Suburban sprawl: Where does emergency medicine fit on the map?

Millard, William B.

doi:10.1016/j.annemergmed.2006.11.021

« Previous Next »Annals of Emergency Medicine
Volume 49, Issue 1 , Pages 71-74, January 2007

Suburban sprawl: Where does emergency medicine fit on the map?

Article Outline

The traumatic implications of sprawl
The poster child
We built this mess ourselves
Time = distance/rate = survival
When seconds count
Moving the patients or moving the hospitals
Planning whole communities, not just houses
References
Further reading

The built environments of the American suburbs stretch out from cities resembling “the end of a Scrabble game,” but these spacious suburban dreamscapes create havoc for emergency care.

In some sense, the scattered environs and the high-speed arteries that connect them created the specialty of emergency medicine and laid the groundwork for emergency medical services. The landmark 1966 National Academy of Science’s report Accidental Death and Disability: The Neglected Disease of Modern Society was largely in response to automobile accidents and the then-nonexistent emergency care system. The notion was reinforced in 2006’s Institute of Medicine report titled The Future of Emergency Care in the United States Health Care System, which criticized the still-fragmented nature of trauma care.

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The traumatic implications of sprawl

Though certainly not all emergency medicine is trauma and not all trauma is vehicular, the high-speed collisions beyond the fringes of major US cities and the multiple injured victims they produce are a large part of the daily routine in many of America’s emergency departments (EDs). And an underlying cause—a primary reason all these people are driving so far and fast enough to get seriously injured—can be summed up in the pejorative term: sprawl.

Population density in these outlying spaces is low, and single-use zoning separates homes, industry, offices, retail, and civic space, instead of mixing these functions as traditional cities do. This particular type of suburb or exurb that characterizes recent growth in the US, especially in the Sunbelt, is widely dispersed, often centerless, prone to leapfrog development, and structured so that private cars are essentially the only transportation option. And it has attracted a host of critiques among physicians, public health officials, urban planners, environmentalists, architects, community activists and others.

Centrifugal development, these commentators charge, fosters unnecessary and avoidable levels of environmental degradation, energy inefficiency, socioeconomic polarization, aesthetic homogeneity, unhealthy behavior, and a variety of other social ills. Definitions vary but always include low density. Other common features include a paucity of planning, a plethora of strip retail, negligible pedestrian space, and gridless layouts based on a tripartite system of limited-access arterial highways, collector roads, and local roads (often cul-de-sacs), minimizing navigational options. Richard Jackson, MD, MPH, professor of environmental health at Berkeley’s School of Public Health, gives as recognizable a description as any: “a landscape that looks like the end of a Scrabble game.”

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The poster child

Since new housing is faster and easier to develop than hospitals, the health care implications of such an environment can be alarming. In rapidly expanding Phoenix, for example, Level I trauma care is available only downtown, and rush-hour traffic can turn even a short emergency medical services (EMS) pickup into a 30- or 40-minute stop-and-go ride.

“Talk about sprawl—this is the poster child… the housing developments [are] way out ahead of the infrastructure,” says Tim Johns, MD, medical director of Gilbert Hospital. “The traditional community hospital likes to open up with about 100 beds. Out in Queen Creek they won’t be ready for a hospital like that in 10 or 12 years; meanwhile, they’re adding 500 people a month. Something’s got to be done. Ambulances at some hospitals are backed up 6 to 7 deep for 3, 4 hours at a time.”

Along with outpacing essential services, researchers say, sprawl correlates with exaggerated health risks (either increasing risks directly through its physical design or attracting residents who are at high risk because of demographic and behavioral factors) while also posing barriers against ready access to treatment. In addition, these environments can exert regional economic effects that are detrimental not only to denser traditional urban settlements but to their full-service hospitals and medical personnel—and to patients who have seldom considered the variables of medical access and medical costs when first opting for a move to the exurbs.

