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143 8 Cities, Suburbs, and Urban Sprawl Their Impact on Health Howard Frumkin Introduction All would agree that Harlem, Piccadilly Circus, the Latin Quarter, and the Ginza are parts of cities, and all would agree that Yosemite, Ayers Rock, and the African savannah are not. But in the vast middle ground—the transitional zones between the urban and the rural, the regions known as “suburbs” and “exurbs”—the boundaries are not so clear. This middle ground is important because in demographic and physical terms it is one of the defining realities of modern urbanization. As described in Chapter 1, urbanization is proceeding rapidly in much of the world. Ongoing migration from rural areas to urban centers and high birth rates in cities combine to increase the urban population in both absolute and relative terms. However, an equally dramatic change is occurring in many cities, especially in developed countries: Cities are changing their traditional form, sprawling over vast geographic areas, and embodying new patterns of land use, transportation, and human activity. These changes have important consequences for health. This chapter begins by reviewing the history of suburbanization, leading to the modern pattern that has become know as “urban sprawl” (or, interchangeably, “suburban sprawl”). It then defines sprawl and outlines several potential health implications of sprawl. Finally, it turns to the future, speculating on the growth patterns of sprawling cities during coming decades and presenting some options for healthy place-making across metropolitan areas. At the outset, it is important to acknowledge an aspect of sprawl that is deeply relevant to health but is not discussed here: poverty in the central city. In many cities during the past half century and longer, as capital investment and economic opportunity shifted from the center to the periphery, pockets—and sometimes wide 144 Part III: Local and Global Perspectives on Changing Cities swaths—of deprivation were left behind.1, 2 Cities have been home to poor people since ancient times, but the intense concentration of poverty in cities—to the point that “urban health” is functionally equivalent to “health problems of poverty”—is an artifact of the sprawling abandonment of cities of the past half century. These aspects of urban health are discussed in the other chapters of this book. The Origins of the Suburbs From Ur to Babylon to Rome, from Athens to Paris to London, people have settled outside cities for as long as there have been cities, seeking privacy, rural amenities , and other advantages.3, 4 Yet the modern suburb, based on commuting between a suburban home and an urban workplace, originated in the 19th century and reached its full bloom during the latter half of the 20th century. As explained by Kenneth T. Jackson5 in his authoritative history, Crabgrass Frontier, several factors drove this evolution. By the early 19th century, Jackson explains, cities shared five features: they were densely settled and congested; there was a clear distinction between city and country; there was a mixture of functions, including housing , commerce, manufacturing, recreation, and education; distances were short, and people lived close to where they worked—a necessity when commuting was on foot; and finally, the most fashionable and respectable addresses tended to be located close to the center of town. In fact, it was the lower classes that tended to live at the edges, and “sub-urb” connoted moral inferiority, the lairs of prostitutes, ne’er-do-wells, and rascals. “Suburbs, then,” according to Jackson, “were socially and economically inferior to cities when wind, muscle, and water were the prime movers of civilization” (p. 19). Gradually, however, a combination of technical advances, cultural values, commercial opportunities, and policy initiatives recast the suburbs and how they were viewed. Each of these deserves mention. The technical advances that made suburbs possible on a large scale occurred principally in transportation and construction. The “transportation revolution” of the 19th century introduced one after the other the steam ferry, omnibus, commuter railroad, horsecar, elevated railroad, and cable car. It became practical for the first time for large numbers of people to commute to a job in the city from a residence well beyond walking distance. Trolleys played a special role after their introduction in the 1880s. Within 20 years there were 30,000 miles of trolley lines in the United States, most of it electric. Trolleys, together with contemporary technological advances such as elevators and skyscrapers, were a major contributor to the phenomenal growth of cities from 1890 to 1950. Large numbers of workers could now...

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