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The Built Environment, Climate Change, and Health

Opportunities for Co-Benefits

      Abstract

      The earth's climate is changing, due largely to greenhouse gas emissions resulting from human activity. These human-generated gases derive in part from aspects of the built environment such as transportation systems and infrastructure, building construction and operation, and land-use planning. Transportation, the largest end-use consumer of energy, affects human health directly through air pollution and subsequent respiratory effects, as well as indirectly through physical activity behavior. Buildings contribute to climate change, influence transportation, and affect health through the materials utilized, decisions about sites, electricity and water usage, and landscape surroundings. Land use, forestry, and agriculture also contribute to climate change and affect health by increasing atmospheric levels of carbon dioxide, shaping the infrastructures for both transportation and buildings, and affecting access to green spaces. Vulnerable populations are disproportionately affected with regard to transportation, buildings, and land use, and are most at risk for experiencing the effects of climate change. Working across sectors to incorporate a health promotion approach in the design and development of built environment components may mitigate climate change, promote adaptation, and improve public health.

      Introduction

      Evidence indicates that the global climate is changing, resulting in elevated temperatures, rising sea levels, heavier precipitation events (e.g., floods, storms, hurricanes, and cyclones), additional heatwaves, and more areas affected by drought.
      Intergovernmental Panel on Climate Change Climate change 2007: the physical science basis. Contribution of Working Group I to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change.
      Possible health consequences include morbidity and mortality related to heat, extreme weather events, vectorborne and waterborne infections, mental stress, food and water shortages, respiratory diseases, international conflict, and air pollution.
      • McMichael A.J.
      • Woodruff R.E.
      • Hales S.
      Climate change and human health: present and future risks.
      • Patz J.A.
      • McGeehin M.A.
      • Bernard S.M.
      • et al.
      The potential health impacts of climate variability and change for the United States: executive summary of the report of the health sector of the U.S. national assessment.
      Greenhouse gas (GHG) emissions, composed mainly of carbon dioxide, methane, nitrous oxide, and fluorinated gases,
      • Patz J.A.
      Climate change.
      increased 70% from 1970 to 2004,
      Intergovernmental Panel on Climate Change Climate change 2007: mitigation. Contribution of Working Group III to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change.
      contributing to these changes. Carbon dioxide (CO2) emissions, in particular, accounted for 77% of total anthropogenic GHG emissions in 2004.
      Intergovernmental Panel on Climate Change Climate change 2007: mitigation. Contribution of Working Group III to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change.
      Because these emissions are largely a result of human activity,
      Intergovernmental Panel on Climate Change Climate change 2007: the physical science basis. Contribution of Working Group I to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change.
      changes in policies and behaviors can help reduce GHG emissions, climate change, and adverse health consequences.
      The built environment influences human choices, which in turn affect health and the global climate. Distinct from the natural environment, the built environment is comprised of manmade components of people's surroundings, from small-scale settings (e.g., offices, houses, hospitals, shopping malls, and schools) to large-scale settings (e.g., neighborhoods, communities, and cities), as well as roads, sidewalks, green spaces, and connecting transit systems. The development of the built environment involves many sectors, including urban planning, architecture, engineering, local and regional governments, transportation design, environmental psychology, and land conservation. Neighborhood design not only influences health by affecting physical activity, respiratory and cardiac health, injury risk, chronic disease risk, social connectedness, and mental health,
      • Ewing R.
      • Kreutzer R.
      Understanding the relationship between public health and the built environment A Report Prepared for the LEED-ND Core Committee.
      but many current community design practices also adversely contribute to global climate change.
      The UN Intergovernmental Panel on Climate Change has noted the relationship between components of the built environment and climate change, reporting that global GHG emissions have grown largely as a result of the following sectors: energy supply, transportation, industry, land use and forestry, agriculture, and buildings.
      Intergovernmental Panel on Climate Change Climate change 2007: mitigation. Contribution of Working Group III to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change.
      Strategies that aim to reduce atmospheric CO2 include decreased use of motor vehicles, increased energy efficiency in buildings, and reduced deforestation.
      • Pacala S.
      • Socolow R.
      Stabilization wedges: solving the climate problem for the next 50 years with current technologies.
      Based on these strategies, the current study focuses on three built environment components: transportation, buildings, and land use (including forestry and agriculture).
      These aspects of the built environment may disproportionately affect vulnerable populations, such as children, the elderly, people with disabilities, racial and ethnic minorities, and people of low SES, particularly when effects on health are not incorporated into built environment decision making. These populations are also among the groups most susceptible to health effects caused by climate change.
      • Frumkin H.
      • Hess J.
      • Luber G.
      • Malilay J.
      • McGeehin M.
      Climate change: the public health response.
      The health effects experienced by vulnerable populations are highlighted in this article.
      Because the built environment constitutes an important contributor to climate change and health outcomes, alternative practices offer opportunities both for improved health and reduced climate change. This article presents the current evidence and potential co-benefits of alternative practices, and illustrates built environment strategies that minimize the effects of climate change and improve health (Table 1). Opportunities for partnerships between health sectors and non–health sectors sharing similar goals are also examined. Finally, next steps and areas for further research are suggested.
      Table 1Relationships among the built environment, climate change, and health
      Built environment categoryLink to greenhouse gas emissions and climate changeBuilt environment strategiesImpactsHealth co-benefits
      Transportation
      • Fuel consumption associated with personal and commercial vehicle use
      • Number of vehicle miles traveled per capita
      • Long distances between homes, jobs, schools, and other destinations
      • Long distances from farm and factory to market
      • Increase proportion of people and goods transported on rails rather than roads
      • Promote telecommuting
      • Decrease air travel
      • Decrease distances between destinations (denser and mixed-use development)
      • Increase facilities and opportunities for transit use, walking, and bicycling
      • Promote safe routes to school programs
      • Promote use of food and goods from local suppliers
      • Develop infrastructure for alternative fuel generation and distribution
      • Improved air quality from reduced motor vehicle emissions
      • Increased physical activity from walking and bicycling
      • Enhanced social capital
      • Reduced motor vehicle injuries and fatalities from reduced motor vehicle travel
      • Reduced levels of respiratory illnesses (e.g., asthma) due to improved air quality
      • Reduced likelihood of cardiovascular diseases, some cancers, and osteoporosis, due to increased physical activity
      • Improved mental health and decreased depression and anxiety, due to enhanced social capital
      Buildings
      • Energy use in producing and transporting construction materials (“embedded energy”)
      • Energy use in construction practices
      • Energy use in heating and cooling
      • Energy use in building operations, such as lighting and elevators
      • Building site choices that promote automobile dependency and sprawl
      • Increase use of sustainable, local, and/or recycled construction materials and reuse of older buildings
      • Increase heating and cooling efficiency through site orientation, insulated windows, green roofs, and natural ventilation
      • Decrease electricity use by occupants by providing convenient stairs, compact florescent bulbs, day-lighting, and motion sensor light switches
      • Adopt LEED guidelines for energy-efficient buildings
      • Use less square footage when designing and building houses
      • Reduce drive-through services that typically involve idling automobiles
      • Improved air quality from reduced coal-generated electricity
      • Increased physical activity from stair use
      • Decreased heat island effects
      • Reduced levels of respiratory illnesses (e.g., asthma) due to improved air quality
      • Reduced likelihood of cardiovascular diseases, some cancers, and osteoporosis, due to increased physical activity
      • Improved mental health and productivity from use of day-lighting
      • Reduced susceptibility to heat-related illnesses due to decrease in heat island effects
      Land use, forestry, and agriculture
      • Deforestation associated with logging, agriculture, and sprawling development
      • Separation of land uses, which increases travel
      • Buildings constructed in vulnerable areas, such as coastal regions and flood plains
      • Develop mixed-use communities following smart growth and LEED-ND principles
      • Preserve and expand parks, trails, and green space
      • Encourage community gardens and farmers' markets
      • Reduce construction in coastal locations, flood plains, and other vulnerable areas
      • Provide incentives to protect, manage, and sustain forests
      • Coordinate regional planning
      • Support sustainable logging and agriculture
      • Reduce demand for meat consumption
      • Increased physical activity from walking and bicycling in mixed-use communities
      • Improved social capital from use of parks and trails and contact with nature
      • Improved nutrition and social capital from locally grown food
      • Increased multi-use forests for recreation and commercial use
      • Reduced likelihood of cardiovascular diseases, some cancers, and osteoporosis, due to increased physical activity
      • Improved mental health and decreased depression and anxiety, due to improved social capital
      • Reduced fatal and nonfatal injuries from severe weather events
      LEED, U.S. Green Building Council's Leadership in Energy and Environmental Design rating systems; LEED-ND, for neighborhood development