Those who study America’s dominant developmental pattern are converging on a portrait of a uniquely hazardous place. Sprawl’s health effects are of concern to emergency physicians and public health officials alike, since poor planning at early stages of community growth magnifies problems that eventually appear in EDs.

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We built this mess ourselves

Causes of sprawl are manifold. Its defenders, such as Kotkin,¹ Bruegmann,² and Gordon and Richardson,³ describe it as simply the natural outcome of many residents’ preference for single-family dwellings on large pieces of private property located far from the hazards of denser cities. Other scholars, less inclined to attribute to nature or free choice a social formation with this particular history, have identified numerous forms of public subsidy and private economic interest that have added institutional weight to the centrifugal tendency.

The extensive and highly privatized transportation system that differentiates the US from most other developed nations, critics say, is the chief instrument in the construction of sprawling environments. This choice may have been heedless or deliberate, depending on one’s taste for narratives of organized villainy, but it has been destructive either way. Road building has attracted large federal subsidies since the Federal Aid Highway Act of 1956: $128.9 billion as of the 1991 Interstate Cost Estimate, when the system was designated essentially complete.

The roads cost even more to operate than they did to build: New Urbanist architect/planner Andres Duany, citing the data of Hart and Spivak,⁴ counts the total annual subsidies doled out to US automotive and road-related industries at $700 billion, with subsidies for highways and parking alone amounting to 8-10% of the gross national product. This inefficiency is passed along to every citizen through taxes and increased prices for products, whether or not that citizen drives a car. Gasoline prices that reflected the full social costs of auto dependence, such as pollution and emergency medical treatment, Duany states (using Hart and Spivak’s 1993 dollar figures), would have to include a tax of $9 per gallon.⁵

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Time = distance/rate = survival

The cost of commuting and driving for routine activities is incurred daily in many forms, measurable in time if not always money. Other costs, medical ones included, can become apparent more insidiously or more dramatically. Recent scholarship has associated sprawl with undesirable conditions ranging from vehicular slaughter to physical deconditioning to psychological anomie and road rage.

For emergency physicians, the salient effect of sprawl’s transportation monoculture remains the high prevalence of vehicular trauma. Indeed, the entire discipline of out-of-hospital emergency care is in a sense an artifact of the paving of America. The June 2006 Institute of Medicine report⁶ notes that the federal institutional home and lead agency for EMS is not a medical agency but the National Highway Traffic Safety Administration (NHTSA). The report points out how the EMS field and the construction of an environment that creates a need for it have grown in tandem over the past half-century.

Long distances, high speeds, 2-lane highways with hazardous curves and suboptimal lighting, and limitations in funding, 911 coverage, and regional coordination of services combine to make remote roads risky, both by being conducive to collisions and by delaying out-of-hospital response. Ewing and colleagues⁷ have noted that low-density centrifugal development (determined according to a “sprawl index”) correlates strongly with high accident rates.

In the mid-1990s Esseks and colleagues,⁸ in a report for the American Farmland Trust (which advocates preserving agrarian land against developmental encroachment), studied EMS response times on rural/exurban fringes in northeastern Illinois with a development pattern that the authors termed “scatter,” essentially a precursor of sprawl. Response times in the “early scatter site,” one of three areas studied, averaged 9.6 minutes, compared with 6.4 in an adjacent small city. A similar difference appeared with a “transitional scatter site” annexed to a city: an average of 7.5 minutes, compared with a citywide mean of 4.6 in the study year.

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When seconds count

Three-minute differences in run time are medically significant not only under the “Golden Hour” trauma paradigm but in situations such as myocardial infarction and cardiac arrest. Long run times are at odds with the “time is myocardium” principle and the steep decline in survival when intervals between notification of a dispatcher and defibrillation initiated by a first responder begin to exceed 5 minutes.⁹ Subsequent studies comparing rural and urban EMS responses have found that the times diverge consistently and substantially.⁶

Research on EMS performance in sprawl areas (as distinct from the countryside) is only beginning to emerge, notes economist Thomas Lambert of Indiana University Southeast and the University of Louisville. One reason is that the US Census Bureau has traditionally divided the landscape into urban and rural categories, based not on population but on the presence or absence of articles of incorporation. It has no separate designation for suburban tracts. The NHTSA follows a similar binary classification for its Fatal Accident Reporting System. Lambert points out that the 2000 census for the first time included the category “rural, non-farm,” which allows study of low-density areas as such, separated from agricultural land uses.

