Special Article

Public Health

Building Healthy Community Reports 2018, Vol. 133(Supplement 1)

35S-43S ª 2018, Association of
Schools and Programs of Public
Environments: A Public Health Approach Health
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permissions DOI:
10.1177/0033354918798809
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Kirsten Koehler, PhD1 , Megan Latshaw, PhD1, Thomas Matte, MD, MPH2,
Daniel Kass, MSPH2, Howard Frumkin, MD, DrPH3, Mary Fox, PhD4,
Benjamin F. Hobbs, PhD1, Marsha Wills-Karp, PhD1,
and Thomas A. Burke, PhD, MPH 4

Abstract
Environmental quality has a profound effect on health and the burden of disease. In the United States, the
environment- related burden of disease is increasingly dominated by chronic diseases. At the local level, public health
practitioners realize that many policy decisions affecting environmental quality and health transcend the authorities
of traditional health department programs. Healthy decisions about the built environment, including housing,
transportation, and energy, require broad collaborative efforts. Environmental health professionals have an
opportunity to address the shift in public health burden toward chronic diseases and play an important role in the
design of healthy communities by bringing data and tools to decision makers. This article provides a guide for
community leaders to consider the public health effects of decisions about the built environment. We present a
conceptual framework that represents a shift from compartmentalized solutions toward an inclusive systems
approach that encourages partnership across disciplines and sectors. We discuss practical tools to assist with
environmental decision making, such as Health Impact Assessments, environmental public health tracking, and
cumulative risk assessment. We also identify priorities in research, practice, and education to advance the role of
public health in decision making to improve health, such as the Health Impact Assessment, as a core competency for
environmental health practitioners. We encourage cross-disciplinary communication, research, and education that
bring the fields of planning, transportation, and energy in closer collaboration with public health to jointly advance the
systems approach to today’s environmental challenges.

Keywords
air pollution, built environment, energy and health, environmental health, public health, transportation and health

In the early part of the 20th century, public health agencies health once focused on infectious disease prevention,
focused on eliminating major infectious diseases. Efforts to now the environmental health
improve sanitation, treatment of drinking water, food
inspec- tions, and vector control led to major progress in
health and the quality of the environment.1 In the 1970s,
major episodes of air and water pollution led to the
establishment of the US Environmental Protection Agency
(EPA) and the adoption of national laws focused on air,
water, and soil pollution control and remediation. An
unintended consequence of creation of the EPA was the
disengagement of traditional public health agencies from
environmental protection.2
Now, the broad environmental and public health effects
of
air pollution, the built environment, and global climate
change are becoming increasingly evident,3-6 and our
understanding of the relationship between the environment
and human health is evolving. Whereas environmental
challenges have shifted toward the prevention of chronic dis-
ease. Cardiovascular disease is the leading cause of mortality in
the United States.7 Important risk factors for cardiovascular
disease include environmental risks (eg, exposure to air pollu-
tion8) and local built environment factors that discourage

1
Department of Environmental Health and Engineering, Johns Hopkins
University, Baltimore, MD, USA
2
Vital Strategies, New York, NY, USA
3
Our Planet, Our Health, Wellcome Trust, London, UK
4
Department of Health Policy and Management, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD, USA

Corresponding Author:
Thomas A. Burke, PhD, MPH, Johns Hopkins Bloomberg School of Public
Health, Department of Health Policy and Management, 615 N Wolfe St,
Baltimore, MD 21205, USA.
Email: [email protected]
36 Public Health Reports 133(Supplement 1)
S