      Transportation

      Transportation, a key feature of the built environment, encompasses roads, highways, airports, railroads, public transit, ports, and bicycle trails, as well as the interaction of these systems with cities and communities. Transportation accounted for 28% of total U.S. GHG emissions in 2006, of which 94% was from energy-related CO2 emissions. Furthermore, transportation was the largest end-use sector producing energy-related CO2 emissions in 2006, nearly all of which was caused by petroleum combustion.
      Energy Information Administration
      Emissions of greenhouse gases in the United States 2006.
      Three aspects of the transportation sector contribute to GHG emissions: fuel efficiency of vehicles, carbon content of fuel, and vehicle miles traveled.
      • Ewing R.
      • Bartholomew K.
      • Winkelman S.
      • Walters J.
      • Chen D.
      Growing cooler: the evidence on urban development and climate change.
      Of these, vehicle miles traveled affects GHG emissions directly through the built environment.
      Transportation infrastructure and systems affect both GHG emissions and public health. Transportation patterns are related to pedestrian and motor vehicle fatalities and nonfatal injuries.
      • Balbus J.
      • Triola D.Y.
      Transportation and health.
      Motor vehicle crashes account for more than 40,000 deaths and almost 3 million injuries a year in the U.S.
      U.S. Department of Transportation
      Traffic safety facts 2005.
      In addition, injury rates among pedestrians and bicyclists are higher in the U.S. than in Germany or the Netherlands, although Germany and the Netherlands have substantially greater rates of walking and bicycling.
      • Pucher J.
      • Dijkstra L.
      Promoting safe walking and cycling to improve public health: lessons from the Netherlands and Germany.
      By reducing distances between destinations and decreasing vehicle miles traveled, transportation designs can be altered, thereby affecting injury rates among drivers, pedestrians, and bicyclists, as well as climate change.
      Climate change and air quality have an interactive relationship. Climate change affects air quality by altering local weather patterns, such as temperature and wind speed, which affect the distribution of air pollution. Anthropogenic sources of air pollution (e.g., motor vehicles) promote climate change through their emission of CO2, volatile organic compounds (VOCs), and nitrous oxide.
      • Bernard S.M.
      • Samet J.M.
      • Grambsch A.
      • Ebi K.L.
      • Romieu I.
      The potential impacts of climate variability and change on air pollution-related health effects in the United States.
      The combination of VOCs, nitrous oxide, and sunlight form ozone and smog, which are harmful to health.
      U.S. Environmental Protection Agency
      Ground-level ozone.
      U.S. Environmental Protection Agency
      Ground-level ozone: health and environment.
      Although no direct health effects are attributed to increased ambient levels of CO2,
      • Bransford K.J.
      • Lai J.A.
      Global climate change and air pollution: common origins with common solutions.
      high concentrations of indoor CO2 are associated with drowsiness, headaches, poor concentration, and increased heart rate; and extremely high concentrations of CO2 (>5000 parts per million [ppm]) potentially lead to oxygen deprivation and serious health effects.
      Wisconsin Department of Health and Family Services, Division of Public Health
      Carbon dioxide.
      Other byproducts of fossil fuel combustion (e.g., ozone and fine particulate matter) contribute to air pollution and associated respiratory illnesses.
      • Bernard S.M.
      • Samet J.M.
      • Grambsch A.
      • Ebi K.L.
      • Romieu I.
      The potential impacts of climate variability and change on air pollution-related health effects in the United States.
      • Brunekreef B.
      • Holgate S.T.
      Air pollution and health.
      • Bell M.L.
      • Samet J.M.
      Air pollution.
      Exposure to air pollutants is linked to chronic obstructive pulmonary disease hospitalizations,
      • Peel J.L.
      • Tolbert P.E.
      • Klein M.
      • et al.
      Ambient air pollution and respiratory emergency department visits.
      respiratory and cardiovascular morbidity and mortality,
      • Diez Roux A.V.
      • Merkin S.S.
      • Arnett D.
      • et al.
      Neighborhood of residence and incidence of coronary heart disease.
      acute asthma care events,
      • Friedman M.S.
      • Powell K.E.
      • Hutwagner L.
      • Graham L.M.
      • Teague W.G.
      Impact of changes in transportation and commuting behaviors during the 1996 Summer Olympic Games in Atlanta on air quality and childhood asthma.
      diabetes mellitus prevalence,
      • Brook R.D.
      • Jerrett M.
      • Brook J.R.
      • Bard R.L.
      • Finkelstein M.M.
      The relationship between diabetes mellitus and traffic-related air pollution.
      lung cancer risk,
      • Nyberg F.
      • Gustavsson P.
      • Jarup L.
      • et al.
      Urban air pollution and lung cancer in Stockholm.
      birth defects,
      • Ritz B.
      • Yu F.
      • Fruin S.
      • Chapa G.
      • Shaw G.M.
      • Harris J.A.
      Ambient air pollution and risk of birth defects in Southern California.
      lung impairment, fatigue, headaches, respiratory infections, and eye irritation.
      • Bell M.L.
      • Samet J.M.
      Air pollution.
      Air pollution health effects are particularly associated with SES and age. Asthmatic children living in areas with low SES were found to be more affected by air pollution than asthmatic children in high-SES regions.
      • Lee J.T.
      • Son J.Y.
      • Kim H.
      • Kim S.Y.
      Effect of air pollution on asthma-related hospital admissions for children by socioeconomic status associated with area of residence.
      Emergency room visits for air pollution–related asthma were highest among young children and the elderly.
      • Villeneuve P.J.
      • Chen L.
      • Rowe B.H.
      • Coates F.
      Outdoor air pollution and emergency department visits for asthma among children and adults: a case-crossover study in northern Alberta Canada.
      Thus, increased exposure to air pollutants, which climate change may intensify, can exacerbate respiratory illnesses for those most vulnerable, such as children,
      • Shea K.M.
      Global climate change and children's health.
      athletes, asthmatics, and people with cardiac or pulmonary conditions.
      • Bernard S.M.
      • Samet J.M.
      • Grambsch A.
      • Ebi K.L.
      • Romieu I.
      The potential impacts of climate variability and change on air pollution-related health effects in the United States.
      Transportation infrastructure affects physical activity as well. A study of five pedestrian and bicycling trails in Nebraska found the average cost per user in 2002 was $235, but resulted in medical cost savings of $622 per person from engaging in physical activity.
      • Wang G.
      • Macera C.A.
      • Scudder-Soucie B.
      • et al.
      Cost analysis of the built environment: the case of bike and pedestrian trails in Lincoln Neb.
      Trails offer multiple co-benefits, by improving physical activity levels, providing alternative transportation routes, and preserving green space. Walking, bicycling, and using mass transit (which often includes walking) for commuting purposes can increase physical activity,
      • Besser L.M.
      • Dannenberg A.L.
      Walking to public transit: steps to help meet physical activity recommendations.
      • Wener R.E.
      • Evans G.W.
      A morning stroll: levels of physical activity in car and mass transit commuting.
      which in turn enhances psychological well-being and reduces risks of mortality, cardiovascular disease, stroke, colon cancer, diabetes mellitus, and depression.
      USDHHS
      Physical activity and health: a report of the Surgeon General.
      Less time in automobiles reduces exposure to busy traffic and “road rage”
      • Harding R.W.
      • Morgan F.H.
      • Indermaur D.
      • Ferrante A.M.
      • Blagg H.
      Road rage and the epidemiology of violence: something old, something new.
      • Parker D.
      • Lajunen T.
      • Summala H.
      Anger and aggression among drivers in three European countries.
      and decreases the likelihood of obesity,
      • Frank L.D.
      • Andresen M.A.
      • Schmid T.L.
      Obesity relationships with community design, physical activity, and time spent in cars.
      while simultaneously reducing GHG emissions.
      Communities highly dependent on automobiles pose mobility barriers for children, the elderly, those without vehicles, and people with mobility impairments. Accessible, walkable, and safe neighborhoods with mixed-land use, good connectivity, public transit options, and recreational facilities encourage people with limited mobility or special needs to stay physically active, independent, and involved in community activities.
      • Clarke P.
      • George L.K.
      The role of the built environment in the disablement process.
      • Berke E.M.
      • Koepsell T.D.
      • Moudon A.V.
      • Hoskins R.E.
      • Larson E.B.
      Association of the built environment with physical activity and obesity in older persons.
      Among the elderly, exercise is associated with lower rates of functional decline
      • Wang L.
      • van Belle G.
      • Kukull W.B.
      • Larson E.B.
      Predictors of functional change: a longitudinal study of nondemented people aged 65 and older.
      and dementia,
      • Larson E.B.
      • Wang L.
      • Bowen J.D.
      • et al.
      Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older.
      and may enable seniors to remain independent longer.
      • Berke E.M.
      • Koepsell T.D.
      • Moudon A.V.
      • Hoskins R.E.
      • Larson E.B.
      Association of the built environment with physical activity and obesity in older persons.
      Aspects of the built environment that facilitate physical activity for all populations offer the co-benefit of reducing motor vehicle associated pollution, thereby diminishing both health hazards and the GHG emissions contributing to climate change.
      Transportation in the U.S. has been influenced by policies encouraging highway expansion,
      • Savitch H.V.
      How suburban sprawl shapes human well-being.
      decreasing fuel efficiency standards,
      Transportation Research Board, National Research Council
      Effectiveness and impact of corporate average fuel economy (CAFE) standards. Committee on the Effectiveness and Impact of CAFE Standards.
      and providing purchasers of trucks and sport utility vehicles with considerable tax deductions.
      • Hicks K.E.
      • Dabbs D.
      Begin year-end tax planning with a look at vehicle purchases.
      Although strategies to reduce the contribution of transportation to climate change have focused on technologic improvements (e.g., alternative fuels or more efficient vehicles), personal transportation choices and the policies that influence those choices must also be considered. Policies that influence personal transportation choices include those that facilitate increased use of mass transit options, land-use planning that results in decreased travel distances between destinations, and workplace options that reduce travel (e.g., telecommuting). “Complete streets” can be designed to accommodate all users, including pedestrian, bicycle, and vehicular traffic.
      Complete the Streets Let's complete America's streets!.
      Communities can be planned and redeveloped with “smart growth” principles to account for various modes of travel.
      Smart Growth America How is smart growth achieved?.
      A decaying shopping mall in Denver, for instance, has been transformed into a mixed-use community with access to the city's light-rail system, thus providing convenient travel alternatives that promote health and reduce climate change.
      • Geller A.
      Smart growth: a prescription for livable cities.
      Personal choices such as walking, bicycling, reducing vehicle miles traveled, combining trips, and living in transit-oriented mixed-use developments not only reduce CO2 emissions, but also increase levels of physical activity.

