 Thanks to the AIA San Antonio and we'll start by thanking Tori, I'm not sure if she's in the room or out front. She's out front. Well we'll wait till she comes in or maybe she can hear the applause. Give her a round of applause for all the hard work she did to put this together. This is a really exciting event. The theme is designing healthy communities and we have a terrific keynote speaker. I had the opportunity to spend some time with him last night. He is as personable and passionate as he is smart. Dr. Richard Jackson from UCLA and Dr. Jackson will have you introduced a little bit more formally later. This could conceivably be a lunch with some really important dignitaries here today but they're not here yet. And you're asking yourself, I wonder who might come? Well thanks to Term Limits we are blessed in San Antonio with seven living former mayors and the one that I would describe as the wisest of that group is Lila Cockrell and so she's going to be here we hope. And then a name you may recognize from the hike and bike and creek trails. Howard Peake is going to join us today so I hope Howard is with us. And I'm looking around for my state representative Mike Virial. I don't see him yet and I don't see District Seven City Councilman Chris Medina yet. Am I wrong or any of you here? We'll clap if you are. We won't clap if you're not. And I'm going to add I don't know if dignitary is the right word but maybe one of my heroes from the San Antonio Sports Foundation is here. This guy is a nine-time Paralympic medal winner including two golds Ross Davis. Where are you Ross? Ross is involved in a really cool new innovative program called Spark which stands for school parks and I hope you'll read more about that on the Rivard report soon. And I also want to acknowledge Mike McGlone from Alamo Architects because Mike is the current I think president is the right title of of AIA. Mike where are you please stand up. And very quickly I want to thank our sponsors but in particular our presenting sponsor which is the San Antonio River Authority and its general manager Suzanne Scott is with us today. Suzanne please stand up. If if you have not been down to the mission reach lately it is amazing what is happening starting with the the trail improvements across from the Blue Star right along the mission there in phase one but also if you drive down farther or ride your bike down toward Mission San Juan you can see what's happening with phase three. It's really coming along it's very exciting and you guys are doing really incredible stuff down there it's really cool. Other table sponsors I mentioned Mike or I see Irby Hightower is here Alamo Architects hold your applause Barry and partners show of hands maybe where's Barry and partners are they here today. CPS Energy Ford Paul and Carson Lake Flato Architects North Central Baptist Hospital OCO Architects Pape Dawson Engineers the Pearl Bill Shown I know you're here somewhere from the Pearl where are you Bill thank you somewhere. Port San Antonio the UT Health Science Center the Center for Medical Humanities and Ethics also the UT Health Science Center the School of Nursing and via Metropolitan Transit thank you so much for your support because we wouldn't be here if you hadn't helped. If you have not had the chance to get over to the Full Goods building and the AIA offices this week the the specific programs and entities that are being honored for helping us design healthy communities in San Antonio are all on display on the walls there. Some of them I just mentioned when I thanked a few people but I'm going to read them real quickly and you can go over after lunch or you can stop by anytime at your convenience and see them but when you when you think about all of these relatively new initiatives that are going on here it's just amazing what we have happening in the city and the pace of acceleration. The mission reach which I mentioned Seclovia and the next iteration of Seclovia is coming up in October toward the end of the month I think and the last one brought 20,000 people and I think they're expecting that to possibly double. I don't know if Julia Diana is here from the city of San Antonio and she's sort of the bike Zarina of the city there she is hi Julie stop hiding stand up and say hello and we'll give you credit for B-Cycle and everything the city council did yesterday the city of council approved the funding out of the federal grant that that Metro Health operates to extend that program six new stations down on the mission reach as well as a innovative program that will make San Antonio housing authority residents able to buy memberships annual memberships and B-Cycle for only $20 which is really cool. Fitness in the park is honored H Park Hemisphere Park Area Redevelopment Corporation a lot going on there the Pearl of course the green space alliances of San Antonio and if you've never been out to this school it would almost make you think high school could have been good Madison High School Agro Science Magnets School it's really an extraordinary place so let's give all of the award winners or honorees a round of applause as well. There are there should be some note cards at your table and if you are the type that does not particularly want to get up in front of an audience at the microphone that's over here during our question and answer period when I'll moderate questions for Dr. Jackson then why don't you go ahead and fill out your question legibly for you architects on a card who are my card gatherers would you just stand up so people can see who you are around the room thank you so much they'll be fetching those and bringing them up to me so I do hope we have plenty of time for a very engaging conversation at the end of our keynote presentation and I think that concludes all my opening remarks and I want to turn the microphone over to the person who deserves a special note of thanks from us because this luncheon was her idea a year or more ago when it was launched and that is the chairwoman of the luncheon and architect at Lake Flado Tena Florian. Tena come on up. Thanks Bob and thanks to everyone for attending the second annual sustainable urban development luncheon. Last year I stated the goals of this luncheon to be to bring together a cross section of architects and planners developers city and county leaders and other visionaries to for the purpose of reinforced forcing the virtues of dense urban growth and transit oriented development. I think that purpose needs to be restated. First of all I don't think that reinforcing the virtues is really much of a purpose. The purpose of this event should be to affect change in our community and secondly I'd like to add that we would like to welcome the medical community as an important part in this venture. We want you to add us to your toolkit as an important element that can help you improve the health of the citizens of San Antonio. On my way home on Wednesday I stopped by the Pearl to pick up Dr. Jackson's book my two year old in the backseat immediately wanted to read the book and she opened it up and the first thing she said was no pictures which I thought was funny because it's probably the first thing architects think when they open up a book without pictures. So we went on home and about eight minute drive and as we approached the house she closed the book and said the end. Unlike her I have not yet had the chance to read Dr. Jackson's book in its entirety. After the girls were in bed I finally had a chance to open it and I intended to skim the prologue but I ended up reading every single word because Dr. Jackson has really led a fascinating life and I encourage you all to take a look at his book. At the end of the prologue it said see chapters 11, 12 and 13 for ways in which the reader can use this information to improve his or her local community. So I immediately flip back to the end of the book and landed on chapter 13 and the first sentence says worrying about a problem and talking about a problem are not the same thing as solving a problem. I think architects are really good at worrying and even better at talking about a problem and we're actually trained to be creative problem solvers but I think a problem as big as the health of our community deserves a broad involvement that starts with each of you in this room. I think that if we all work together with our collective wisdom we can make great strides towards solving the health and environmental challenges our community faces. How do we do this? Well AI San Antonio has some ideas and I'm sure you guys are all aware of the mayor's initiative with SA 2020 and the progress they've made there but we really want your ideas so please don't ignore those comment cards that are on your chair. I think the very most important questions actually the last one that asked for recommendations on how we can continue the dialogue that is started here today and recommendations on next year's events but really it's more important we don't want this to just be something that happens once a year where we talk. We really want to continue the conversation and make some change in our community. Now all that said some great strides have already been made towards making San Antonio healthy healthier community and Bob mentioned the nine projects that we're honoring in our Designing Healthy Communities exhibit that you can see at the Center for Architecture. These are all success stories that are making or will soon be making a difference in the health of our community and we also encourage you to if you haven't don't already have Dr. Jackson's book he'll be available afterwards to sign books. Another important event that's happening in March is the city of San Antonio Metro Health District is hosting a public health and built environment conference so that's one one way that this dialogue can continue and I encourage all of you to to learn more about that there's also a board out in the lobby more information. Now an organization that I believe is a success story in terms of collaborating is the San Antonio River Authority also known as CERA. Last year's luncheon CERA approached the AIA to help them spread the word about the virtues of low-impact development. We have and will continue to help them in their efforts and we're glad to have them as presenting sponsors for today's luncheon. I also think it's very appropriate last night we learned that one of Dr. Jackson's passions is to turn the LA River which is currently a concrete ditch into a nice river through San Antonio that can really improve the health of its community so there are some similar missions here. Now Karen Bishop is now going to give a brief talk on expanding San Antonio's sustainable equation to include sustainable land use. Karen has 11 years experience with the San Antonio River Authority she helped create and now leads CERA's sustainable watersheds implementation program. This program houses projects aimed at improving the water quality and ecosystem health of our basin's river system through sustainable land use restoration