Could Health Do for Transport What It Did for Smoking?
Key Takeaways
- Our transport systems harm our health in many ways, from crashes and air pollution to stress, loneliness and inactivity.
- Many governments now include healthier transport in their strategies, and some have written it into law, but little has changed on the ground.
- Once health benefits are counted, walking and cycling projects often have the strongest business cases in transport, but decisions tend to follow political popularity.
- Many people, including those working in health and transport, don't realise how much our transport systems harm their health.
- When people do understand the harm, change can gain political traction.
- Public health changed the culture around smoking, and a similar push on transport, starting with public sector workforces, could help build support for change.
What Next?
Do you have a plan to work with health departments to educate the public sector about the damage our current transport systems do to their health?
Introduction
This week, I'm continuing my series on our transport systems through different lenses, this time the lens of health.
As with last week's environmental lens, the health case is uncontroversial. We know our transport systems harm our health in many ways, so listing them all again wouldn't add much.
Instead, I want to ask a different question. Health is one of the public's top five priorities in many countries. Could it help bring about the paradigm shift our transport systems need?
On paper, it should be an easy case to make. Many governments have already put healthier transport into their strategies, and some have written it into law. Yet on the ground, very little has changed. I'll look at why, and what we might learn from how public health changed attitudes to smoking.
But first, a quick overview of how our transport systems affect our health.
How Our Transport Systems Affect Our Health
Our transport systems harm our health in at least six ways:
- Crashes: road crashes cause deaths and serious injuries.
- Air pollution: vehicle emissions damage our lungs and hearts.
- Noise: traffic noise disturbs sleep and adds to stress.
- Inactivity: when driving is the default, we walk and cycle less, which contributes to obesity and heart disease.
- Stress: driving in congested peak-hour traffic, and walking or cycling on routes that feel unsafe, make everyday travel stressful.
- Isolation: places designed around cars can leave people who don't drive, especially older people, lonely and cut off.
It's quite a list. Every item on it would improve if our transport systems were designed to move people rather than cars, with walking, cycling and public transport working together.
Progress - Sort Of
Despite this long list of health misdemeanours, until a decade ago our transport systems weren't seen as a big deal in health circles. People simply accepted the harm as part of how our societies work.
That has started to change. But when health tries to shape transport policy on its own, without transport expertise, it can fall into the same traps as anyone else who doesn't understand induced demand. The now infamous New York Times op-ed calling for autonomous vehicles to be rolled out as quickly as possible to cut crash deaths was written by a medical doctor. It overlooked the unintended consequences of AVs at scale, such as inducing more vehicle travel, and the likely harm to health compared with other approaches.
The good news is that some jurisdictions are now bringing health and transport together. South Australia, where I now live, has integrated health into all its policies, including transport. Health features heavily in its transport strategy, with a key strategic action to "Enable healthy transport choices that enhance wellbeing. Understanding and addressing barriers to active travel will deliver health and other benefits associated with increased active mode choices."
Some places have gone further still. In Victoria, health, safety and wellbeing are written into law as core objectives of the transport system.
So if health and transport strategies agree on the need for healthier transport, and the law backs them up, surely we're on our way to fixing the problem?
If only.
Take Adelaide, home to nearly 80% of South Australia's population. Its bike lanes are terrible: narrow painted lines on the road, often operating only at certain times of day and blocked by parked cars the rest of the time. There's little or no action to change that. Instead, most transport funding in Adelaide is going the wrong way, into new and wider roads in a futile attempt to solve congestion.
South Australia isn't alone. In Victoria, the legislation has made little difference. Around the world, many transport strategies have aimed to increase walking and cycling in recent years, but most places are making slow, incremental changes at best, not the step change their strategies envisage.
So, what's going wrong?
The Real Challenges
In theory, transport projects are chosen on the strength of their business cases. Why else would we spend many millions of dollars every year preparing them? And once health benefits are included, walking and cycling projects often have the strongest business cases in transport.
In practice, business cases are widely ignored or, at best, a minor consideration. Most transport projects are chosen for political reasons: what's popular with voters, or a political leader's hobby horse. And in many places, more and bigger roads are far more popular than cycle lanes.
So if health is one of the public's top priorities, why aren't people more supportive of transport investments that would make them healthier?
I suspect a big reason is that many people don't realise how much our transport systems harm their health. That includes many people working in health and transport.
Where the link is less obvious, as with obesity, the problem tends to be put down to personal failings or treated as something to fix with medication. The systemic causes, of which transport is a significant part, are all but ignored.
But when people do see the link, things can change.
School Streets, which temporarily close roads to motor traffic at the start and end of the school day, have sometimes gained political traction once parents became aware of the safety benefits and high levels of pollution outside their children's schools.
London's Ultra Low Emission Zone was argued for mainly on health grounds, to reduce air pollution. It was politically controversial, but it currently looks set to stay.
I saw first-hand how air pollution can mobilise people when I was responsible for transport on Putney High Street, a notorious pollution hot spot in London. (Fortunately, the air there is getting cleaner, with nitrogen dioxide (NO2) levels down by around 40% since 2021.)
All of this suggests that raising awareness of how our transport systems affect our health could help build political support for bigger changes.
Can Health Help Change Our Transport Systems?
I don't think there's a magic bullet that will suddenly deliver a paradigm shift in our transport systems. Instead, we need to push on several leverage points at once to build a broader consensus for change. Health is one with real potential, because the public cares so much about it.
So what would that look like?
Changing our transport systems needs a big cultural shift away from what has been called motonormativity, the tendency to accept risks and harms from driving that we wouldn't accept in other parts of life. Without that shift, it's hard to build and keep support for a different approach.
A 2023 UK study showed how deep this runs: 75% of people agreed that people shouldn't smoke in highly populated areas where others have to breathe in the fumes, but only 17% agreed with the same statement about car fumes.
Smoking is a useful comparison, because it's the clearest example of health changing a culture before.
In the 1950s, around half the adult population in the developed world smoked. Smoking in offices, pubs and almost everywhere else was normal. Over decades, public health campaigners kept raising awareness of the damage smoking did, and that created demand for more and more action: higher taxes, advertising bans, packaging rules and bans on smoking in enclosed spaces.
Today, smoking rates in most places have more than halved.
That success makes me wonder what health could achieve if it made a similar push to raise awareness of the damage our transport systems do to our health.
A good place to start might be close to home. Health and the wider public sector employ large numbers of people, so governments have a vested interest in keeping their workforces healthy. Helping their own staff understand how transport affects their health could begin to shift the car-first culture.
Conclusion
Our transport systems are bad for our health, and few people would argue otherwise. Many governments have already included healthier transport in their strategies, and some have even made it law. Yet on the ground, little has changed. Most funding still goes to new and wider roads, while cycle lanes remain painted lines that disappear behind parked cars.
We already have the evidence. Once you count health benefits, walking and cycling projects often have the strongest business cases in transport. But projects tend to be chosen on what is popular with voters.
That is why awareness matters. When people understand the harm, as parents did with pollution outside their children's schools and Londoners did, which led to the Ultra Low Emission Zone, change gains political traction. Public health has done this before: it took smoking from a cultural norm to a minority habit.
As I said above, there is no magic bullet. But health is one of the strongest levers we have, because the public really cares about it. If health professionals and governments made the same sustained case about transport that they made about smoking, starting with their own workforces, support for better cycle lanes and pedestrian facilities could follow.