      Buildings

      Global CO2 emissions from energy use in buildings grew approximately 3% per year between 1999 and 2004.
      • Levine M.
      • Ürge-Vorsatz K.
      • Blok K.
      • et al.
      Residential and commercial buildings.
      Residential, commercial, and industrial buildings account for 43% of U.S. CO2 emissions, with most (71%) of these emissions caused by electricity consumption in residential and commercial buildings.
      • Brown M.A.
      • Southworth F.
      • Stovall T.K.
      Towards a climate-friendly built environment.
      U.S. Department of Energy
      2007 buildings energy data book.
      Coal, the predominant energy source consumed by the electric power sector, produced 83% of U.S. CO2 emissions in 2006 and contributed to methane emissions as well.
      Energy Information Administration
      Emissions of greenhouse gases in the United States 2006.
      Buildings affect GHG emissions through various aspects of their design, location, orientation, and use, such as their relationship to each other and the neighboring landscape, the material composition and design elements of their interiors and exteriors, and the energy and water resources used by their occupants. A building's energy use is also affected by features of its surrounding environment (e.g., sunlight, wind, trees, and water), which in turn affects its GHG emissions.
      Various building aspects influence the health of users. For example, design characteristics of hospitals, such as better lighting, layout, and ventilation, have resulted in reduced stress and fatigue in patients and staff, as well as improvement in overall health.
      • Ulrich R.
      • Quan X.
      • Zimring C.
      • Joseph A.
      • Choudhary R.
      The role of the physical environment in the hospital of the 21st century: a once-in-a-lifetime opportunity.
      Similarly, building placement relative to residential and commercial areas influences whether occupants must depend on automobiles or are able to walk, bicycle, and use public transit to other destinations,
      • Saelens B.E.
      • Sallis J.F.
      • Frank L.D.
      Environmental correlates of walking and cycling: findings from the transportation, urban design, and planning literatures.
      • Frank L.D.
      • Schmid T.
      • Sallis J.F.
      • Chapman J.
      • Saelens B.
      Linking objective physical activity data with objective measures of urban form: findings from SMARTRAQ.
      • Handy S.L.
      • Boarnet M.G.
      • Ewing R.
      • Killingsworth R.E.
      How the built environment affects physical activity: views from urban planning.
      and has been shown to have a considerable impact on BMI.
      • Pendola R.
      • Gen S.
      BMI, auto use, and the urban environment in San Francisco.
      The conditions of a building affect the health of its occupants. Mold, pests, lack of safe drinking water, and inadequate heating or cooling, waste disposal, and ventilation systems result in adverse health effects, including respiratory illnesses, asthma, infectious diseases, injuries, and mental health disorders. These conditions, which are characteristic of substandard housing, predominantly affect vulnerable populations, specifically people of low SES and racial minorities.
      • Krieger J.
      • Higgins D.L.
      Housing and health: time again for public health action.
      Moreover, susceptibility of poor and minority populations to hazards may be increased due to underlying health conditions,
      • Frumkin H.
      Urban sprawl and public health.
      such as asthma
      National Heart, Lung, and Blood Institute Working Group
      Respiratory diseases disproportionately affect minorities.
      and cardiovascular disease.
      • Geronimus A.T.
      • Bound J.
      • Waidmann T.A.
      • Hellemeier M.M.
      • Burns P.B.
      Excess mortality among blacks and whites in the United States.
      Therefore, maintaining the conditions of a building improves the health of its occupants.
      Decisions to use sustainable building materials and operation practices can promote health and protect the environment by mitigating the urban heat island effect (higher temperatures in metropolitan areas than in surrounding areas),
      • Watkins R.
      • Palmer J.
      • Kolokotroni M.
      Increased temperature and intensification of the urban heat island: implications for the human comfort and urban design.
      conserving resources, and allowing safe disposal of contaminated or hazardous waste products.
      • Berry L.L.
      • Parker D.
      • Coile Jr, R.C.
      • Hamilton D.K.
      • O'Neill D.D.
      • Sadler B.L.
      The business case for better buildings.
      Environmentally friendly supplies (e.g., recycled materials) can be substituted for products that use nonrenewable resources. Buildings constructed with locally produced materials support local economies and reduce transportation-related air pollution.
      Smart Communities Network
      Green building principles—environmental impact.
      In addition, building and landscape designs can encourage routine physical activity by providing accessible, attractive stairwells with clear signage
      • Kerr J.
      • Eves F.
      • Carroll D.
      Six-month observational study of prompted stair climbing.
      • Eves F.F.
      • Webb O.J.
      Worksite interventions to increase stair climbing; reasons for caution.
      and outdoor walking paths.
      Carbon dioxide emissions from buildings are primarily caused by the use of electricity to provide heating, cooling, lighting, water, information management, and entertainment systems.
      • Brown M.A.
      • Southworth F.
      • Stovall T.K.
      Towards a climate-friendly built environment.
      Because of their long life expectancies, buildings affect the environment and public health for many years. Commercial buildings last an estimated median of 70–75 years. One fourth of existing commercial floor space was constructed prior to 1960. Similarly, approximately one fourth of existing residential housing in 2003 had been built before 1949.
      U.S. Department of Energy
      2007 buildings energy data book.
      Both older building renovation and new construction offer opportunities to promote energy efficiency and support healthier working and living for future decades.
      Energy-efficient materials may cost more initially, but offer long-term savings.
      • Brown M.A.
      • Southworth F.
      • Stovall T.K.
      Towards a climate-friendly built environment.
      Although strained budgets can limit opportunities to use environmentally friendly, sustainable (“green”) technologies and building materials, forward-thinking clients, architects, and developers are working together to design and build energy-efficient buildings. For instance, as part of its Office of Sustainability Initiatives,
      Emory University
      Office of Sustainability Initiatives.
      Emory University is renovating existing university buildings for energy efficiency and constructing new buildings according to green building standards.
      Emory University Sustainability Committee
      Sustainability vision for Emory.
      The Yang and Yamazaki Environment and Energy (Y2E2) building at Stanford University is another example of energy efficiency and innovation in an academic setting.
      • Sullivan K.J.
      Sustainable Stanford Stanford Report.
      • Pẽna M.
      How Y2E2 slashes energy and water consumption Stanford Report.
      In the last several years, there have been efforts to green the healthcare industry and promote sustainability and health. Health Care Without Harm, an international coalition of hospitals and healthcare organizations, supports green building practices and ecologically sustainable policies. Environmental conferences, such as CleanMed, bring together healthcare leaders to discuss ways to green health care.
      CleanMed
      Conferences for greening health care.
      In addition, the Green Guide for Health Care, a toolkit for healthcare institutions, was developed to aid in the design and construction of sustainable buildings that promote the health of staff, patients, and visitors, as well as the environment.
      Green Guide for Health Care
      About the green guide for health care.
      Creation of a green hospital at the University of Pittsburgh includes constructing innovative buildings and retrofitting existing buildings using green practices, altering procedures in waste management and housekeeping, supporting strategies that improve air quality, and promoting water and energy conservation.
      Institute of Medicine of the National Academies
      Green healthcare institutions: health, environment, and economics workshop summary.
      Sustainable hospitals can recover incremental costs after 1 year and accrue financial benefits during subsequent years.
      • Berry L.L.
      • Parker D.
      • Coile Jr, R.C.
      • Hamilton D.K.
      • O'Neill D.D.
      • Sadler B.L.
      The business case for better buildings.
      These activities illustrate the involvement of the healthcare sector in the green movement, thereby mitigating climate change and promoting human health.
      Mitigation strategies, such as reducing overall meat consumption and supporting local farmers' markets and community gardens, ease the burden of food production an GHG emissions by decreasing the distance goods are transported and the demand for deforestation. LEED rating systems consider the development of sustainable sites, water savings, energy efficiency, material choice, and quality of indoor environments.
      U.S. Green Building Council
      LEED rating systems.
      LEED-ND for neighborhood development considers location and connectivity, pattern and design, and construction on a community scale.
      U.S. Green Building Council
      LEED for Neighborhood Development.
      Through tax rebates, LEED incentives, energy-efficient appliances, and reuse of existing materials, clients and developers are beginning to realize economic benefits from promoting sustainability and health through building decisions.
      • Meyerson A.
      The dollars and cents of green construction.
      Compared to a standard building, a LEED-certified building uses 32% less electricity and reduces annual average CO2 emissions by 350 metric tons (385 tons).
      U.S. Green Building Council
      Building design leaders collaborating on carbon-neutral buildings by 2030.
      Through specific energy-saving strategies, such as building sites, building form, material selection, window location, day-lighting, and energy-efficient systems for heating, cooling, and ventilation,
      American Institute of Architects
      Architects and climate change.
      the impact of climate change can be lessened. Sustainable and healthy building design principles are cost effective,
      • Kats G.
      • Alevantis L.
      • Berman A.
      • Mills E.
      • Perlman J.
      The costs and financial benefits of green buildings: a report to California's sustainable building task force.
      promote health, conserve energy, protect the environment, and mitigate the GHG emissions that contribute to climate change.
      • Frumkin H.
      Healthy places: exploring the evidence.