and watershed master planning practices. Please join me in welcoming Karen Bishop and once again thanking the San Antonio River Authority for their support of this event. Thank you Tenna for those remarks and also thank you AIA for this wonderful event. You know people have lived along the San Antonio River for thousands of years. Some of you may know of the old ox cart trail which brought commerce to and from the coast in Mexico and San Antonio and commerce and the river have been linked a long time in the San Antonio community. When you leave today look around in any direction and what you're going to see is that our river has continued and does continue to spur development in our community. We at the San Antonio River Authority believe that healthy accessible watersheds still drive economic growth. We also believe that sustainable land use practices are vital to healthy watersheds. In fact our board of directors has created a series of position papers and a couple of those are dedicated to sustainability issues and the reason is because the greatest remaining threat to our river's water quality is stormwater runoff, non-point source pollution. There are solutions and those include low impact development, green infrastructure and conservation development that incorporates LID. These are practices that mimic the land's natural pre-development hydrology. They reduce stormwater's volume and velocity as the water hits the rivers from our communities. It promotes filtration of contaminants again before the water from our communities hits the storm drain system and enters our river. It decreases erosion from the force of the water as it enters our river system and importantly it capitalizes upon a growing body of evidence showing that sustainable land use practices decrease stormwater infrastructure costs, have lower life cycle maintenance costs, increase property values and increase people's quality of life. Now we need the architects and the landscape architects to be at the planning table very early when projects are being planned and sites are being selected because when there's a multidisciplinary team of all those professionals at the table at the same time, there can be a reduction in traditional infrastructure and the costs associated with it. You can capitalize on the dual benefits of landscaping to provide both aesthetics and stormwater management. You can balance the environmental quality of life and economic components of a project. San Antonio is lagging behind some of the other progressive communities and the nation in land use sustainability, but we are taking steps in the right direction. At the River Authority, we recognize that there's more involved in the incorporation of LID than waking up one morning and saying, we're going to do it. So some of the things that the River Authority is doing along with the Bayer Regional Watershed Management Partnerships and private sector is we're looking at ordinances and codes. We're looking for barriers and incentives that can replace them. We're looking at the kind of training that needs to be brought to the professional community, to the contractors, to the construction individuals, and to O&M staffs. And as Tenen mentioned, SA 2020 embraces LID as a solution to land use management concerns. And H-Park also recognizes the significance of LID. So I'd like to take just a moment and have all the folks from H-Park raise their hands. The River Authority nominated them as an honoree for today's presentation, so I wanted to give them a little bit of an acknowledgement. In closing, Sarah asked that everyone here help us expand San Antonio's understanding of sustainability to include land use development and stormwater best management practices. Thank you. Thank you very much. Well, it's my privilege now to introduce a distinguished physician and leader in public health. I'm not introducing our keynote speaker. I'm introducing one of our own, Dr. Thomas Schlenker, who is the director of the San Antonio Metropolitan Health Organization, a position he assumed last year after the retirement of Fernando Guerra, Dr. Guerra, our longtime metro health leader. And Thomas couldn't be a more perfect fit for our community right now. He, let me tell you a little bit about him. His medical degree is from Northwestern University in Evanston. He did pediatric studies at, I believe it was Wisconsin, and then went on to graduate from the Harvard, the, excuse me, my Harvard University School of Public Health. He's practiced general and hospital-based pediatrics in Wisconsin, which makes him a very timely specialist in this community with what's going on with children's hospitals. And he's led health departments in Milwaukee, Madison, Wisconsin, and Salt Lake City, where he last was before coming here. He also has another valuable line on his resume, I think, that connects him to San Antonio. And that is his work in Latin America, including a year as a senior Fulbright Fellow at the National Institute of Public Health in Cuernavaca. So he's had experience in Mexico, too, on the ground. Subjects of his published research include epidemiology, got that word wrong, measles and hepatitis A, and immunization strategies, and childhood-led poisoning and infant mortality. So please welcome Dr. Thomas Schlenkler to the podium, and he'll give us a conversation about our city's health. Hello, everybody. Great to see all here. Wonderful crowd in a beautiful place like this, in a beautiful setting here at the Pearl Brewery Complex. I'm just delighted to be able to introduce my old friend Dick Jackson, who is now professor and chairman of the Department of Environmental Health Sciences at UCLA, School of Public Health. We are both physicians who practice public health, who started out as pediatricians. And about 25 years ago, and this is how we first got to know about each other, we were very much engaged in the issue of lead poisoning in children. Which, for me, I think for both of us, was a very, very dramatic example about how the physical environment that someone lives in can have a tremendous effect on health. And in addition to that, lead poisoning in children, in most cases, comes from the homes where they live. So we had a crash course that lasted years, actually, in issues of housing and construction and rehabilitation, finance, the politics of urban housing markets, and many, many other things, which, believe me, there were no courses like that in medical school. So we had to learn it on the fly. But I think it served us well in that it, for me, at least, it opened up the entire universe of the environment in which we live and how that affects our health. And there are so many different ways that that happens. And that's why we're all here today. So from that beginning in childhood lead poisoning, Dr. Jackson has gone on to many wonderful things. He became the health officer for the entire state of California and does not so very good impression of Arnold Schwarzenegger, but he learned that firsthand. Then he became the director of the CDC's National Center for Environmental Health, where he was for a number of years, did tremendous work until, more recently, he moved back to the West Coast and is now based at UCLA and has become a national figure in the subject that we are also interested in here today. And that is how to design a healthy community and what is a healthy community. I have a set of color PowerPoint slides that describe obesity in the United States that are really terrific. But I forgot to bring them today. So if you could imagine with me, imagine a map of the United States, a color coded map of the United States with all the states depicting the percentage of obesity within the population. And obesity is defined medically as a body mass index, a BMI over 30, which and that's a way that we correlate somebody's weight with their height so that it makes sense. But an obese person, somebody with a BMI over 30, that would correspond to, if you're five foot four, you're 30 pounds overweight. And so it's considerable and it is an issue that was first mapped out nationally in 1985. So imagine this map from 1985. It has three colors on it, white, light blue and kind of a darker blue. Half of the map is white because from those states, no data was reported. And then the light blue is from zero to 10% obese. Zero to 10% of the population is obese and the darker blue is from 11 to 14% of the population is obese. So in 1985, you saw white, light blue and blue. There were eight states that were obese in the higher category up to 14% in 1985. Then go to the next year, 1990, and look at the same map. And the dark blue now includes 31 states. So in five years, we went from eight to 31 states. Go ahead, 10 more years to the year 2000. And the first thing that you notice is that they had to add two more colors. They did not have enough colors. And in the year 2000, there was only one state that was in the dark blue category, 11 to 14%. And that was Colorado. But of course, the irony is, is that Colorado was and is the fittest state in the country. So every single state in the United States was above 14% of their population being obese in the year 2000. And of the two new colors, they went all the way up to greater than 20% obese. And there were 22 states in the year 2000 that were greater than 20% obese. So let's move up to 2010. And guess what? They still didn't have enough colors. They had to add two more colors. And in 2010, which is the most recent data, every single state in the United States is over 20% obese, including Colorado. And 11 states, including Texas, are over 30% obese. So try to picture these five maps in your mind and just imagine the progression over just the past 25 years or so. What is happening to us? It truly is a national disaster. We could talk about why it's happening and everybody has five or six theories on why it's happening and probably they're all right. But I think where we're at now is what to do about it and what to do about it in a very fast way as in now. San Antonio, one third of our local population is obese. Another third is overweight. So two thirds of our local population is either overweight or obese. The latest statistics suggest that 14% of our population actually has the diagnosis of diabetes. That requires them to take medication to control their blood sugars. And I think most of us in this room are aware of the complications of diabetes. We can certainly see it every day. Just walking down the street, all of our fellow citizens without limbs. Most of them, that's because of diabetic amputation. And also we know that 22.5% of our local population is physically inactive. And by physically inactive, the definition for that is no physical activity other than what you do at your job in the past month. 