a doctor’s appointment due to transportation barriers. USDOT is working to address this issue head-on, understanding its potential in helping to reduce the burden of chronic disease by improving access to healthcare services.
Bringing together public health stakeholders with transportation practitioners is also crucial in improving the built environment. In 2012 USDOT’s Federal Highway Administration released the Metropolitan Area Transportation Planning for Healthy Communities report, which documented leadership among local transportation planning entities that successfully integrated health and transportation. Local communities are highlighted, showing how decision-makers took a comprehensive and holistic approach to health that went well beyond the well-established assessments of health impacts related to safety and air quality.
In addition, interagency collaborations have yielded significant impacts. Last year, the Centers for Disease Control and Prevention and USDOT came together to launch the Transportation and Health Tool. Intended for transportation practitioners, this interactive database helps decision-makers understand many of the issues at the intersection of transportation design and public health with the intent to strengthen collaboration between these two sectors. In 2009, the Environmental Protection Agency (EPA), the Department of Housing and Urban Development and USDOT came together to form the Partnership for Sustainable Communities to improve access to affordable housing, increase transportation options and lower transportation costs while protecting the environment. Creating livable and affordable communities is critical in the public health space, as the built environment is one of the many structural elements that have a direct impact on health outcomes. Breaking down the silos between these stakeholders and implementing a “health in all polices” approach allows for alignment of action that places the health and well-being of a community at its center, improving outcomes and promoting equity.
Secretary Foxx’s Ladders of Opportunity Ted Talk-style presentation and agenda is a call to action for decision-makers, practitioners and community leaders to be invigorated around the potential for transportation policy and infrastructure to be beacons for social change, economic mobility and improved health. Every American should have the ability to create his or her own destiny, instead of that destiny being dictated by zip code. As Secretary Foxx has said, “Through transportation, we can ensure that the rungs on the ladder of opportunity aren’t so far apart – and that the American dream is still within reach for those who are willing to work for it.”
- Raj Chetty and Nathaniel Hendren. “The Impacts of Neighborhoods on Intergenerational Mobility: Childhood Exposure Effects and County-Level Estimates.” May 2015.
- Bluestein, G. “Raquel Nelson Fights Murder Charges in Son’s Jaywalking Death in Georgia.” Huffington Post. April, 17, 2012.
- Hughes-Cromwick, et al. “Cost Benefit Analysis of Providing Non-Emergency Medical Transportation.” Prepared for the Transit Cooperation Research Program, Transportation Research Board of the National Academies. October 2005.
- Metropolitan Area Transportation Planning for Healthy Communities. Prepared by U.S. Department of Transportation Research and Innovation Technology Administration, John A. Volpe National Transportation Systems Center, Federal Highway Administration. December 2012.