      Land Use, Forestry, and Agriculture

      Land use, land-use change, and forestry accounted for 12% of U.S. GHG emissions in 2005 and were responsible for 16% growth in net carbon accumulation between 1990 and 2005.
      Energy Information Administration
      Emissions of greenhouse gases in the United States 2006.
      Carbon accumulation is important because forests “sequester” CO2 by absorbing it from the atmosphere, therefore reducing the amount contributing to the overall levels of GHG emissions. In 2005, 85% of net U.S. CO2 sequestrations were from forests.
      Energy Information Administration
      Emissions of greenhouse gases in the United States 2006.
      Deforestation increases the levels of atmospheric CO2 and promotes climate change.
      • Salwasser H.
      Introduction: forests, carbon and climate—continual change and many possibilities.
      Thus, reducing deforestation offers the greatest and most immediate impact for decreasing carbon emissions.
      • Nabuurs G.J.
      • Masera O.
      • Andrasko K.
      • et al.
      Forestry.
      Agriculture and land-use development have led to increasing rates of deforestation in recent decades.
      • Salwasser H.
      Introduction: forests, carbon and climate—continual change and many possibilities.
      Agriculture accounted for an estimated 10%–12% of total anthropogenic GHG emissions worldwide in 2005,
      • Smith P.D.
      • Martino D.
      • Cai Z.
      • et al.
      Agriculture.
      and specifically for 30% of U.S. methane emissions in 2006.
      Energy Information Administration
      Emissions of greenhouse gases in the United States 2006.
      Emissions from the agricultural sector come primarily from livestock production (80%), which includes land used for grazing, energy for growing grains for feed, transportation of grain and meat for processing and sale,
      • McMichael A.J.
      • Powles J.W.
      • Butler C.D.
      • Uauy R.
      Food, livestock production, energy, climate change, and health.
      and methane produced by livestock digestive processes.
      U.S. Environmental Protection Agency
      Ruminant livestock: frequent questions.
      Livestock production contributes significantly to deforestation, as seen in Latin America, where 70% of once-forested land in the Amazon is now used as pastures and feed crops.
      • Steinfeld H.
      • Gerber P.
      • Wassenaar T.
      • Castel V.
      • Rosales C.
      • de Haan C.
      Livestock's long shadow: environmental issues and options.
      Mitigation strategies, such as supporting local farmers' markets and community gardens, ease the burden of livestock production on GHG emissions by reducing the distance goods are transported and the demand for deforestation.
      In a traditional urban setting, residential and commercial land uses are mixed, allowing for proximity of home, work, school, and other destinations. Workplace proximity is a major influence on the commuting decision to walk, particularly for women.
      • Cerin E.
      • Leslie E.
      • du Toit L.
      • Owen N.
      • Frank L.D.
      Destinations that matter: associations with walking for transport.
      Similarly, situating schools near residential areas encourages students to walk or bike to school, thereby yielding the co-benefits of physical activity and reduced GHG emissions.
      U.S. Environmental Protection Agency
      Travel and environmental implications of school siting.
      • Timperio A.
      • Ball K.
      • Salmon J.
      • et al.
      Personal, family, social, and environmental correlates of active commuting to school.
      • McDonald N.C.
      Active transportation to school: trends among U.S. schoolchildren, 1969–2001.
      Parents who walk their children to school accrue the health benefits of physical activity, as well as the advantages of interacting with other parents and strengthening community ties.
      • Cohen D.A.
      • Inagami S.
      • Finch B.
      The built environment and collective efficacy.
      In general, walkable communities are associated with higher physical activity levels, lower obesity prevalence, lower car dependency,
      • Frank L.D.
      • Saelens B.E.
      • Powell K.E.
      • Chapman J.E.
      Stepping towards causation: do built environments or neighborhood and travel preferences explain physical activity, driving and obesity?.
      and higher levels of social capital.
      • Leyden K.M.
      Social capital and the built environment: the importance of walkable neighborhoods.
      The location of community resources is particularly relevant for vulnerable populations. A disparity often exists because poor people and ethnic minorities live far from high-quality schools, supermarkets, and employment opportunities,
      • Lopez R.P.
      • Hynes H.P.
      Obesity, physical activity, and the urban environment: public health research needs.
      resulting in a cycle of poverty that is difficult to escape.
      • Frumkin H.
      Health, equity, and the built environment.
      Situating community facilities, such as libraries, parks, health centers, and fire and police departments, near residential and commercial areas can have a positive effect on the health of all residents.
      Unlike traditional neighborhoods, sprawling developments outside of city centers feature low-density land use, extensive road systems, a lack of centralized community centers, and a greater distance between destinations such as home and work. These factors contribute to increased automobile dependence and decreased ability to walk, bike, or use mass transit,

      Ewing R, Pendall R, Chen D. Measuring sprawl and its impact. Washington DC: Smart Growth America. www.smartgrowthamerica.org/sprawlindex/MeasuringSprawl.PDF.