22%. So we have some very, very serious issues locally. But we I think are beyond the stage of talking about it and worrying about it where we need to take action. And my own personal mathematical equation for health is healthy food, an active lifestyle, and community. And the first two are sort of no-brainers. It's well-accepted, part of the cultural wisdom. Not everybody does it, but everybody knows it. The third one, community, is a new concept for a lot of us. And it's one though that I think we will learn a lot more about in the next hour or so because it is absolutely essential to becoming a healthy community. And so much of that has to do with the design of our physical spaces and structures. So as was mentioned, I've only been here for a year and I'm still discovering this new place where I live. And it was a complete surprise and pleasure to me to be invited by the local chapter of the American Institute of Architects to participate in this luncheon and this project and to come to know that we have a group of smart and creative architects who know the community, who care about the community that we all live in and are working very hard to try to transform it to what it needs to be. And so we are all blessed and it's wonderful to sit at a table and be in a hall that's a bunch of doctors and a bunch of architects and a bunch of other folks all kind of focusing on the same thing. So I can't describe to you how pleased I am to discover that that is a situation we have. And there are nine examples of wonderful work that's been done. As others have mentioned, it's worth a walk over to the full goods building, to the offices of the AIA to view the exhibit. And I won't mention them all again because they've been done before, but they're all extremely worthwhile. The one thing that I will mention is that one of the honorees is C. Clovia. And the next one is coming up October 7th. And those of you who participated in the previous ones, you don't need to be invited. I know you're going to be there. And the biggest reason is it's just so darn much fun. But for those of you who haven't really, you need to be there and bring your friends and bring your family, neighbors, workmates, grab some of these posters, cards that are out there on the table. The last C. Clovia was actually 40,000 people in the spring of this year. And I'm predicting 80,000 people on October 7th. So that's something that truly is not to be missed. But then it takes more than a single event like today. It takes more than a single event like C. Clovia. It takes an ongoing campaign where we bring people together from science, from urban design, the builders, the financiers, the bankers, bring us all together and in a continuing way, reconstruct this wonderful city that we live in that, yes, it needs a lot of work. But there's just so much potential here. And we have to take advantage of all that is being offered us. One way that I think will move us in that direction is next March 19th, we will be having here a full day conference called Public Health in the Built Environment that, number one, I invite everybody here to attend, but not just attend as part of the audience. I expect that many of you in the audience will be presenting at this conference, showing some of the great achievements that we have already in place here in San Antonio and talking about some of the dreams for the future. There will be people from all over Texas coming and we'll hear some of them, some of their successes and failures too. But this is a process that we all have to commit ourselves to and make sure that it is ongoing. So without further ado, we are so fortunate to have Dr. Richard Jackson with us this morning. Please come on up, Dick. Welcome to San Antonio. I worked for 30 years doing epidemic investigations and looking at chemical effects on people, air pollution, a whole series of issues. And about 10 years ago, while I was at the Centers for Disease Control and Prevention, I became really engrossed, almost obsessed with the fact that we have built America in a way that is, I believe, fundamentally unhealthy. How many of you are taking medicine for asthma? See your son's not be able to take a breath is one of the hardest things I've ever had to deal with. Every parent out there whose child has asthma understands how I feel. We could not have designed an environment that is more difficult for people's well being at this point, particularly as we look at epidemics of obesity, diabetes. Diabetes is not a good thing to follow around with. I went in for some treatment. They said I was going to take my foot off. With young people that I work with, the population that were obese are now heading towards morbid obesity. We're looking at the first generation in American history to have a shorter lifespan than their parents. In 2001, members of Congress thought that I should be fired because I did suggest that how we are building America might be bad for our health, might be making us overweight, unfit, depressed, and lonely. In 2001, my views were considered so controversial they almost got me fired. Today, they are at the center of a provocative new television series. Now being broadcast on public television stations throughout the United States, designing healthy communities is a four hour mini series and companion book based on my extensive work in the field of public health. Folks that are providing people good and healthy food, you're more a doctor than I am. As a practicing physician, author, former director of the National Center for Environmental Health at CDC, and current professor and chair of Environmental Health Sciences at UCLA. I'm a professor at UCLA, but my passion is how we build where we live and how it affects people's health and why we need to rebuild all the places that we live in ways that make us all better, young, old, and everybody in between. Too big a topic to be contained in just one program, we traveled around our nation filming in communities large and small with a vast variety of design and health related issues. Each of the one hour episodes tackles specific problems and offers realistic solutions that will promote better health and enhance the overall quality of our lives. On the first of four episodes, the time has come for the retrofitting of suburbia. We will see communities that are combating the causes of diabetes, not through medication and amputation, but by redesigning our car-centric society. The second episode gives insights on rebuilding places of the heart. We visit cities struggling to resuscitate their dying downtowns, where the polluting sins of past industries haunt the future. This lake is a super fund lake. The only super fund lake in the United States. You look at the problems and you recognize them and you grieve over them, but at the same time, you look and see what can be done and you do your best to help. All across our nation, young people are working to better their cities and neighborhoods by redesigning places of the heart. Social policy in concrete is our third program. Differences in life expectancy between the poorest neighborhoods and the wealthiest neighborhoods exceed 10 years. When we tell people in our county, give me your address. I'll tell you how long you live. We see how low-income neighborhoods are affected by pollution and how the city of Detroit struggles to save itself. And today, we are ground zero. We are the New Orleans without Katrina. On the last episode, I go searching for Shangri-La. Can the perfect community exist? It would be a place where kids would feel safe and senior citizens could walk and feel like they were protected and well thought of. We seek to find perfect communities large and small, past and present, that embody the intricate balance of health-promoting design and the human needs for fulfillment and happiness. When you come home, you want to feel a sense of haven and that's what people feel here. In addition to the series, educator Stacy Sinclair and I have written a companion book that offers in further detail the root causes of our national health crisis and highlights community design solutions to these problems. I was recently honored to be the sole guest on the PBS nationally broadcast, Tavis Smiley Show. And for too long, we've been worrying about things far away or very minute. And it was time to think about designing and building places that work for people. Let's hope that message gets through and I'm honored to have you on this program. Thank you for the work that you are doing and all the best to you. Thank you, Tavis. Here's what people are. So is this oh good this mic is on. So that's the promo for the video series and boy did I learn a lot going around the country. I was in Detroit with two camera crews for three days and you see a city that's gone from two million people to 700,000. It really hits you. Just the social and economic changes that hit at one time. I want to thank Tom Schlenker. I actually had Fernando Guara on my advisory committee when I was at CDC. Wonderful public health leader and Tom I tried to recruit away from Wisconsin but somehow he didn't want to come to sprawlanta. So we never got him to come to CDC but we've done lots of lead poisoning work together. In fact, 1975, 1970, what do you think your blood lead was? It was probably about 22. The definition of lead poisoning back then was a blood lead of 60. The lowest blood lead that was found on planet earth was a blood lead of 3 and the problem of lead poisoning in children we had 10 kids a year in every major city die of lead poisoning. It felt insurmountable. Lead was in the water. Lead was in our food. It was in our paint. There were three grams of lead in every gallon of gasoline and over time over a generation we turned down all those dials. We got rid of it from paint, gasoline and elsewhere. What do you think the average blood lead of a baby underage 12 months in America is today? It's about .5. Spectacular decline. We have added six IQ points to every single child born in America by the removal of lead from our environment. Huge driver. In fact, when I presented this data to the Ministry of Health of China, it actually led to China removing lead from gasoline. You don't need to tell the Chinese people that smart kids are important to them. Anyway, it's been there. These are the two books. One is the textbook that I use in my course at UCLA. That's making healthy places. It's well referenced. The other is the companion book for the video series and that's the flyer for the video series if you want. I should have put some out. They're available for 20 bucks. I want to get it shown in San Antonio, Bob, so we're going to work hard. It's actually been shown now in about between one and 10 million homes in the United States. It's hard to know exactly because of the way it's shown and done. I was searching for what would be my link to San Antonio other than I served on the Armed Forces Epidemiology Board and met a chiff of him a fair number of times. The young man you see there at age 21 had just gotten his wings. He married a year later, the woman who was my mother. Bob flew P40s and P51s. After my mother died last year in her stuff, I found his diploma from flight school from Brooks Field. It gave me a bit of a smile as I read about certifies by prayer, perspiration, peeping, and