by James A. Kushner. Durham, NC: Carolina Academic Press, 2007. 240pp. Paperback. $30.00. ISBN: 9781594603358.

Reviewed by Michele Morrone, School of Health Sciences, Ohio University. Email: Morrone [at]


HEALTHY CITIES addresses an increasingly important topic in public health, namely how the built environment affects our health and the environment. Evidence of the importance of understanding the public health implications of the built environment is found in the fact that the US Centers for Disease Control and Prevention (CDC) has made this a priority. CDC has expressed great concern over obesity rates and is examining how neighborhood design is related to unhealthy lifestyles. As this book suggests, one of the greatest factors contributing to the public health impacts of the built environment is the automobile because of its relation to both personal health and environmental health.

James A. Kushner notes that his book “builds on a paper” that was presented at an international conference in 2006, and it reads like a paper presentation rather than a scholarly publication. There are 38 chapters in the 177 total text pages, which averages a little over 4 pages per chapter. Indeed some of the chapters consist of only one paragraph of text with a picture or two that are not referenced in the text. Kushner states that the book is a “call to arms to combat the increasingly high costs of transportation and the unacceptable costs of a deteriorating environment and declining health.”

Kushner frames the discussion in the first section, which is a very brief overview of some of the major issues related to the built environment and health. These issues include the environment, transportation, and housing. All of these problems are complex, and entire books can be written about the environmental health effects of poorly planned cities and neighborhoods. Here, unfortunately, the author provides a one-paragraph chapter that notes environmental impacts such as water and air quality associated with use of automobiles.

The second section is identified as “The American Planning Law System.” This section consists of seven short chapters that attempt to cover zoning, comprehensive planning, and project development review. The text is heavily footnoted, thus allowing the reader to seek additional information about these important issues. Considering the superficial discussion included in this book, access to such additional source material is very useful.

Kushner claims to present a “critique of American planning law” in his third section. He begins by arguing that there is too much local control over land use planning decisions. This local control, or “home rule,” neglects to consider the regional impacts of development which can include segregating socioeconomic [*570] classes. Furthermore, traditional low-density neighborhoods, such as those in American suburbs, lead to reliance on the automobile which, in turn, minimizes public transportation options and creates environmental and human health impacts – usually negative.

Kushner offers some solutions to low-density planning, such as financial disincentives in order to encourage developers to “densify” their neighborhoods. Included among these initiatives are additional costs when constructing residential neighborhoods without adequate access to public transportation and requirements to address housing in which school-age children can not safely walk to schools. The solutions also include impact fees that require the community to develop new service facilities, such as police and fire. The lists of solutions for addressing the density issues are among Kushner’s most provocative offerings and should make people think about the possibilities of using the built environment to promote health. The point is, that well-planned, high density neighborhoods are one of the major solutions to negative health effects resulting from the lack of physical activity that is encouraged by low density development.

Transportation and health is the focus on the fourth section. The transition into consideration of transportation is somewhat confusing, however. Every other major section starts with a single page that identifies a set of issues, except for this one (and the Conclusion section). So, while reading the critique of American planning law, the discussion abruptly switches to transportation and health without segue. While this is probably a minor production error, the inconsistency does not enhance clarity of the presentation.

In his discussion about transportation and health, Kushner presents statistics about car crashes and the mental strain of commuting, and he notes that the major environmental effect of transportation is air pollution. He also makes interesting point about parking, asserting that communities actually provide too much parking. He argues that planning for high parking capacities encourages people to drive rather than walk into commercial districts. He suggests some ideas to address the traffic problems, including increasing enforcement through technologies such as cameras and design elements such as speed bumps and better sidewalks.

Land use planning that segregates social classes has fostered a situation in which the urban poor are subject to substandard housing conditions, and the fifth section considers the connections between housing and health. The US government plays a role in creating inequities in housing due to the tax law that offers incentives to homeowners. Specifically, Kushner argues that richer people may purchase bigger houses because of the tax breaks associated with mortgage interest. On the other hand, the government has tried housing subsidies targeted to the poor, but these have not been effective.

Other housing and health issues include neighborhood security and homelessness, which are related to a certain extent. For example, Kushner [*571] explains that one cause of homelessness and neighborhood insecurity is deinstitutionalization. He argues that certain criminals, such as predators, “simply should not be permitted in the community” (p.128). For these people, there should be “civil commitment facilities” that can monitor them.

In the first chapter of the section, entitled “American Urban Design and Health,” Kushner states that the reason why neighborhoods are so poorly designed in the US is due to a “conspiracy of urban planners, politicians, and developers” (p.141). This conspiracy has created one of the most unhealthy generations in American history. Indeed, Kushner discusses some of the concerns raised by the CDC in this context, specifically those related to rising levels of obesity and diabetes.

The health impacts on children are also noted, as Kushner argues that children are less active because of the way communities are designed to accommodate the automobile. Providing access to recreational facilities is one approach to address some of the health effects that result from poor land use planning. In addition, renewed emphasis on physical education in schools and a comprehensive health education program are suggested as possible solutions.

Overall, Kushner offers a cursory review of some of the major topics related to urban planning and health. This approach could make HEALTHY CITIES a valuable asset to other scholars who are interested in exploring these important issues in more detail. However, it is difficult to identify the intended audience. Most public health professionals will probably find the volume frustrating in its brevity and sketchy coverage.

One of the strengths of the book is the extensive footnotes and the Table of Authorities at the end. If the reader has the patience to review the references, he or she will find a wealth of information both in print and on-line. The book could also serve as the basis for framing arguments in favor of land use planning that will enhance rather than detract from public health.

© Copyright 2007 by the author, Michele Morrone.