      as well as loss of farmland and forests.
      • Galea S.
      • Vlahov D.
      Environmental Health: From Global to Local.
      Highways, which link suburbs to downtown areas, are often routed through low-income neighborhoods, thereby creating a physical barrier that interferes with community cohesion.
      • Lopez R.P.
      • Hynes H.P.
      Obesity, physical activity, and the urban environment: public health research needs.
      Poor people and people of color are disproportionately affected because they often live near highways, which are major sources of air pollution.
      • Gunier R.B.
      • Hertz A.
      • Von Behren J.
      • Reynolds P.
      Traffic density in California: socioeconomic and ethnic differences among potentially exposed children.
      Urban sprawl affects air and water quality, physical activity level, mental health, and social capital, resulting in elevated risk of respiratory, cardiovascular, and chronic diseases, cancer, psychological and emotional disorders, and injuries. In addition, the increased driving time typical of urban sprawl contributes to climate change.
      • Frumkin H.
      Urban sprawl and public health.
      • Frumkin H.
      • Frank L.
      • Jackson R.
      Urban Sprawl and public health: designing, planning, and building for healthy communities.
      Increasing density in urban areas is only part of the solution to urban sprawl. Although most urban environments offer sidewalks, mixed-land use, public transportation options, and connectivity, these aspects may be undermined by factors that pose health threats, such as crime,
      • Gómez J.E.
      • Johnson B.A.
      • Selva M.
      • Sallis J.F.
      Violent crime and outdoor physical activity among inner-city youth.
      • Gordon-Larsen P.
      • McMurray R.G.
      • Popkin B.M.
      Determinants of adolescent physical activity and inactivity patterns.
      waste or industrial sites,
      • Perlin S.A.
      • Sexton K.
      • Wong D.W.
      An examination of race and poverty for populations living near industrial sources of air pollution.
      and inadequate infrastructure maintenance.
      • Lopez R.P.
      • Hynes H.P.
      Obesity, physical activity, and the urban environment: public health research needs.
      Neighborhood indicators characteristic of underprivileged communities (e.g., the lack of nearby walkable destinations, or sidewalks in disrepair) are significantly associated with obesity.
      • Boehmer T.K.
      • Hoehner C.M.
      • Deshpande A.D.
      • Brennan Ramirez L.K.
      • Brownson R.C.
      Perceived and observed neighborhood indicators of obesity among urban adults.
      Living in disadvantaged neighborhoods is linked to higher rates of cardiovascular and stroke mortality.
      • Finkelstein M.M.
      • Jerrett M.
      • Sears M.R.
      Environmental inequality and circulatory disease mortality gradients.
      When these areas are redeveloped, gentrification often occurs, causing property values to rise and forcing lower-income residents to move out.
      • Frumkin H.
      Health, equity, and the built environment.
      Involvement by health professionals and adequate representation of vulnerable populations in zoning and planning decisions represent important opportunities to benefit public health and climate change.
      Improved urban green space planning and management can help mitigate climate change while offering considerable co-benefits for human health. Urban green spaces reduce atmospheric CO2 levels through direct sequestration and accumulation of carbon by trees and shrubs. In addition, urban green spaces decrease building heating and cooling needs, thus reducing fossil fuel consumption.
      • Jo H.K.
      Impacts of urban greenspace on offsetting carbon emissions for middle Korea.
      Lack of contact with nature can influence the mental, physical, and emotional health of the public, particularly children.
      • Louv R.
      Last child in the woods: saving our children from nature-deficit disorder.
      Urban green spaces such as parks and trails provide access to nature and encourage physical activity, thereby helping combat obesity and its co-morbidities, such as hypertension, osteoarthritis, sleep apnea, and stroke.
      CDC
      Overweight and obesity: health consequences.
      Access to green space decreases aggression and violence, improves mental fatigue,
      • Kuo F.E.
      • Sullivan W.C.
      Aggression and violence in the inner city: effects of environment via mental fatigue.
      and increases social capital and community building.
      • Kuo F.E.
      • Sullivan W.C.
      • Coley R.L.
      • Brunson L.
      Fertile ground for community: inner-city neighborhood common spaces.
      Finally, exposure to nature reduces pain in patients undergoing bronchoscopy,
      • Diette G.B.
      • Lechtzin N.
      • Haponik E.
      • Devrotes A.
      • Rubin H.R.
      Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy.
      improves attention among children with attention deficit disorder (ADD),
      • Taylor A.F.
      • Kuo F.E.
      • Sullivan W.C.
      Coping with ADD: the surprising connection to green play settings.
      and increases the life span of the elderly.
      • Takano T.
      • Nakamura K.
      • Watanabe M.
      Urban residential environments and senior citizens' longevity in megacity areas: the importance of walkable green spaces.
      Improved land-use planning can be a cost-effective way to mitigate climate change and promote public health. Specific approaches for reducing GHG emissions include creating new green spaces (e.g., on roofs and along streets and railroad lines),
      • Gill S.E.
      • Handley J.F.
      • Ennos A.R.
      • Pauleit S.
      Adapting cities for climate change: the role of the green infrastructure.
      maintaining existing green spaces, conserving natural lands through controlled development, and planting trees with high growth rates for additional green cover.
      • Jo H.K.
      Impacts of urban greenspace on offsetting carbon emissions for middle Korea.
      Land-use planning is particularly relevant for cities. Dark, impervious surfaces on buildings and roads and the lack of shade and vegetation cause urban areas to have higher average temperatures than rural areas, resulting in the urban heat island effect. This effect decreases the relief available from nighttime cooling and amplifies the susceptibility of urban residents to heat-related illnesses, including those anticipated to occur more frequently under climate change scenarios.
      • Watkins R.
      • Palmer J.
      • Kolokotroni M.
      Increased temperature and intensification of the urban heat island: implications for the human comfort and urban design.
      Reuse of previously developed land such as greyfields and brownfields is also an important method for mitigating climate change and its health implications. Greyfield sites, such as underutilized shopping centers, can be redeveloped into valuable real estate assets because they are usually located along well-traveled areas with good infrastructure.
      Congress for the New Urbanism, Pricewaterhouse Coopers, Sobel LS
      Greyfields into goldfields: from failing shopping centers to great neighborhoods.
      Similarly, brownfield sites, which are properties contaminated with hazardous substances,
      U.S. Environmental Protection Agency
      About brownfields.
      can be decontaminated and redeveloped into healthy communities that feature mixed-land use and connectivity. In addition to economic benefits, such projects help preserve existing agricultural and forest lands.

      Discussion

      The built environment offers opportunities to improve health and livability while reducing the GHG emissions that underlie climate change. This article contributes to a growing dialogue addressing the impacts of climate change on human health, by highlighting built environment strategies that minimize the effects of climate change and concurrently improve health. Research on these relationships, although needed, is difficult because built environment data are infrequently collected and usually local in nature. By contrast, climate change indicators such as temperature, weather, wind, and precipitation trends are often measured on a macro-scale level.
      Intergovernmental Panel on Climate Change The climate research unit global climate dataset.
      Although work is underway to identify key indicators for the built environment
      • Brennan Ramirez L.K.
      • Hoehner C.M.
      • Brownson R.C.
      • et al.
      Indicators of activity-friendly communities: an evidence-based consensus process.
      • Curran A.
      • Grant J.
      • Wood M.E.
      Indicators for community action: built environment and community health.
      and climate change,
      Clean Air-Cool Planet, Wake CP
      Indicators of climate change in the Northeast 2005.
      Department for Environment, Food, and Rural Affairs
      Review of UK climate change indicators.
      using these divergent data to describe and understand the relationships among the built environment, climate change, and human health is a complex challenge for researchers.
      Adaptation strategies, although not the focus here, merit attention because they can help prepare the built environment to better withstand the effects of climate change. An example of an adaptation strategy is a policy that limits situating buildings in flood plains or low-lying coastal regions because of the increased risk of flooding from heavy precipitation and rising sea levels.
      • O'Connell M.
      • Hargreaves R.
      Climate change adaptation: guidance on adapting New Zealand's built environment for the impacts of climate change.
      Some adaptation strategies may have a negative impact on climate change. For example, although air conditioning in buildings is an important adaptation strategy to reduce heat-related illnesses caused by higher temperatures,
      • Nicol F.
      • Rudge J.
      • Kovats S.
      Safe and warm; effect of climate change on thermal comfort and health.
      the energy used to cool a building contributes to GHG emissions and climate change.
      • Roaf S.
      • Crichton D.
      • Nicol F.
      Adapting buildings and cities for climate change: a 21st century survival guide.
      Although some literature discusses adaptation strategies for various built environment components to address climate change effects,
      • Burton I.
      • Diringer E.
      • Smith J.
      Adaptation to climate change: international policy options.
      Allen Consulting Group
      Climate change risk and vulnerability: promoting an efficient adaptation response in Australia.
      Marbek Resource Consultants
      Impacts of climate change on transportation in Canada: final workshop report.
      more research on this interplay is needed, especially in relation to health impacts.
      Future research could include cost–benefit analyses of the impact of built environment interventions on GHG emissions and public health. For instance, a light-rail transit line in Charlotte NC with 15 stations covering 9.6 miles averaged 14,000 daily riders in its first year (2007), exceeding projections by 55%.
      Charlotte Area Transit System
      November 24, 2007: where were you? LYNX blue line grand opening. Transitions, Spring.
      Estimates suggest this transit line will save $12.6 million dollars in total healthcare costs over 9 years.
      • Stokes R.J.
      • MacDonald J.
      • Ridgeway G.
      Estimating the effects of light rail transit on health care costs.
      Possible research projects from this transit system include climate change–impact assessments by measuring transit users' vehicle miles traveled, the health outcomes for residents and transit riders, and social cohesion and economic impacts on the city. Similar monitoring and evaluation research may be conducted for GHG emissions associated with larger projects such as new buildings, transportation systems, land-use patterns, and major infrastructure changes, as well as for smaller projects such as new sidewalks, bicycle lanes, and parks. Research that examines how built environment interventions both affect the health of vulnerable populations and reduce climate change is encouraged.
      Because health systems will need to address the effects of climate change on public health, it is important for healthcare providers to become leaders in the built environment discussion. Co-benefits from promoting these changes will directly improve health. CDC scientists have described how ten public health functions can help alleviate and respond to the health effects of climate change.
      • Frumkin H.
      • Hess J.
      • Luber G.
      • Malilay J.
      • McGeehin M.
      Climate change: the public health response.
      As part of this response, individual physicians can be models for behaviors that promote sustainability. It has been shown that physicians with healthier personal habits are more likely to encourage patients to adopt similar habits.
      • Frank E.
      • Rothenberg R.
      • Lewis C.
      • Belodoff B.F.
      Correlates of physicians' prevention-related practices: findings from the women physicians' health study.
      This effect may hold true for behaviors related to sustainability through transportation choices, energy use, and involvement in local policies affecting land use and community design. Healthcare providers can collectively and individually influence the built environment and climate change through their actions and leadership.
      Decisions about the built environment are routinely made by city planners, architects, political leaders, financiers, and public service officials. Because the built environment affects health, public health professionals should be included in land use and transportation decision-making processes. Health Impact Assessment is a tool that can be used by public health practitioners to assist planners and developers in understanding the health impacts of the decisions they make about land use and transportation planning.
      • Dannenberg A.L.
      • hatia R.
      • Cole B.L.
      • Heaton S.K.
      • Feldman J.D.
      • Rutt C.D.
      Use of health impact assessment in the United States: 27 case studies, 1999–2007.
      Fostering such multidisciplinary collaboration can help maximize the positive health impacts of infrastructure changes and reduce their negative effects.
      Potential for collaboration exists among scientists, politicians, urban and transportation planners, healthcare providers, and concerned individuals across numerous agencies and organizations. These partnerships can promote the concept that built environment interventions will yield the co-benefits of mitigating climate change and promoting public health. Although some of the impacts of climate change cannot be predicted or fully understood today, the precautionary principle suggests there is enough evidence to justify proceeding with known mitigation strategies to counter the effects of climate change. Through careful planning of transportation systems, buildings, and land uses, built environment programs can support climate change mitigation and enhance human health.