politics as completed instrument flying as a classic sort of military humor. Bob survived a crash at Iwo Jima. He was in the drink. One time he flew escort missions for the bombing runs. Survived World War II, came back, had three little kids and in 1949 had trouble breathing on August 17th and by August 19th was dead of polio, leaving my mother with three babies and diapers. I tell this story because a five dollar polio shot would have prevented a catastrophe and in fact when my mom died last year, she wanted to be buried with her first husband who had died 65 years before. So I think in a lot of ways it ended up leading me to pediatrics because of the intensity of my childhood experience and leading me to public health and just the importance and one of the high points of my life was working on smallpox eradication in India and then later on polio eradication and it gave a nice symmetry to my life. That FAAP after my name stands for fellow of the American Academy of Pediatrics. It's not very pretty. In fact one day my kids came up to me and said dad why does it say miles per hour after your name, the MPH, Master of Public Health. Every time you take your child and you were taking your six month old to the doctor this morning, they plot out the height and weight on a growth chart for your child and you want your baby or your child to have a weight level that is about the same percentile as the height. So if your child is really tall like you and it's a child's 80th percentile, you want her to be 80th percentile for weight. You don't want 10 percentile because you don't want the baby to be too skinny but you also don't want the child at 99th percentile at the same time. So this happens at every visit. So here is a about a 10 year old comes in and the child looks fine but he's 50th percentile for height and 95th percentile for height. If you're overweight it raises your risk of high blood pressure, of metabolic syndrome, of borderline diabetes and raises your cholesterol and child seems kind of depressed. So what's a good doctor do? What does she say? They don't immediately put the child on drugs. No TV in the bedroom, no soft drinks in the house. If you remember nothing else from this talk, no soft drinks in homes with children in them. They just don't have them. And get the child more active, go to PE. Well two months later the child comes back and what change do you think you've seen? Or do you see? Nothing. Child can't change the routine at school. He can't walk or bike to school. He can't change the food that's serving at school. They don't have PE at school. And two months after that the child's taking about $400 worth of medication. Something for the elevated blood sugar, something for maybe even something for his depression and something for his overweight. And what I'm going to argue to the architects in this room is we have medicalized what in fact are environmental problems and environmentally driven problems. And the environment is rigged against the child, but it's also rigged against the doctor. And my physician friends are seeing five, six children like this today. My son's an internist and he's saying about 20% of all the patients I see essentially have overweight disorders that are related to too much mass, body mass, and too little physical activity. When I was young we ran an event on the skyrocketing cost of medical care. 7% of all the dollars in America going to medical care. And today it's 19%. You cannot run an economy based upon medical. By the way, did you notice the word I just used? I didn't say health care. I said medical care. With all that money, you would think we'd be the healthiest people in the world. And we're a little better than Slovenia, but we're nowhere near as good as Costa Rica, which spends seven times less money in terms of life spans. So we're not getting very much for our money because we're sitting at the end of the disease pipeline. And those of us in public health have got to move upstream and start intervening with where these diseases are occurring, whether it's farm policy, transportation policy, building policy, agricultural policy, and the rest. We've added 30 years to the lifespan of an American since over the last 100 years. How much of that has come from medical care? About five years have come from medical care. And the other 25 comes from the two big eyes. Immunization and infrastructure. And that's what public works does. It's what architecture does. It's creating the physical facility. So clean water, clean air, clean food, safer workplaces have been the big change in life spans in America. So in 1994, I was offered the director position at CDC in Atlanta. And we were living in Northern California. I married to California and even though I was a Jersey boy, I've suffered from bicoastiality ever since. And you could imagine in August moving three middle school kids to Atlanta on a 99 degree day with 99% humidity out of the Bay Area. They thought I was the stupidest man in the world. But the director of CDC was writing a paper in 1999 on what will be the leading causes of death in the 21st century. The leading diseases. And the injury guys are thinking, oh, injuries are really important. The chronic disease people are thinking, oh, diabetes and asthma. The health statistics people are saying, you know, we doubled the population just over the last 80 years. We're going to double the population again. I'm doing environmental health. I'm thinking about environmental chemicals, global warming and a whole series of other issues. And I'm driving down Buford Highway in Atlanta. And you have streets like this. It's three lanes in each direction. It's got a suicide lane in the middle as they call it there. And it's got two and three story homes of garden apartments of the very poor all the way along the road. It's two miles between crosswalks. And what happens when poor people trying to get to work have to walk a mile to get to a crosswalk. This street had the highest pedestrian death rate in the state of Georgia, which had one of the highest pedestrian death rates in the United States. And every time you'd read an article about somebody being killed on the road, it would always say Jay Walker killed rather than negligent transportation and design engineers not having a way that people can get safely across the street. So I'm driving I'm rushing to this meeting and I'm going along and it's really hot out and I look to the right and here's an elderly woman struggling she's bent over with osteoporosis and she's got a shopping bag one in each hand. She's clearly in her late 70s and it's really hot. And I want to stop and give her a ride. I don't do it. I go to my meeting and we're talking big stuff. All I can think is that poor woman if she collapses, because of death will be heat stroke. And it won't be absence of trees, heat island effects, lack of transportation. And if she's killed by a truck going by, the cause of death will be motor vehicle trauma. And it won't be absence of public transit absence of sidewalks poor urban planning and failed political leadership. What I want to say and I say this to my students, public health is about the causes of the causes of death. And when you start going upstream dealing with the causes of the causes, it is inherently political. And Tom even said the word, you get a political education when you start dealing with the landlords and all these other issues. We picked 10 things that was published. And I'm going to argue at least half the big killers in the 21st century are related to how we build where we live. What's the message of this building? In the United States we built about 3 million of these a year in 2004, 2005, 2006. I would say the message of that building is the family is an appendage to the automobiles. Because it occupies, the automobile is really dominating the lifestyle. And you look at their day and people that are living in Tracy California and work in the Bay Area are spending three to four hours a day in the car. You can imagine after a three hour and a half commute back home after a long day of work, what kind of food are you likely to serve your kids and what kind of meal are you going to have at that point. It's fast food and it's you're exhausted. This is a picture of the California state flower. And the problem is they work really well for about six to 10 years and then everybody discovers, everybody discovers, oh you can end up in a pretty nice house on a big lot and it's only 20 miles away and in the beginning it was 20 minutes of driving and after a while it's an hour of driving. But here's the line that I'd like the architects to remember. The affordable housing policy of the United States since World War II is drive until you qualify. Because that's how we dealt with it. You just drive, drive, drive and that's how you get there. Well, I was alive in 1955 when they opened Disneyland. And I remember watching on the black and white TV and they had Tomorrowland and Frontierland. They had like a main street where you should go and see where people could walk and have shop fronts and everything else. I thought, gee, I'd like to visit Disneyland. But during the opening, they took a shot looking at the five freeway over in Anaheim. And the five freeway had five cars on it. That's what all of our roads look like at this point. And so young people in America now are, many of them are not even going and getting driver's licenses because it is so difficult to get anywhere. And if you ask the average person in many of our cities, whether it's Los Angeles or Atlanta, probably a number of the Texas cities, what's the hardest part of your day? What's the hardest part of your job? They say, oh, my job's not bad, but the commute's killing me. And the more time you spend in the car, the higher the risk of not only being obese but of having high blood pressure. One of our sessions in the video series is called Health Policy in Concrete. The health policy in Northwest Atlanta was they did not want MARTA. And I remember being at a public meeting where someone said, MARTA stands for Moving African Americans Rapidly Through Atlanta. And the social policy in Northwest Atlanta was they didn't want the wrong element coming in. And I remember that, the tones being, the terms being used quite a bit. So they didn't build a road thing. So now there are 23 lanes that stop three to four hours a day. I think God's punishing them for their bigotry in one sense. But it's also sooner or later it makes no sense to move a 175-pound human being by moving 3,500 pounds of steel. On October 12th, all the major university newspapers in the country had this half-page ad. And the half-page ad, they had done focus, GM, General Motors, had done focus group testing, I am sure, with college kids. What message will resonate best with college kids? Reality sucks. You can even imagine the kids said, you know, I've got all these loans. I can't pay them back. I can't get a job. I'm stressed out with all the things I've got going on. Reality sucks. General