Lambert and Meyer¹⁰ have thus recently extended the earlier findings, noting that the suburban/exurban response pattern more closely resembles the rural than the urban. These authors’ work, along with that of Ewing and others, suggests that sprawl areas pose distinct and underrecognized risks—at least of vehicular death, and presumably of other situations requiring EMS attention (in the absence of a national database on all-causes EMS response, the authors used fatal accident run time, the subject of NHTSA reporting, as the closest proxy).

“You can make the argument,” Lambert says, “that anyone who can afford a large-lot home has the right to country-style living, but still in a suburban location. OK, but do these folks really know, when they buy a home, the full package of public services that they’re getting? Some economists argue ‘everybody’s fully rational, or close’… but people really can’t tell a surveyor how close they are to the nearest hospital.”

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Moving the patients or moving the hospitals

As development moves out of reach of older local hospitals, facilities can either adapt their transportation systems or relocate. Houston—known nationwide for extreme traffic congestion, and unique among major US cities in having no zoning whatsoever—offers instructive experience with growth outstripping emergency medical resources.

“We definitely have an EMS problem,” says Charles Begley, PhD, co-director of the Center for Health Services Research at the University of Texas School of Public Health. “Houston doesn’t have as many Level I trauma centers relative to population,” he continues; “our major trauma centers are located in the big Texas Medical Center,” the major not-for-profit teaching hospital complex near the central business district. “There are challenges in terms of traffic: ambulances and helicopters have to go to the periphery of the city and bring everybody into one location. We don’t have hospitals spread out to match the spread-out nature of the city.”

Over 100 ambulance companies compete in Houston’s primary county, Harris, and communication over where to take patients is poorly coordinated. Patients’ insistence on going to certain hospitals known for high levels of care, rather than to smaller outlying facilities that could provide appropriate care faster, distorts the system further.

“We have crowding of less serious cases” in the prestigious Hermann and Ben Taub hospitals, Begley reports, “and they have to shut down. Our two highest-level hospitals are on drive-by status about a third of the time.”

Occupied ambulances often sit in a hospital bay for 5- or 6-hour waits, unable to deliver their patients or to return to active duty.

Local hospitals’ response to the pattern of growth, Begley says, has not been favorable to emergency care. Houston’s hospital association disbanded two decades ago, reflecting a shift toward adversarial market behavior and away from coordinated planning. New and expanded facilities do appear in the suburban peripheries, but these tend to be small, often specialty hospitals, with no ED or only a small room catering to orthopedic cases. The preference for affluent, well-insured, basically healthy patients over lower-income, uninsured trauma patients (often recent immigrants), Begley finds, shifts burdens to older charity hospitals and teaching hospitals, with the built environment reinforcing the trend.

A local EMS trauma policy council has been active in developing an improved communication system; however, it is too soon to determine its effect on dispatching practices. If he could reform any single aspect of Houston’s emergency care system, Begley says, he would institute systemic regionalized coordination to create incentives directing each ambulance toward appropriate facilities according to urgency and medical need, not patients’ preferences or business imperatives.

Institutional sprawlward flight is not limited to the Southwest. Similar motivations underlie some hospitals’ decisions to close urban facilities outright, notes DiFerdinando. In sprawl-prone central New Jersey, hospitals in Princeton and Trenton have announced plans to abandon their traditional urban settings for new facilities alongside Route 1 and the New Jersey Turnpike, respectively. The new sites remind DiFerdinando of “hotels in the middle of nowhere,” far from either public transit or sidewalks, making their EDs inaccessible to walk-in patients—and reducing uncompensated care.