      Conclusion

      The built environment, climate change, and public health are closely connected. Built environment strategies that promote climate change mitigation through transportation infrastructure, building construction, and land-use planning provide opportunities both to improve health and reduce climate change. By combining various built environment strategies through complimentary policies and programs, multiple co-benefits emerge. Encouraging leadership and collaboration among various professions within the built environment, climate change, and public health fields is an important step toward reducing GHG emissions, thereby mitigating climate change effects and promoting healthier living.
      The authors thank Howard Frumkin, George Luber, Margaret Kelly, Arthur Wendel, Sarah Heaton, and Jamie Rayman for their thoughtful comments on this manuscript.
      No financial disclosures were reported by the authors of this paper.

      References

      1. Intergovernmental Panel on Climate Change.
        in: Solomon S. Qin D. Manning M. Cambridge University Press, Cambridge UK and New York2007 (www.ipcc.ch/ipccreports/ar4-wg1.htm)
        • McMichael A.J.
        • Woodruff R.E.
        • Hales S.
        Climate change and human health: present and future risks.
        Lancet. 2006; 367: 859-869
        • Patz J.A.
        • McGeehin M.A.
        • Bernard S.M.
        • et al.
        The potential health impacts of climate variability and change for the United States: executive summary of the report of the health sector of the U.S. national assessment.
        Environ Health Perspect. 2000; 108: 367-376
        • Patz J.A.
        Climate change.
        in: Frumkin H. Environmental health: from global to local. Jossey-Bass, San Francisco CA2005
      2. Intergovernmental Panel on Climate Change.
        in: Metz B. Davidson O.R. Bosch P.R. Dave R. Meyer L.A. Cambridge University Press, Cambridge UK and New York2007 (www.ipcc.ch/ipccreports/ar4-wg3.htm)
        • Ewing R.
        • Kreutzer R.
        Understanding the relationship between public health and the built environment.
        Design, Community & Environment, Lawrence Frank and Company, Inc. 2006; (www.usgbc.org/ShowFile.aspx?DocumentID=1480.)
        • Pacala S.
        • Socolow R.
        Stabilization wedges: solving the climate problem for the next 50 years with current technologies.
        Science. 2004; 305: 968-972
        • Frumkin H.
        • Hess J.
        • Luber G.
        • Malilay J.
        • McGeehin M.
        Climate change: the public health response.
        Am J Public Health. 2008; 98: 435-445
        • Energy Information Administration
        Emissions of greenhouse gases in the United States 2006.
        Energy Information Administration, Office of Integrated Analysis and Forecasting, U.S. Department of Energy, Washington DC2007 (DOE Publication No. DOE/EIA-0573(2006). www.eia.doe.gov/oiaf/1605/ggrpt/.)
        • Ewing R.
        • Bartholomew K.
        • Winkelman S.
        • Walters J.
        • Chen D.
        Growing cooler: the evidence on urban development and climate change.
        Urban Land Institute, Washington DC2007
        • Balbus J.
        • Triola D.Y.
        Transportation and health.
        in: Frumkin H. Environmental health: from global to local. Jossey-Bass, San Francisco CA2005
        • U.S. Department of Transportation
        Traffic safety facts 2005.
        National Highway Traffic Safety Administration, National Center for Statistics and Analysis, Washington DC2005 (DOT Publication No. DOT HS 810 631. www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSFAnn/TSF2005.pdf.)
        • Pucher J.
        • Dijkstra L.
        Promoting safe walking and cycling to improve public health: lessons from the Netherlands and Germany.
        Am J Public Health. 2003; 93: 1509-1516
        • Bernard S.M.
        • Samet J.M.
        • Grambsch A.
        • Ebi K.L.
        • Romieu I.
        The potential impacts of climate variability and change on air pollution-related health effects in the United States.
        Environ Health Perspect. 2001; 109: 199-209
        • U.S. Environmental Protection Agency
        Ground-level ozone.
        • U.S. Environmental Protection Agency
        Ground-level ozone: health and environment.
        • Bransford K.J.
        • Lai J.A.
        Global climate change and air pollution: common origins with common solutions.
        JAMA. 2002; 287: 2285
        • Wisconsin Department of Health and Family Services, Division of Public Health
        Carbon dioxide.
        • Brunekreef B.
        • Holgate S.T.
        Air pollution and health.
        Lancet. 2002; 360: 1233-1242
        • Bell M.L.
        • Samet J.M.
        Air pollution.
        in: Frumkin H. Environmental health: from global to local. Jossey-Bass, San Francisco CA2005
        • Peel J.L.
        • Tolbert P.E.
        • Klein M.
        • et al.
        Ambient air pollution and respiratory emergency department visits.
        Epidemiology. 2005; 16: 164-174
        • Diez Roux A.V.
        • Merkin S.S.
        • Arnett D.
        • et al.
        Neighborhood of residence and incidence of coronary heart disease.
        N Engl J Med. 2001; 345: 99-106
        • Friedman M.S.
        • Powell K.E.
        • Hutwagner L.
        • Graham L.M.
        • Teague W.G.
        Impact of changes in transportation and commuting behaviors during the 1996 Summer Olympic Games in Atlanta on air quality and childhood asthma.
        JAMA. 2001; 285: 897-905
        • Brook R.D.
        • Jerrett M.
        • Brook J.R.
        • Bard R.L.
        • Finkelstein M.M.
        The relationship between diabetes mellitus and traffic-related air pollution.
        J Occup Environ Med. 2008; 50: 32-38
        • Nyberg F.
        • Gustavsson P.
        • Jarup L.
        • et al.
        Urban air pollution and lung cancer in Stockholm.
        Epidemiology. 2000; 11: 487-495
        • Ritz B.
        • Yu F.
        • Fruin S.
        • Chapa G.
        • Shaw G.M.
        • Harris J.A.
        Ambient air pollution and risk of birth defects in Southern California.
        Am J Epidemiol. 2002; 155: 17-25
        • Lee J.T.
        • Son J.Y.
        • Kim H.
        • Kim S.Y.
        Effect of air pollution on asthma-related hospital admissions for children by socioeconomic status associated with area of residence.
        Arch Environ Occup Health. 2006; 61: 123-130
        • Villeneuve P.J.
        • Chen L.
        • Rowe B.H.
        • Coates F.
        Outdoor air pollution and emergency department visits for asthma among children and adults: a case-crossover study in northern Alberta Canada.
        Environ Health. 2007; 6: 40
        • Shea K.M.
        Global climate change and children's health.
        Pediatrics. 2007; 120: e1359-e1367
        • Wang G.
        • Macera C.A.
        • Scudder-Soucie B.
        • et al.
        Cost analysis of the built environment: the case of bike and pedestrian trails in Lincoln Neb.
        Am J Public Health. 2004; 94: 549-553
        • Besser L.M.
        • Dannenberg A.L.
        Walking to public transit: steps to help meet physical activity recommendations.
        Am J Prev Med. 2005; 29: 273-280
        • Wener R.E.
        • Evans G.W.
        A morning stroll: levels of physical activity in car and mass transit commuting.
        Environ Behav. 2007; 39: 62-74
        • USDHHS
        Physical activity and health: a report of the Surgeon General.
        USDHHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Atlanta GA1996 (www.cdc.gov/nccdphp/sgr/sgr.htm)
        • Harding R.W.
        • Morgan F.H.
        • Indermaur D.
        • Ferrante A.M.
        • Blagg H.
        Road rage and the epidemiology of violence: something old, something new.
        Stud Crime Prev. 1998; 7: 221-228
        • Parker D.
        • Lajunen T.
        • Summala H.
        Anger and aggression among drivers in three European countries.
        Accid Anal Prev. 2002; 34: 229-235
        • Frank L.D.
        • Andresen M.A.
        • Schmid T.L.
        Obesity relationships with community design, physical activity, and time spent in cars.
        Am J Prev Med. 2004; 27: 87-96
        • Clarke P.
        • George L.K.
        The role of the built environment in the disablement process.
        Am J Public Health. 2005; 95: 1933-1939
        • Berke E.M.
        • Koepsell T.D.
        • Moudon A.V.
        • Hoskins R.E.
        • Larson E.B.
        Association of the built environment with physical activity and obesity in older persons.
        Am J Public Health. 2007; 97: 486-492
        • Wang L.
        • van Belle G.
        • Kukull W.B.
        • Larson E.B.
        Predictors of functional change: a longitudinal study of nondemented people aged 65 and older.
        J Am Geriatr Soc. 2002; 50: 1525-1534
        • Larson E.B.
        • Wang L.
        • Bowen J.D.
        • et al.
        Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older.
        Ann Intern Med. 2006; 144: 73-81
        • Savitch H.V.
        How suburban sprawl shapes human well-being.
        J Urban Health. 2003; 80: 590-607