Motors had a cure. General Motors says, well, stop peddling, start driving. Luckily, the GM college discount doesn't suck. And you can get for $35,000 a GMC Sierra and pay it off over the next seven years along with all your college loans. Well, I was very upset about this and about a thousand people just from LA wrote angry notes to General Motors. They pulled the ad campaign. So I was showing it in class the next day. And they said, what do you make of this? A pretty girl is smirking at the guy who's doing exactly what we want him to do. He's not polluting. He's not. He's getting physical extra exercise. He's not adding to the congestion in the neighborhoods. Dr. Jay, you don't understand what's going on here. She's flirting with him. She doesn't want to be with the flabby guy driving the car. But General Motors was right. In 20 years, we've quadrupled four times increase in the consumption of antidepressants. The United States, second most common medicines taken in the U.S. right now are antidepressants. You think about cars and how many miles, how many of you have bought lottery tickets? Well, what do you think you're one in a million chance of dying in a car crashes? How many miles do you have to drive to get a one in a million chance of dying? Eighty seven miles in the U.S. So some of the people in this room are going to buy two lottery tickets a day with just the commuting that you're doing. About one percent. The leading cause of death ages three to 34 in the United States is car crashes. The more we drive, the worse the air quality. And so the most polluted cities in the United States are those that are hot, sunny and have lots and lots of vehicles, particularly diesel. And if you have bad air quality, oh yeah, yeah, that's everybody's used to bad air. But the truth is more people die from poor air quality in the United States than actually die from car crashes. That's a lot of people when you actually look at the burden of disease. Here's a study one of my friends did out of USC looking at kids in the higher pollution high schools in Los Angeles versus those in the low air pollution schools. They looked at kids that do athletics. And by the end of four years of high school, the kids in the higher pollution had three times the rate of asthma as the kids in the low air pollution areas. So what you put in your car, what goes into the air, and what kids are breathing ultimately is going to dictate or at least influence their well-being. I want to talk about some chronic disease epidemics. And Tom alluded to this, and I will go through them quickly. How many of you have seen these obesity maps? So maybe 15% of the people in the room. CDC interviews on the telephone 200,000 people a year. And they started out by asking lots of things. They weren't terribly interested in height and weight when they first started doing the risk factors survey. They noticed this very odd thing from 1980 going forward. And you can see in 1991, Texas is at about 10 to 14% of its population. I won't go away back to 1980. By 1997, as Tom indicated, we're at 15 to 19% of Texans being obese. This is an overweight obese. By 2004, a brand new color over a quarter of the population of Texas obese. By 2009, still about 25 to 29% and by the year 2010, Texas is now over 30% of the population obese. Being obese is not good for us. It raises our risk of high blood pressure, of stroke, of heart disease, of liver disease, gallbladder disease, bad joints of a woman having a baby with birth defects, bad feet and other health problems. And there are lots of causes for it. And as Tom said, I believe there's probably 6 to 10 causes of it, chemicals in our environment and other things. But this is one of them. My personal opinion is we should not make this stuff dirt cheap and easily available. And McDonald's now is actually labeling caloric load. And the first argument was well, people won't read the number of calories. If you're bored to tears and you're waiting for the kids to finish their snack, you'll sit there and read anything. So I think people will begin to pay attention to it. 7 hours of walking. So here's a fact to what you can take. Next time you take the kids and the guy says, do you want to supersize it? Because you can get a whole lot more for not very much money. When you supersize a meal, you add one ounce of body fat to your body. An ounce of body fat additional lifetime health care costs is about six bucks for a man and three bucks for a woman. Now there's a little tongue in cheek, but the bigger point here is we're too often looking at short term returns on our investment rather than the long term impacts of the things that we are doing. And if you look at the obesity statistics, the obesity rates are much higher in people of color in our minority populations and they're much higher in less educated populations. But I guarantee you there is not a fast food joint in Beverly Hills, California, but there are plenty of them in very poor neighborhoods and I'll talk about this a little more. And so already if you created an environment that is obesogenic for people that are living there, we need to convince every kid in America that if you eat low quality food, if you eat food spelled backwards, you are a doofus. Because I was doing environmental health at CDC, I was worried about the obesity impacts and so between 1990 and the year 2000 we gained about 10 pounds every single adult in America, but jeez I wonder how much jet fuel that is. And so calculated out it's about one and a half billion dollars worth of jet fuel a year to haul around our additional 10 pounds of unneeded adiposity which I wrote up and signed it as being a guy from CDC and one of the medical journals and it was cited by Jay Leno. And that night Jay Leno, CDC says we're burning off lots of jet fuel because we all gained weight. Now I know why the airlines don't feed us anymore. As we gain weight and I talked about all the bad things that happen as we gain weight, but one of the worst and things we worry about worst is this stair step increase in your risk of becoming diabetic. And the lighter line is the risk for a woman. So the body mass index goes up and the woman's risk goes up dramatically. My risk is about four to five times higher than it would be if I were skinny. I'm not proud of that. I'm doing my best. I will talk about that a little bit later on. But if I were morbidly obese and a woman I'd have almost a hundred times the risk of becoming diabetic and a man would have about 40 times the risk. Here's the obesity maps in the United States and you can predict that if obesity has gone up a lot over the last 25 years, pretty soon we're going to see the diabetes maps go up. Look at the change over just 10 years. Here's Texas, it looks like it's about 6%, 2001, maybe 7% in Texas, maybe 8% pretty close. In 2007 the latest map I could find, 9%, tell them I did not know that San Antonio was running 14%. So walking down the street in San Antonio, one person in seven has a disease that's going to cost them their eyes, their kidneys, and their feet and eventually their hearts. When we were young we'd go into the pediatric clinic, the diabetes clinic, we'd never see a child with adult onset diabetes. We call it adult onset. Now we call it type 2 diabetes. Half the kids in the pediatric clinic for diabetes have adult onset type 2 diabetes and we're not managing them well. Medically they're very, very difficult to manage. It's a very costly disease, we're now spending 2% of the entire gross domestic product of the United States just on this one disease. When we were young the fifth reason for a person needing a new kidney was diabetes, it's far and away the first reason. We talk about transplant campaigns and others, I think it's great and we all should be organ donors but I'd rather prevent the need for new organs than to have to look at this. I would argue in part it's being driven by how we have built America. Suppose you're an 8-year-old child and you're living at the top of the dead end, call the sack up there and you want to visit your house, your friend who lives three houses away. What would be the best way to go see her? You could climb over the fence and pass the Doberman and the Rottweiler and pass the pervert and the other guy up there and you could go to your friend's house, four houses away or you could get on your little bike and you could bicycle for two and a half miles all through and you all have been in places like this where you can't get 100 yards away without driving and there are plenty of kids that are within sight of schools who cannot walk to school because of how we've designed America. This has implications for the women in this room. The women in this room drive twice as much as your mother did who drove twice as much as her mother did and a lot of it's chauffeuring. I will assert that every American ought to have the right to buy a carton of milk without getting in a car. This is Northern Europe and about 40% of their short trips one to two miles are made walking and biking. What do you think it is in the USA? It's about 7% of the trips walking by even worse than Canada. How many of you walked or bike as kids to school? Wow. How many of you have children or grandchildren who walk to school? That's still very good. I'm going to assert that we have committed malpractice in terms of our sighting of schools. We build these big box schools way outside of town. The capital costs are less because the land is cheap but the operating costs, particularly as the families are carrying and moving these kids back and forth or you're paying for school buses to get them back and forth, are really very expensive when you look over the long term, not over the short term, back to the hamburger analogy. You think taking kids' legs away from them is bad for them? This is how many kids, what percentage of our, we require the fitness gram on the report card in California. We don't put the body mass on the report card but we do require the fitness gram. So two-thirds of our kids can't run, walk a 12-minute mile in high school. Bob can run walk a 12-minute mile and he's no chicken. I mean, but this is very worrisome. The Pentagon is extremely concerned that two out of every seven applicants for the military cannot get in because of obesity and lack of fitness at this point. I'm going to skip these because I can see. So I did something very foolish last night after listening to my brilliant table mates, I decided I was going to do a completely new talk and talk about solutions using the San Antonio 2020 plan. So I'm breaking new ground but I love it. And it's interesting because it's alphabetical and I had never thought about going after all the problems in an alphabetical order but it's great. So I'm going to take arts and culture. If you want to change people, you've got to change the culture. You watch Mad Men and you think on television and you think it's perfectly normal for everybody to drink three martinis and smoke cigarettes all day long. So we've seen an amazing cultural