Just Read: Street Smart: The Rise of Cities and the Fall of Cars

Street Smart: The Rise of Cities and the Fall of Cars by Samuel I. Schwartz (Author), William Rosen (Contributor)

In my regular sojurns into the things that produce health, such as well designed communities and transportation systems, I happened upon this title, a fantastic 101 of what any physician needs to know about the lever of transportation to reduce patients’ reliance on us.

What’s “normal” – a motordom-dominated, car-for-every-human, streets as wide as football fields society, or something else?

The historical anomaly, after all, wasn’t the desire to live in densely populated, walkable communities. That’s how human beings have lived ever since they started building permanent habitations, and then towns and cities, ten thousand years ago. It’s how most people still live outside the United States today. What was different about the United States of America (and a few other places) from the 1920s to the 2000s was the aspiration of most people to live as far away from work and shopping as they could afford.

It turns out that something else is normal. As a 20th Century child, I was completely duped by motorized mobility. However, I, like Schwartz, had a spark, as I recall riding my bicycle to my medical school classes, and learning, slowly over time, that I really disliked driving, despite living in world engineered to glorify it.

What we gained in “mobility” we lost in “access,” which was taken away from our communities in the 20th Century, and is slowly coming back in the 21st.

But mobility isn’t what’s really important, for either happiness or prosperity. What matters is access. And it’s just as easy, and a lot more efficient, to improve access— to stores, or entertainment, or employment— by decreasing the distance between, for example, home and supermarket than it is by increasing the speed by which to get from one to the other.

Totally makes sense to me, as it was almost immediately apparent when I moved to Washington, DC sans car and realized that what I left was ABnormal.

What I didn’t realize until I read the book was that I performed a “deprivation” study on myself – so called when people who are regular drivers are asked to forgo using a car for one week. And, here’s what happens:

Before and after their week of auto deprivation, the study’s participants were interviewed in depth about their experiences. Two-thirds of them reported that the absence of a car exposed them to new experiences. They felt more connected to their communities. Many felt literally claustrophobic when they returned to driving after the deprivation experiment.

Yep, me too.

My fellow Washingtonians are clearly joining me on this journey, as US Census data shows:

Car-Free Generation Y, Washington, DC #ActiveTransportation

I didn’t realize until half-way through that I’m actually featured in author Sam Schwartz’ (@GridlockSam – so named because he came up with the term when he was New York City’s Traffic Commissioner) book from 2012. “Steps to a Walkable Community” was produced for AmericaWalks (@AmericaWalks). I’m page 148 – where two of my favorite things are highlighted – walking meetings and Washington, DC 🙂 . So, I was primed to enjoy the education.

Doctors love designers and traffic engineers, too, especially the ones that think like us…

As I have written previously:

Just Read: The Third Mode: Toward a Green Society, (how engineers impact our health as much as doctors)

So this book is a great companion to that idea, explaining in human terms how enlightened engineers plan cities, including conventional wisdom, unconventional pitfalls, and trends that we need to know about in health. It’s similar to the education I’m getting from architects and other physicians catalyzing the design for health movement.

Millennials and the decline of the car

One of the most important trends Schwartz points out is the relatively unexpected (or unwanted by some) decline in vehicle miles traveled per person:

If all eighty million Millennials retain their current driving habits for the next twenty-five years, the US population will increase by 21 percent, but total VMT will be even less than it is today, and per capita VMT— the vehicle miles traveled per person— will fall off the table.

They’re just not driving as much. And it’s not because they’re environmentalists. As Schwartz points out

In a 2011 poll, only 16 percent of Millennials strongly agreed with the statement, “I want to protect the environment, so I drive less.”

Driver Licenses – addicting people to cars in their youth as much as cigarettes?

We know that if teens can avoid smoking before age 18, they’re unlikely to ever pick it up. Almost no one starts smoking after age 25.

So it goes with driver licenses:

GDL (Graduated Driver License) programs don’t just delay driving; in many cases they reduce it permanently, since history shows that, if drivers haven’t gotten licensed by the time they’re twenty, they’re unlikely ever to do so.

So as teens get driver licenses later in life, they’re less likely to adopt driving. That plus their experience as children of parents experiencing societal gridlock for the first time in history puts us in the position we’re in now, which is a great opportunity.