        • Transportation Research Board, National Research Council
        Effectiveness and impact of corporate average fuel economy (CAFE) standards. Committee on the Effectiveness and Impact of CAFE Standards.
        National Academy Press, Washington DC2002 (www.nap.edu/openbook.php?isbn=0309076013.)
        • Hicks K.E.
        • Dabbs D.
        Begin year-end tax planning with a look at vehicle purchases.
        Optometry. 2005; 76: 619-621
      3. Complete the Streets.
      4. Smart Growth America.
        • Geller A.
        Smart growth: a prescription for livable cities.
        Am J Public Health. 2003; 93: 1410-1415
        • Levine M.
        • Ürge-Vorsatz K.
        • Blok K.
        • et al.
        Residential and commercial buildings.
        in: Metz B. Davidson O.R. Bosch P.R. Dave R. Meyer L.A. Climate change 2007: mitigation Contribution of working group III to the fourth assessment report of the Intergovernmental Panel on Climate Change. Cambridge University Press, Cambridge UK2007
        • Brown M.A.
        • Southworth F.
        • Stovall T.K.
        Towards a climate-friendly built environment.
        Pew Center on Global Climate Change, Arlington VA2005
        • U.S. Department of Energy
        2007 buildings energy data book.
        D&R International, Ltd, Oak Ridge TN2007 (buildingsdatabook.eren.doe.gov)
        • Ulrich R.
        • Quan X.
        • Zimring C.
        • Joseph A.
        • Choudhary R.
        The role of the physical environment in the hospital of the 21st century: a once-in-a-lifetime opportunity.
        Center for Health Design, Concord CA2004 (www.healthdesign.org/research/reports/pdfs/role_physical_env.pdf)
        • Saelens B.E.
        • Sallis J.F.
        • Frank L.D.
        Environmental correlates of walking and cycling: findings from the transportation, urban design, and planning literatures.
        Ann Behav Med. 2003; 25: 80-91
        • Frank L.D.
        • Schmid T.
        • Sallis J.F.
        • Chapman J.
        • Saelens B.
        Linking objective physical activity data with objective measures of urban form: findings from SMARTRAQ.
        Am J Prev Med. 2005; 28: 117-125
        • Handy S.L.
        • Boarnet M.G.
        • Ewing R.
        • Killingsworth R.E.
        How the built environment affects physical activity: views from urban planning.
        Am J Prev Med. 2002; 23: 64-73
        • Pendola R.
        • Gen S.
        BMI, auto use, and the urban environment in San Francisco.
        Health Place. 2007; 13: 551-556
        • Krieger J.
        • Higgins D.L.
        Housing and health: time again for public health action.
        Am J Public Health. 2002; 92: 758-768
        • Frumkin H.
        Urban sprawl and public health.
        Public Health Rep. 2002; 117: 201-217
        • National Heart, Lung, and Blood Institute Working Group
        Respiratory diseases disproportionately affect minorities.
        Chest. 1995; 108: 1380-1392
        • Geronimus A.T.
        • Bound J.
        • Waidmann T.A.
        • Hellemeier M.M.
        • Burns P.B.
        Excess mortality among blacks and whites in the United States.
        N Engl J Med. 1996; 335: 1552-1558
        • Watkins R.
        • Palmer J.
        • Kolokotroni M.
        Increased temperature and intensification of the urban heat island: implications for the human comfort and urban design.
        Built Environ. 2007; 33: 85-96
        • Berry L.L.
        • Parker D.
        • Coile Jr, R.C.
        • Hamilton D.K.
        • O'Neill D.D.
        • Sadler B.L.
        The business case for better buildings.
        Front Health Serv Manage. 2004; 21: 3-24
        • Smart Communities Network
        Green building principles—environmental impact.
        • Kerr J.
        • Eves F.
        • Carroll D.
        Six-month observational study of prompted stair climbing.
        Prev Med. 2001; 33: 422-427
        • Eves F.F.
        • Webb O.J.
        Worksite interventions to increase stair climbing; reasons for caution.
        Prev Med. 2006; 43: 4-7
        • Emory University
        Office of Sustainability Initiatives.
        • Emory University Sustainability Committee
        Sustainability vision for Emory.
        Emory University, Atlanta GA2006 (www.finadmin.emory.edu/policies/SustyReportFinal.pdf)
        • Sullivan K.J.
        Sustainable Stanford.
        • Pẽna M.
        How Y2E2 slashes energy and water consumption.
        • Health Care Without Harm
        About us.
        • CleanMed
        Conferences for greening health care.
        • Green Guide for Health Care
        About the green guide for health care.
        • Institute of Medicine of the National Academies
        Green healthcare institutions: health, environment, and economics workshop summary.
        National Academies Press, Washington DC2007
        • U.S. Green Building Council
        LEED rating systems.
        • U.S. Green Building Council
        LEED for Neighborhood Development.
        • Meyerson A.
        The dollars and cents of green construction.
        J Accountancy. 2005; 199
        • U.S. Green Building Council
        Building design leaders collaborating on carbon-neutral buildings by 2030.
        • American Institute of Architects
        Architects and climate change.
        • Kats G.
        • Alevantis L.
        • Berman A.
        • Mills E.
        • Perlman J.
        The costs and financial benefits of green buildings: a report to California's sustainable building task force.
        • Frumkin H.
        Healthy places: exploring the evidence.
        Am J Public Health. 2003; 93: 1451-1456
        • Salwasser H.
        Introduction: forests, carbon and climate—continual change and many possibilities.
        in: Forests, carbon and climate change: a synthesis of science findings. Oregon Forest Resources Institute, Portland OR2006: 3-19 (www.oregonforests.org/media/pdf/CarbonRptFinal.pdf)
        • Nabuurs G.J.
        • Masera O.
        • Andrasko K.
        • et al.
        Forestry.
        in: Metz B. Davidson O.R. Bosch P.R. Dave R. Meyer L.A. Climate change 2007: mitigation Contribution of working group III to the fourth assessment report of the Intergovernmental Panel on Climate Change. Cambridge University Press, Cambridge UK2007: 541-584
        • Smith P.D.
        • Martino D.
        • Cai Z.
        • et al.
        Agriculture.
        in: Metz B. Davidson O.R. Bosch P.R. Dave R. Meyer L.A. Climate change 2007: mitigation Contribution of working group III to the fourth assessment report of the Intergovernmental Panel on Climate Change. Cambridge University Press, Cambridge UK2007: 497-540
        • McMichael A.J.
        • Powles J.W.
        • Butler C.D.
        • Uauy R.
        Food, livestock production, energy, climate change, and health.
        Lancet. 2007; 370: 1253-1263
        • U.S. Environmental Protection Agency
        Ruminant livestock: frequent questions.
        • Steinfeld H.
        • Gerber P.
        • Wassenaar T.
        • Castel V.
        • Rosales C.
        • de Haan C.
        Livestock's long shadow: environmental issues and options.
        Livestock, Environment, and Development Initiative, Food and Agriculture Organization of the United Nations, Rome Italy2006
        • Cerin E.
        • Leslie E.
        • du Toit L.
        • Owen N.
        • Frank L.D.
        Destinations that matter: associations with walking for transport.
        Health Place. 2007; 13: 713-724
        • U.S. Environmental Protection Agency
        Travel and environmental implications of school siting.
        Development, Community, and Environment Division, Washington DC2003 (EPA Publication No. EPA 231-R-03-004. www.epa.gov/smartgrowth/school_travel.htm)
        • Timperio A.
        • Ball K.
        • Salmon J.
        • et al.
        Personal, family, social, and environmental correlates of active commuting to school.
        Am J Prev Med. 2006; 30: 45-51
        • McDonald N.C.
        Active transportation to school: trends among U.S. schoolchildren, 1969–2001.
        Am J Prev Med. 2007; 32: 509-516
        • Cohen D.A.
        • Inagami S.
        • Finch B.
        The built environment and collective efficacy.
        Health Place. 2008; 14: 198-208
        • Frank L.D.
        • Saelens B.E.
        • Powell K.E.
        • Chapman J.E.
        Stepping towards causation: do built environments or neighborhood and travel preferences explain physical activity, driving and obesity?.
        Soc Sci Med. 2007; 65: 1898-1914
        • Leyden K.M.
        Social capital and the built environment: the importance of walkable neighborhoods.
        Am J Public Health. 2003; 93: 1546-1551
        • Lopez R.P.
        • Hynes H.P.
        Obesity, physical activity, and the urban environment: public health research needs.
        Environ Health. 2006; 5: 25-35
        • Frumkin H.
        Health, equity, and the built environment.
        Env Health Perspect. 2005; 113: A290-A291
      5. Ewing R, Pendall R, Chen D. Measuring sprawl and its impact. Washington DC: Smart Growth America. www.smartgrowthamerica.org/sprawlindex/MeasuringSprawl.PDF.