change about the acceptance of tobacco and for that matter three martinis at lunch. But I do think that art, I think the 1% to 2% set aside for art is so important as design goes forward and really good design. You almost don't notice that it's so beautifully done. And I just want to commend this. Actually, I have given lots of talks in hotels and medical centers. I think this is the most beautiful room that I have spoken in perhaps in my whole life and I'm going to actually commend the architects and the people that designed this room. And that ceiling is just out of this world and building. So the art that a lot of Americans look at is commercial art. And this is a project one of my students did a presentation. They drove down Sunset Boulevard and they looked at the billboards. Billboards are extremely effective advertising tools and I can't read it quite well from here but you can see what the prevalence of billboards are and the digital billboards we really got to begin to look at a lot more because I'm concerned about them. Of interest, one of my students who is Latina said this is very interesting because when we do murals on the sides of buildings, for example, in the mission, they're done to empower the people. And I think that the billboards we put up are about disempowering people. But anyway, you can see what these ads are. They then went through the poor neighborhoods of down in Hawthorne, California for two miles, looking at the ads. Drink stuff that makes you fat, stupid, and ugly, eat stuff that makes you unhealthy, and go get stomach stapling surgery in order to fix all the things that you've been doing that we've been telling you to do. I mean, think about the way we've shaped. This is a physical environment shaping people's health and their behaviors. It's not a great slide but it basically says that 7,600 food ads for an average kid. So community safety. I think this is actually taken right here and I love the fact that the officer is on a mountain bike. Every kid ought to be able to walk or bike safely to school, in my opinion. Maybe mom needs to walk or dad or there needs to be a walking school bus but kids need to walk to school. And there ought to be police officers patrolling up and down the main streets as kids are going in and people should not have loose dogs running around and the pound and the animal control is an important public health program because nobody's going to have their kid walk to school if a vicious dog is roaming around the parking lots. This is the Academy of Pediatrics statement on what neighborhood children should grow up in. Wait a minute. Pediatricians prescribe medicines and vaccines and this is the first time they've ever written a statement on urban planning and design. Essentially saying children need to be in environments where they have increasing autonomy and increasing ability to encounter and deal with the world. Policy statement of the Academy of Pediatrics. So I'm just thrilled. I saw all the bikes today when I was coming over here. I came out of Union Station in Washington, D.C. a while back and this was these bikes for sale and for rent in D.C. And I was taking pictures and I looked over and I saw these two vehicles. One is a Trek mountain bike and one is a Segway. The police officers were having lunch, I guess. And I thought, gee, I wonder. What turns out that four to five days in a Segway you've gained a pound of body weight compared to bicycling as a police officer on the mountain bike. I particularly like these two ads that I took as screenshots because the cop on the mountain bike is considerably skinnier than the cops on the Segways. I actually, by the way, I don't understand paying 10 times as much for a vehicle where people stand around. I don't know. You want to talk to a cop on a mountain bike but you don't ever want to talk to a cop on a gyroscope. Downtown development. I'm going to argue that health ought to be at the table in terms of downtown development. It is unhealthy to walk past hot baking parking lots. Air quality degrades over these parking lots. Water collects over the parking lots. Wind gets more intense. Stuff goes in your eyes more readily. The more we can fill in parking lots and get rid of the gap tooth in American downtowns, the better off we are. And guess where really bright, well-educated, energetic young people want to live. They want to live in lively places with people like themselves. And they don't want to move to a place that's filled with empty parking lots. This is the Los Angeles, Ciclavia, I'm just stunned that a city of one and a half million people had 40,000 turnout for their Ciclavia. It's wonderful. The thing in LA, we had about 80,000, but it's a much bigger city. But what was remarkable was how many people turned out and said, I've driven along this boulevard 10,000 times and I had no idea how beautiful it was and how nice the people could be. And I got there faster than I would in my car. This is an odd slide. Why did I put the loss of farmland into downtown development? And I'm going to argue that the best way to preserve high-quality farmland is to create urban densities that people want to stay in so they don't feel the need to sprawl all over high-quality agricultural land. Economic competitiveness, I had to stretch a tiny bit for health, but the fifth or sixth most dangerous job in America is what? No job. So having a job is good for your health, particularly for men. The three biggest killer jobs are deep rock mining, deep sea fishing, and deep woods logging. And then long-distance trucking are some of the major killers. But right down that list is being out of work. So that's a health issue if a lot of people are unemployed. 56% of all the people looking to buy a house at this point in the United States buying a home or a condo want to be in walkable neighborhoods. Older folks don't want it because they don't want all the work of a big house and the younger folks don't want it because they saw the rat race that their parents were leading over the last generation. Anybody see the article this morning in the paper about a declining lifespan in Americans of a certain group? It was quite fascinating. The biggest predictor for people that are going to have a decline lifespan turns out to be a low level of education. And for American women, we've lost seven years of lifespan, women who are poorly or inadequately educated over the last decade. So it's really been a dramatic diminishment. Family well-being. This is when I was the Secret Service Man guarding Governor Schwarzenegger. And this is an event on the West Steps of the Capitol. But what it was really about was that we spent $14 billion a year in price supports for corn, soy, and four other commodity crops. And we provide no price supports to the things that are good for you. Fruits, vegetables, other kinds of food. I'm going to skip this. I'm going to skip this one as well. So I saw the work that you're doing in healthy schools here and gardens, McDonald's, posting food. I did make this slide after seeing the wonderful work of, I think that every kid ought to be able to walk and bike to school. I think every school ought to have a school garden. Kids need to know how to grow food, where food comes from. Some of the successful programs actually have grandparents teaching children to handle recipes. People were completely freaked out that sixth graders are being handled knives to cut food. And yet, every other culture in the world thinks nothing of having kids handle knives and cut food. Government accountability and civic engagement. I just think that what you're doing with the rivers is magnificent. If you want someone to go for a walk, put water nearby. Put natural features. By the way, a V of concrete somehow isn't as appealing as a green water bottom or a green riparian area that we can walk along. And you don't need to order people to wag your finger and say you need to do 10,000 steps a day. You give them a pleasant and attractive place to go, and they want to do the walk. And Mayor Peake, I want to thank you for all the work. I think we all thank you for all the work you've done to create places that really entice us to be active. Employers need to entice people to be active. Kaiser Permanente had this campaign. All new buildings that they build have pleasant, attractive stairways when you walk in. You have to look a little bit for the elevator with the message take the stairs. They need to be clean. Well, although Kaiser somehow didn't have their safety people, look at this picture before they put it in. Boring slide, and it's about, it's going to sound totally boring, four months ago, the Institute of Medicine of the United States came out with a 300-page report on reversing the obesity epidemic in the United States. Strategy one, recommendation one, goal number one, build communities that make it easier for people to walk. And it says to all the Tom Schlenkers in the country, you need to engage upstream with the people that are devising and building our communities. You need to be at the table. If you go from being unfit to fit in middle age, you add about six to eight years of lifespan. It's almost as good as stopping smoking. New York City has essentially redesigned, all their public buildings now have to be redesigned to enhance and encourage physical activity. I don't know if you've done the same thing here, but the public works is directed to do this in New York. Thanks to Mayor Bloomberg and leadership in New York, there's a 32-mile bike route around Manhattan now. If somebody had said to me five years ago, there'd be a 32-mile bike route around Manhattan, I would have said, that's crazy. It's never going to happen. And you know what? You see these people, and you think, they're not depressed. Everybody seems to be smiling. Protect the natural environment. And we've talked a little bit about this, but I just want to stay with us for a minute. In Germany, you're taxed for how much water runs off your property. In Santa Monica, we require that water that falls has to go into the land. You have different ways, swales, and other things to make the water go into the land. Once it goes in, it's filtered. Water you get out of the ground in these places is six times cheaper than water that's being in. So there's economic reasons, but it's also much better quality water as well. Parks, critical Olmsted called the parks the lungs of the city. You put a park in place, it gets cooler. You get less ozone formation. It's an attractive place for people to be. I actually gave a talk about a week ago at a big transportation meeting. The head of all the transportation agencies in the country at the session said, you know, our job is to move cars. I said, no, no, your job isn't to move cars. Because it's right there on the mission statement of the federal highway administration. No, no, your job is to move people and goods. It's not to move vehicles. 