Americans spent 421 million fewer hours stuck in traffic in 2011 than they did in 2005. For the first time, the number of cars being “retired” is actually greater than the number of new cars being sold.

Making Streets Smart, the physician role, because we do have one.

Designed to Move 30121
Watching New York City completely change before our eyes – circa 2013 – Designed to Move 30121 (View on Flickr.com)

I like the approach to educating neophytes like me in the book.

Schwartz covers everything from the dynamics of movement in our cities, for example the impact of “skinny streets” (they reduce rather than increase congestion), to the modeling of pedestrians traveling on sidewalks, to the promise of driverless cars (hint, maybe the science of movement doesn’t support the promise).

There’s a really good discussion of equity in transportation as well in the examples of Houston, and the transportation meltdowns in Atlanta, Georgia, created by inequity, which has held the entire city hostage. For active transportation to work for cities, it has to be inclusive.

We talk about the penetration of things like step counters, fitness bands, and wellness programs, usually in the 10-20% range. The penetration of utilizing transportation of some kind on a daily basis is near 100% (and spending time in a building 90%).

It’s not a question that our cities are changing, it’s a question of how they are going to change. Just walk outside and take a look. It’s what I did in September, 2013, with Jeff Olson, one of the founders of the bikeshare system used in much of North America. We just sat in front of the flatiron building in New York and watched the bikers go by (A Walk Through New York – Designed to Move – is this our 1968 moment in creating active cities?).

2016.07.19 Smart Growth America Policy Forum 00840
2016.07.19 Smart Growth America Policy Forum 00840 (View on Flickr.com)

Today, I enjoy giving people the tour of the complete street that the Center for Total Health in Washington, DC sits on.

After I ask if they know what Complete Streets are (most in health care don’t), I remind that communities do not become this way magically, and also that a complete street by itself does not create health. Humans do that, and now it’s our time to take priority.

Isn’t this century marvelous?

Infographic - tracking a complete street - a year of active transportation - center for total health
Infographic – tracking a complete street – a year of active transportation – center for total health (View on Flickr.com)


Last year when I had a patient engagement fellowship at NEHI in Cambridge, I got to learn a lot about NEHI’s years of work for Massachusetts documenting exactly this, among other things – complete streets. I’d seen changes around me but had no idea there was a concept and comprehensive strategy behind it. And by golly, it works!

When I became an active walker last year, and runner this year, as part of preventing type 2 diabetes, I became acutely aware of where paths and sidewalks do and don’t exist. The 40 pounds I’ve lost in 18 months (most of it in the first 4) make me a strong advocate for, as I said in my book, “Make it easy to do the right thing.”

This goes beyond the oft-quoted behavioral economics principle “Make the right choice the easy choice,” e.g. making the best selection the default (e.g. for organ donation). Doing the right thing is far more active than choosing the right option. Doing requires sustained action, over and over, and for that, supportive infrastructure makes all the difference.

Hey Dave,

I love it! It seems like you and I have both discovered how empowerment extends into all aspects of health. The e in your name could also mean healthy “environment” 🙂 ,


Couldn’t agree more with your observations, Ted. As a transplant to DC from Los Angeles (5 yrs ago), living in the District has by far been the best decision of my move here. I had a 3-yr stint in North Bethesda, MD which still required reliance on a car. While I do still own a car, I down-sized from a Volvo SUV to a VW Jetta, and only drive on wknds to schelp my son around from one activity to another (some of which are outside of the District). It has been liberating living in DC where I walk to my neighborhood grocery store, post office,
restaurants, metro to the office/meetings, and my son walks to/from school. My hours long girlfriend “walk and talk” meet-ups take us on area trails and is not only good for my physical health but also my mental health.
My son at 14 – and many of his peers- also embrace walking + other modes of active transportation (metro bus and rail). It truly is a gift that we give ourselves when we explore our neighborhoods on foot and bike and stay upright!! The unfortunate reality is that in this city (and many others), there are stark disparities in access to this health-promoting lifestyle that you and I celebrate. Let’s work to change that!

Thanks for your insightful perspective.

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Ted Eytan, MD
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