        • Galea S.
        • Vlahov D.
        Environmental Health: From Global to Local.
        in: Frumkin H. Urbanization. Jossey-Bass, San Francisco CA2005
        • Gunier R.B.
        • Hertz A.
        • Von Behren J.
        • Reynolds P.
        Traffic density in California: socioeconomic and ethnic differences among potentially exposed children.
        J Expo Anal Environ Epidemiol. 2003; 13: 240-246
        • Frumkin H.
        • Frank L.
        • Jackson R.
        Urban Sprawl and public health: designing, planning, and building for healthy communities.
        Island Press, Washington DC2004
        • Gómez J.E.
        • Johnson B.A.
        • Selva M.
        • Sallis J.F.
        Violent crime and outdoor physical activity among inner-city youth.
        Prev Med. 2004; 39: 876-881
        • Gordon-Larsen P.
        • McMurray R.G.
        • Popkin B.M.
        Determinants of adolescent physical activity and inactivity patterns.
        Pediatrics. 2000; 105: E83
        • Perlin S.A.
        • Sexton K.
        • Wong D.W.
        An examination of race and poverty for populations living near industrial sources of air pollution.
        J Expo Anal Environ Epidemiol. 1999; 9: 29-48
        • Boehmer T.K.
        • Hoehner C.M.
        • Deshpande A.D.
        • Brennan Ramirez L.K.
        • Brownson R.C.
        Perceived and observed neighborhood indicators of obesity among urban adults.
        Int J Obes. 2007; 31: 968-977
        • Finkelstein M.M.
        • Jerrett M.
        • Sears M.R.
        Environmental inequality and circulatory disease mortality gradients.
        J Epidemiol Community Health. 2005; 59: 481-487
        • Jo H.K.
        Impacts of urban greenspace on offsetting carbon emissions for middle Korea.
        J Environ Manage. 2002; 64: 115-126
        • Louv R.
        Last child in the woods: saving our children from nature-deficit disorder.
        Algonquin Books of Chapel Hill, Chapel Hill NC2005
        • CDC
        Overweight and obesity: health consequences.
        • Kuo F.E.
        • Sullivan W.C.
        Aggression and violence in the inner city: effects of environment via mental fatigue.
        Environ Behav. 2001; 33: 543-571
        • Kuo F.E.
        • Sullivan W.C.
        • Coley R.L.
        • Brunson L.
        Fertile ground for community: inner-city neighborhood common spaces.
        Am J Community Psychol. 1998; 26: 823-851
        • Diette G.B.
        • Lechtzin N.
        • Haponik E.
        • Devrotes A.
        • Rubin H.R.
        Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy.
        Chest. 2003; 123: 941-948
        • Taylor A.F.
        • Kuo F.E.
        • Sullivan W.C.
        Coping with ADD: the surprising connection to green play settings.
        Environ Behav. 2001; 33: 54-77
        • Takano T.
        • Nakamura K.
        • Watanabe M.
        Urban residential environments and senior citizens' longevity in megacity areas: the importance of walkable green spaces.
        J Epidemiol Community Health. 2002; 56: 913-918
        • Gill S.E.
        • Handley J.F.
        • Ennos A.R.
        • Pauleit S.
        Adapting cities for climate change: the role of the green infrastructure.
        Built Environ. 2007; 33: 115-133
        • Congress for the New Urbanism, Pricewaterhouse Coopers, Sobel LS
        Greyfields into goldfields: from failing shopping centers to great neighborhoods.
        Congress for the New Urbanism, Washington DC2001 (www.cnu.org/sites/files/Greyfield_Goldfields_vol2.pdf)
        • U.S. Environmental Protection Agency
        About brownfields.
        Brownfields and Land Revitalization program, Washington DC2008 (www.epa.gov/brownfields/about.htm)
      6. Intergovernmental Panel on Climate Change.
        • Brennan Ramirez L.K.
        • Hoehner C.M.
        • Brownson R.C.
        • et al.
        Indicators of activity-friendly communities: an evidence-based consensus process.
        Am J Prev Med. 2006; 31: 515-524
        • Curran A.
        • Grant J.
        • Wood M.E.
        Indicators for community action: built environment and community health.
        J Rural Community Dev. 2006; 2: 59-74
        • Clean Air-Cool Planet, Wake CP
        Indicators of climate change in the Northeast 2005.
        Clear Air-Cool Planet, Portsmouth NH2005 (www.cleanair-coolplanet.org/information/pdf/indicators.pdf)
        • Department for Environment, Food, and Rural Affairs
        Review of UK climate change indicators.
        Department for Environment, Food, and Rural Affairs, London UK2003 (www.ecn.ac.uk/iccuk/.)
        • O'Connell M.
        • Hargreaves R.
        Climate change adaptation: guidance on adapting New Zealand's built environment for the impacts of climate change.
        BRANZ, New Zealand2004 (Study Report No. 130.)
        • Nicol F.
        • Rudge J.
        • Kovats S.
        Safe and warm; effect of climate change on thermal comfort and health.
        in: Roaf S. Crichton D. Nicol F. Adapting buildings and cities for climate change: a 21st century survival guide. Architectural Press, Burlington MA2005
        • Roaf S.
        • Crichton D.
        • Nicol F.
        Adapting buildings and cities for climate change: a 21st century survival guide.
        Architectural Press, Burlington MA2005
        • Burton I.
        • Diringer E.
        • Smith J.
        Adaptation to climate change: international policy options.
        Pew Center on Global Climate Change, Arlington VANovember 2006
        • Allen Consulting Group
        Climate change risk and vulnerability: promoting an efficient adaptation response in Australia.
        Australian Greenhouse Office, Department of the Environment and Heritage, Canberra Australia2005
        • Marbek Resource Consultants
        Impacts of climate change on transportation in Canada: final workshop report.
        Transport Canada, Canmore Alberta2003 (www.tc.gc.ca/programs/environment/nwicct/docs/FullWorkshopReport/Full%20Workshop%20Report.pdf)
        • Charlotte Area Transit System
        November 24, 2007: where were you?.
        • Stokes R.J.
        • MacDonald J.
        • Ridgeway G.
        Estimating the effects of light rail transit on health care costs.
        Health Place. 2008; 14: 45-58
        • Frank E.
        • Rothenberg R.
        • Lewis C.
        • Belodoff B.F.
        Correlates of physicians' prevention-related practices: findings from the women physicians' health study.
        Arch Fam Med. 2000; 9: 359-367
        • Dannenberg A.L.
        • hatia R.
        • Cole B.L.
        • Heaton S.K.
        • Feldman J.D.
        • Rutt C.D.
        Use of health impact assessment in the United States: 27 case studies, 1999–2007.
        Am J Prev Med. 2008; 34: 241-256