20 is plenty. If you're hit by a vehicle going 30 miles an hour, you have a 45% chance of dying. If you're hit by a vehicle going 20 miles an hour, you have a 5% chance. And for many of our downtown areas, people don't need to be going faster than 20 miles an hour. You're doing wonderful living streets. I know you've got an ordinance here, and that's great. This is a law we just signed into law about two days ago in California that says that living streets will be prioritized to the poor neighborhoods. Because you'll notice a lot of times the new public works ends up in the neighborhoods that already have a lot of the resources. Almost done. I like light rail. I can get on, I sort of relax, and eventually I get where I'm going. Charlotte, North Carolina, put in a light rail about five years ago. They happened to be looking at people's health before and after, and someone thought, gee, well, look and see what happened to light rail users. It was a study being done for a different reason. Here's the study, but I'm going to show you the results. After a couple of years, they went back and looked at the people who were taking light rail versus not taking light rail. People taking light rail were doing it to save money to be less stressed, maybe talk to their neighbors and be able to read a book. It turned out they were significantly more likely to meet all the guidelines for physical activity by just using the light rail. And this is really amazing. On average, just for someone only five foot five, after this much time, they on average lost six and a half pounds. So they thought they were just doing this to be physically active and in truth. They were also, is that a weight loss campaign? This is health impact assessment. If you want to talk about in Q&A, I will. This is one of the most amazing ones, which was where they built a brand new bridge over the bay in Charleston, the Ravenel Bridge. The transportation people said, we don't need a bicycle trail and a walking trail along the side. The budget people said it's a waste of money. The community insisted and did a health impact assessment. Eventually it was put in place. The third most dynamic tourist attraction now in Charleston is the walking and bike route on the bridge and people, it connects people and a lot of people using it for commuting. It really does work. If you visited Chinoga, Seoul, South Korea, a rather soulless city, would you like to sit down at a cafe, table and have a glass of wine and go for a walk along the Chinoga freeway here? They ripped it out. It was only about 40 years old. They ripped it out for a cost of close to a billion dollars. They recovered the creek underneath. Would you like to go for a walk there? Would you need to tell your children to go run around and enjoy themselves and be physically active? And this place has become not just a physical heart of the city, but a cultural heart. People want to be there and it's lively and full of people night and day. We in public health really care about these built environment issues. 10 years ago nobody was doing any work on this last APHA meeting, 102 presentations alone on land use, 182 on built environment. The best and the brightest in urban planning want to be doing health. And a lot of the brightest kids now doing public health want to be doing urban planning. How many of you have done this sort of thing on the creek or something else for Boy Scouts or Girl Scouts or Clubs or something? I think that your next project ought to be this one. So remember our 10-year-old? He starts to walk or bike to school one mile, four days a week. He saves $700 of gasoline for the family car back and forth. He makes new friends. He learns how to deal with bullies. He was learning better in school. Kids that walk or bike to school learn better, behave better, and socialize better. 30-minute walk burns about 125 calories. That's 40,000 calories for the school year. 11 and 1 half pounds of body fat. Goes back to the doctor after two years. He's down to the 65th percentile for weight to height, because he's grown four inches over that time. His blood pressure is pretty close to normal. His blood sugar is normal. His cholesterol is much better. His energy level and mood are better. He has a girlfriend, and he lives happily ever after because he's living in a place that entices and encourages him to be physically active. And with that, let me stop. And thank you all very, very much for your attention. That was terrific, Dr. Jackson. Thank you very much. And I realize once you got started, I neglected to tell people at the outset, those parfait desserts on your table were adornments. You weren't supposed to eat them. Don't touch those. Where's Mike Virial? Nothing wrong with happiness. Our state representative in one of the healthiest parts of the city, Mike Virial, is here. District 123, South Sound. And if you were inspired by Dr. Jackson's talk today and we're going to go into Q&A, let your friends and colleagues know that our friends from Nowcast, San Antonio, are here. They are streaming this on the web. It will be available for anyone that wasn't able to come here today. And it's, I think, an important enough occasion that we ought to spread the word and get more people in the city who weren't able to join us today to watch this. So there you go. NowcastSA.com. OK, I have a quick question. Do we have any police officials here? Anybody for the police? You know, I've really learned. We need to have those folks at these meetings. Good point. All right, next year, no dessert, more police. So I think Tori Carlton is roaming with a microphone. Tena Florian has it. Let's engage in a little conversation here. Who would like to share their BMI index? Well, I'll ask the first question, Dr., while Tena finds somebody who's not too shy. And we read a lot about the Austins and Portland and Seattle's of the world but do you have any particular places in America that you're seeing people reverse course and do well? The sole example is wonderful. I hadn't been there in 30 years and it was a city I detested when I was there but who's attacking this as well as we are? Better. One is the era. The stimulus funding, a lot of it has gone into something called CPPW, putting communities to work. And one of the big presses is connecting existing bikeways and walkways. So in the Bay Area, all $100 million went to, there were a bunch of disconnected bicycle routes. So my kids could bike all the way to about six blocks from school and then they were on pretty dangerous streets. So they've connected them all. They've connected it to the BART lines. They've connected it to larger retail. So really doing connections has helped a lot. And by the way, folks say, oh, I don't want a bike route in my backyard because it'll bring in the wrong element and people will come along and they'll steal my big screen TV on their bicycles. And the truth is that it actually raises the economic well-being. Guess what the most bikeable city in America is? And Tom Schleiker is going to know this because it's his neighbor, his former neighbor. Minneapolis, they plow the bike routes before they plow the streets. And you don't need to tell people to go along the La Croix River. There's wonderful bike routes all the way along. So a lot of this has happened. One of the towns we feature is Elgin, Illinois, which was a rust belt town that was struggling terribly after the Elgin Watch Company closed down. There was those pictures of the kids being very active. And they were doing a campaign. And they met with the Chamber of Commerce. They met with the city council saying, how come we can't walk and bike to school? How come the downtown is so boring? We don't want to go to all these boring franchise places way outside of town. We want to have a downtown that's fun to be in. And so many times it's been the young people that have been big leaders. So I don't know if they're education leaders here. Oftentimes the education leaders are so bogged down with budgets and everything else that this big picture of how do we create environments where kids are actualized and feel active and rather than kids feeling like reality sucks. Here's a question from the audience, Dr. Jackson. How can the medical community engage best in the political process at the local, state, and federal level to affect these changes you're promoting? One is at the federal level, CDC is, Senator DeSentral is putting out a fair amount of money for this community building work. It takes somebody whose job it is to be punching at this weekend and week out. And you've got very good leadership here on this. Two is the county medical society where the state medical society does resolutions. There is a resolution of the California Medical Association about kids needing to walk and buy school, about desync food in the school lunches, about school gardens at the schools, about access to the play areas and the playground areas of the schools. Many of the schools close the chain link fence and nobody can go in there and use it during non-school hours and the superintendents are scared to death. Somebody's gonna sue them if they fall down jogging on their trail. So the medical society needs to do that. I don't think doctors need to show up at every planning commission hearing, but it wouldn't hurt to have them come for 15 minutes and say, I'm taking care of 50 people with diabetes I barely can cope with the press of diseases and we need to have places that people can be active. We need to have places that people can get good, healthy food. And as somebody pointed out, the mayor's urologist has his complete attention during certain times. So maybe we can whisper in the elected officials ear when we have their complete attention. We have a question from the audience and if you could identify yourself by name and profession, that'd be great. Tyler Curiel, I'm a medical oncologist at the UT Health Science Center here. Is that on? I think it is. Tyler Curiel, I'm a medical oncologist at UT Health Science Center. So I learned a long time ago that I could never get my patients to wear sunscreen if I told them it would prevent them from getting skin cancer because it was vague and it was in the future. And I learned if I told them well, if you don't, you'll have leathery skin wrinkles and that grabs their attention. So that works. So now my office now, my lab, is on the second floor of a research building and my lab staff is 20-somethings, 30-somethings, young people. I can't get them to walk up the one flight of stairs to our labs. They always take the elevators and I try to get, if I tell them about health effects and heart disease, 30 years in future, it's like the sunscreen. It's not going to do any good. When I talk to people at dinner parties and so on, I tell them I need to be out walking, running. It's the thing, way in the future, they laugh, they're uncomfortable. So the leathery skin wrinkles worked really well for the sunscreen. Do you have something equivalent for that to get people to eat healthy and exercise? Wow, that's a wonderful question. And thank you for the work you do because you have a very hard job. One is, I like trees