“They’re not just moving to where the elective procedures are,” he adds; “they’re moving away from where the New Jersey and New York charity-care patients are. ‘Charity-care elective patients’ are an oxymoron. Somebody doesn’t walk up to a sprawled facility in Burlington County and say ‘I need a colonoscopy.’”

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Planning whole communities, not just houses

Sprawl is carved into the landscape, but perhaps not in stone. Some observers, particularly in the Smart Growth and New Urbanism movements, envision either a conscious shift in community preferences, a response to economic pressures (beginning, but not ending, with rising fuel costs), or both contributing to a return to denser, more centripetal community design.

“I think we’ll reconcentrate, one way or another, and a hospital will think twice about being at the suburban periphery,” says Flint. He identifies various demographic groups (young professionals and families, aging boomers) as natural constituents for a reurbanizing trend, particularly as concerns over sustainability become more widespread.

“I think cities will be the answer in terms of energy efficiency,” he says; “Manhattan as a whole is more energy-efficient than any other arrangement of civilization.”

Portland, OR, is among communities that have used urban growth boundaries to try to prevent sprawl, but a backlash by property rights advocates has complicated that strategy. University of British Columbia planner Lawrence Frank, whose research links unwalkable neighborhoods with prevalence of obesity, proposes an alternate approach using economics rather than legislation or downzoning to accomplish the same end: an Urban Service Area, within which the public sector continues to provide infrastructural elements, from roads to EMS, but beyond which residents must pay for those services themselves.

“For people that live in areas where the consumption of public resources is greater,” he says, “the proportionate tax burden should be commensurate.”

An Urban Service Area amounts to a community’s message to sprawl developers and residents that they are free to move as far outside existing communities as they like—provided they no longer expect the denser traditional areas to continue subsidizing their water, sewers, transportation, schools, EMS, and other civic essentials.

Infrastructure components that address threats to life are certain to be political hot buttons in debates over such antisprawl measures, and emergency care is obviously among them. Involvement of emergency physicians in these and other aspects of community planning, working alongside public health officials and environmental medicine specialists, might have a much greater impact than passive waiting for the patients from the sprawling fringes of the city to show up, belatedly, in the ED.

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References

Kotkin J. The City: A Global History. New York: Modern Library; 2005;
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Bruegmann R. Sprawl: A Compact History. Chicago, IL: University of Chicago Press; 2005;
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Gordon P, Richardson JW. Are compact cities a desirable planning goal?. J Am Planning Association. 1997;63:95–106
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Hart S, Spivak A. The Elephant in the Bedroom: Automobile Dependence and Denial; Impacts on the Economy and Environment. Pasadena, CA: New Paradigm; 1993;
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Duany A. Suburban Nation: The Rise of Sprawl and the Decline of the American Dream. New York: North Point Press; 2000;
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Committee on the Future of Emergency Care in the United States Health System. Future of Emergency Care in the United States Health Care System. Washington: National Academies Press; 2006;
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Ewing R, Schieber RA, Zegeer CV. Urban sprawl as a risk factor in motor vehicle occupant and pedestrian fatalities. Am J Public Health. 2003;93:1541–1545

Esseks JD, Schmidt HE, Sullivan KL. Fiscal costs and public safety risks of low-density residential development on farmland: findings from three diverse locations on the urban fringe of the Chicago metro area. DeKalb, IL: American Farmland Trust; 1999;American Farmland Trust Center for Agriculture in the Environment Working Paper, no. 98-1. Available at: http://www.farmlandinfo.org/documents/29027/wp98-1.pdf.
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De Maio VJ, Stiell IG, Wells GA, Spaite DW. Optimal defibrillation response intervals for maximum out-of-hospital cardiac arrest survival rates. Ann Emerg Med. 2003;42:242–250

Lambert TE, Meyer PB. Ex-urban sprawl as a factor in traffic fatalities and EMS response times in the southeastern United States. J Econ Issues. 2006;40:941-853
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