because they increase oxygen and reduce carbon dioxide and make it cooler and reduce air pollution. And you know, if all of our walks could be done under a beautiful canopy of trees on the sunny day, that's maybe a 10 to 20% reduction in photon load right there in environment changes. Two is when you're building the building, if you put a pleasant, attractive stairway, we knew how to build buildings in 1900 where when you walked in, you wanted to walk up. Some of the buildings are retrofitting it. They're cleaning the stairs, putting in glass doors on the landings and putting in actually music and painting them up in ways that are more attractive. Signage does work and it does increase it. I do not own stock in this company. This is a Fitbit and FIT, BIT. And it is a super pedometer and it actually tells me how much I walked, how many calories I burned. I'm embarrassed because I was planning for this talk, so I'm only at 1200 steps. So I'm gonna have to walk around two different airports on the way home to get to my 10,000 steps. But it's an odd thing. I'm such a nerd because I went to medical school and I was used to the next test and the next test. So I don't wanna get to the end of the day, load this into the computer and not get my 10,000 steps. It shows me exactly how many calories I'm burning. So whatever stimuli I can be, two more quick ones. One is the health insurance companies in many cities now charge you, give you fitness passes for the various gyms and other things. What they did in Washington, Nevada was you got the fitness pass but you had to actually go to the gym. So people are going to the gym and sliding the card and you get $50 or $100 more on your paycheck if you were doing this. It was the other way out. They deduct $50 or $100 from your paycheck if you weren't going. But they found as people were going, sitting around for the first month and pretty soon they actually were joining the Tai Chi and the yoga and even some of the other activities. So I think ultimately the mutual support counts for a lot and people that exercise are happier. Lowell kept telling me this over and over again. He bikes 30 miles every morning. Another question from the audience please. Hi Dr. Jackson. I'm back here, sorry. My name is Angela Hartzell. I work for Grain Spaces Alliance of South Texas. I'm also a graduate student in UTSA's urban and regional planning program. And one of the things that we have a problem with in our community gardens program here in San Antonio is finding financial support. And the main reason that we find financial support or have trouble with finding financial support is we don't have the metrics to sell community gardens to funders. And your presentation had a lot of really great metrics that we can start to connect back because like this room full of people, we have an interdisciplinary need to approach designing healthy communities. And that's why I'm in the urban and regional planning program and I just wanted to make that statement and ask if anyone in the room or if you yourself could share some of your resources so that we can bring more data to San Antonio, more statistics that say how getting a person into a community garden gets them the physical activity, not just the healthier nutrition, but it gets them there and gets them out breathing healthier air. Thank you. Stimulated multiple thoughts. One is the Prius effect. If you can measure it, people pay attention to it. So you've got to do the set aside and do the measurement. Two is one of the things we have to do in LA is to get water into the vacant lots and getting someone to pay for the water coming in is really an important thing, but that's not a lot of money, but we still have to have that. Three is that 10 years ago when I was talking about this stuff, I didn't have any data. I was basically speculating that how we were building was making people unhealthy. The data that take you all away from bad urban design and poor buildings to health are very, very strong now. The specific issue around community gardens is tougher, but I'd be happy to work with you. By the way, I'm happy to make the PowerPoint available to any of you who would like a copy of the set. Tom, I'll give you a set and maybe we'll just make the health department the clearinghouse for that and AIA as well. So we need the data. Her question, Doctor, actually is echoed by a couple people who I think frustrated with the periodic magazine listings of cities that tend to be very superficial. Wonder, is there a more serious index that creates or takes all of the kinds of data sources that you've brought with us today and allows a city to measure its progress or lack thereof? Maybe you should create it. No, that's a good challenge because the best places to live are always about the fanciest bars and the nicest restaurants or the best medical care. And for the doctor, good medical care really counts, especially as we get older, but we don't have this metric for walkability. Actually, we do have a metric. Five years ago, nobody knew what a walk score is. Now, every house that's being advertised, the real estate agent puts the walk score in if it's good. If it's lousy, they don't tell you what it is. There is now a walk score that includes transit and this is being evolved, I think Google owns it, so they're adding a whole bunch of new stuff into it as well. But this would be, this is a very good challenge and getting it in town or Money Magazine or some of the things that people read is a good idea. Here's a question about the reality of the sprawl that ought to exist in our city and others. What's one of the biggest changes anyone can make to employ now that would make a difference where sprawl already exists and is the reality? You know, I'm not an architect and designer. What they did in Elgin, Illinois and the Fox River was lined with super fun sites at old car lots and just these messy things and the big thing one was recovering the river, getting rid of the concrete and putting Parkland along there and then putting two to three story homes with good eyes on the street. So it brought a lot of physical security for the people there. They had a central square. The cupola there that now is being used for weddings and other kinds of events in good weather. So creating a heart for that city. I think the dumbest thing you can do is devote prime land to surface parking lots and maybe this is a rather indirect one. I think initiating a tax on surface parking that is much, much higher to disincentivize it because a lot of people that are owning surface parking lots are holding out for the 10 story building or the 20 story building and maybe they're never gonna get it and they'd get a pretty good return by putting in a three or four story thing. Sacramento did something, city of Sacramento. I hated Sacramento 30 years ago. It was a terrible downtown. Parking lots, hot parking lots. It was hot and sunny and not very pleasant to be in. They now require that there's residential housing in all new, even the state buildings have two and three stories of residential and the Marriott Hotel has residential. It's now become a 24-7 downtown. It's much more lively. They put a minor league ballpark close to town that people can walk to and get to rather than something that everybody had to get in their car. San Francisco, South of Market was terrible. Nobody wanted to go there. They put in Pack Bell Park. Pack Bell Park where the Giants play has not had an empty seat in it for 141 games. And the whole area around it, it's not filled with parking lots. It's got good transit going to it. It's totally lively at this point. So people want a focus for pride such as a ballpark, but it needs to be things that really are in the heart of the community and not distant from the community. And as a public health official, would you advocate for punitive taxes on soft drinks and junk food much as cigarettes are taxed with the revenues being dedicated to public health initiatives? I do not want punitive taxes, but I absolutely want health-promoting taxes. And I think that a penny a teaspoon on sugar would mean that your 12-ounce soda, instead of paying a buck and a quarter for it, would be a buck 35. You can afford it. It would generate in the state of Texas probably about a billion dollars a year. I don't want one nickel of that spent on stomach stapling surgery and medical care. I want it spent on safe routes to schools, school gardens, community gardens, PE programs and spend it on our kids. We're not giving our kids a world that works very well for them and we ought to be doing it. And adding 10, 15 pounds to their body mass is not giving them a gift. We need to be giving them that gift. So I absolutely think we ought to have a fees on sugar. It's killing us. That, we'll make this the last question if there's no one out. We do have one more audience member. Please go ahead. Hi, my name is Hodevegan. I work for the San Antonio Metropolitan Health District. You mentioned a policy in California that was giving, kind of prioritizing a safe street or here we call it complete street policy in low income neighborhoods. Are there any other examples of that because oftentimes you have this interplay of infrastructure and development and promoting this healthy spaces but you also have gentrification that may happen in certain areas. And oftentimes those are the people that suffer from the highest rates of these health problems. The reality is that people with wealth and people with education are going to be better at attracting resources and services than those that don't have it. What this particular law did was say there had to be an explicit description of where money was going and what was the economic status of people and how well they were being served. So it was more of a right to know that that data was very accessible to anyone that would look at it. And so I could easily imagine the pastor in a certain area saying, wait a minute you're putting in a road diet in the wealthy part of town. How about my community? So it isn't necessarily against the law to spend money there, but it's made very explicit. So an elected official has to then make an overt trade-off of where they're gonna spend the money rather than having this happen without people being so much aware of it. Well, Dr. Jackson, this has been a remarkable event. Thank you so much for coming to San Antonio and on behalf of the San Antonio chapter of the American Institute of Architects we want you to come back and we'll be better on all measures of your index the next time you come back, I promise and we'll have some law enforcement people joining us and we're having salad next year. So thank you very much. Thank you very much. That's great. We promise to get you out of here by 1.30 so enjoy your walk back to the office. Dr. Jackson does not wanna take books home with him. He has books out in the lobby. It's a wonderful book. You can support him and support these initiatives by taking a book home with you. He'll be outside inscribing them. Thank you.