physical activity.9 Reducing risks of chronic disease will

United States in 2015, contributing to approximately 88 000
require the reengagement of the public health community in
deaths per year. Ozone exposure contributes to an additional
environmental decision making.10
9000 deaths per year.19 These figures underestimate the full
Achieving a healthy environment will require a more
disease and quality-of-life effects of exposure to poor air
hol- istic view than that behind current regulatory
quality. This underestimation is due to the fact that the
approaches. We must move beyond regulating smokestacks
recent estimates of the global burden of disease do not
and dis- charge pipes toward an inclusive consideration of
include the evolving research on cognitive, metabolic, and
the role of the built environment in environmental quality
mental health outcomes associated with exposure to air
and public health. The built environment is the human-made
pollution.20
or modi- fied structures where we live, work, and play, from
The built environment has an effect on many factors
the large scale of metropolitan areas to the small scale of
related to public health, including obesity, physical
individual buildings. It includes neighborhoods, roads,
activity,21 and mental health.22 Air quality, which is
utility systems, and transportation systems. 11 In this article,
associated with many health outcomes, is strongly
we examine the relationship between the built environment
influenced by the built environ- ment. Car-centered
and health and present a conceptual framework for
development adopted since the 1950s required more roads,
building healthier communities.
highways, and parking lots, leading to less green space, less
availability of public transit or walkable/ bikable transport,
The Relationship Between Environment more traffic-related air pollution, and more injuries.
and Health Vehicles have a major effect on air quality, including a
17.5% contribution to fine particles (PM2.5) emissions in
The quality of the environment is a powerful determinant of
New York City.23 Improvements in the built environment
human health. The World Health Organization (WHO) esti-
can result in substantial improvements to both ambient and
mated that 22% of the total global burden of disease in
indoor air quality.24 The 1990 Clean Air Act Amendments
2012, including 12.6 million deaths each year, was due to
brought about many policy changes relevant to the built
environ- mental risks, including exposure to air pollution,
environment, including vehicle emissions standards,
chemicals, or radiation; inadequate water quality; and poor
promotion of low sul- fur fuels for power generation, and
sanitation.12 The effects on children are even greater; 26%
energy conservation. These changes not only are cost
of all deaths worldwide among children aged <5 in 2012
effective but also greatly improve health: a prospective
were attributable to environmental risks.13
study of the Clean Air Act Amendments of 1990 found that
The environmental burden of disease is an estimate of
their benefits will outweigh the costs of compliance by
the proportion of the global burden of disease that could be
about 30:1 and will save 230 000 lives annually by 2020.25
pre- vented by changes to the environment. The United
Furthermore, improvements to the built environ- ment
States has the highest environmental burden of disease
frequently are associated with other co-benefits, includ- ing
among compar- ably high-income countries.14 Today, most
reducing greenhouse gas emissions.26
diseases caused by environmental factors in the United
Environment-related disease has enormous economic
States are highly prevalent chronic illnesses with broad
effects. In 2008, the annual US cost of environment-related
effects on mortality and disability across all age groups. In
pediatric disease (including lead poisoning, asthma, child-
2012, the US burden of chronic disease attributable to
hood cancer, and neurobehavioral disorders) was estimated
environmental risks amounted to 8.8 million disability-
to be $76.6 billion, representing 3.5% of total health care
adjusted life years, a measure of overall disease burden
costs.27 State studies have shown similar effects on health
expressed as the number of life years lost to illness,
care costs.28,29
disability, and early death.15 These estimates are dom-
Not all populations are affected equally by
inated by cardiovascular disease, neuropsychiatric
environmental risks. A 2018 study found that population-
disorders, cancer, asthma, and chronic obstructive
weighted exposures to air pollution in Massachusetts were
pulmonary disease.16 According to WHO, environmental
highest among urban non-Hispanic black populations and
risks related to these dis- eases include air, water, and soil
that the inequities, partic- ularly for NO2 exposures in urban
pollution; ultraviolet and ionizing radiation; the built
areas, increased from 2005 to 2010.30 Nationally,
environment; electromagnetic fields; occupational risks;
population-weighted exposures of NO2 for nonwhite people
anthropogenic climate change; eco- system degradation;
were 4.6 parts per billion higher than for white people in
noise; and not washing hands or contam- inating food with
2006, and reducing the exposure levels of nonwhite people
unsafe water or dirty hands. These estimates do not include
to the exposure levels of white people would save 7000
injury due to road traffic (responsible for an estimated
lives per year that are lost due to ischemic heart disease. 31
34000 fatalities in the United States in 2013)17 and other
The environmental justice movement has increased the
factors that can be influenced by the built environment.
public’s awareness of the combination of increased expo-
Despite major improvements in air quality since the
sures to environmental risks and social inequities that result
1970s, air pollution is the largest environmental health risk
in more disease related to such exposures in disadvantaged
in the United States.18 Exposure to particulate matter air
com- munities compared with wealthier, less exposed
pollution was the sixth-leading risk factor for death in the
areas.32 The increased environmental exposures faced by
disadvantaged communities are due, in large part, to
 Koehler et 37
al made around the built environment, including
decisions S
industrial siting, roadway
locations, and resulting traffic; pollution and toxic including zoning, energy exploration, redevelopment, hous-
emissions; lack of accessible green space; and poor building ing, industrial siting, mass transit, and road construction. 39,40
and housing conditions.33 Reducing the burden of Other tools that support environmental health decision
environmental disease depends on identification of the most making include quantitative and qualitative risk assessment
vulnerable populations and reducing disparities in exposure, tools, mapping tools, and baseline data on environmental
disease outcomes, and disease prevalence. factors and health status (Table). These tools are useful not
only for the design of new communities or cities but also for
the redeve- lopment of existing neighborhoods or cities.
The Public Health Approach
Today, the increasing proportion of disease burden caused A Framework for Healthy Communities
by chronic diseases, coupled with a recognition of the role
of the environment in these diseases, requires an inclusive, We propose a framework for building healthy communities
cross- sector approach to improving the built environment that applies the aforementioned public health tools and
for healthier communities. The public health approach to approaches to strengthen the connections between public
solving environmental health problems is a stepwise process health and the built environment (Figure). The framework
that includes: is adapted from WHO’s proposed road map for a global
response to the health effects of air pollution.46 Our frame-
● Defining the public health problem (identifying work is intended as a road map for reducing the adverse
health risks of concern) effects of the environment on communities. In the current
● Measuring the magnitude (understanding measures of state, it encourages cities to use baseline health and environ-
disease or exposure in the population) mental risk factors to define challenges related to the built
● Identifying key determinants of risk (including epide- environment. The desired state presents public health and
miologic, social, and political factors) environmental goals for a healthy community. The frame-
● Developing and recommending policies (ways to work includes needed public health tools and guidance and
reduce risk and promote health) suggests cross-sector collaborators. It presents examples of
● Assessing health effects of policy options (eg, Health health-informed practice (policies and investments) and
Impact Assessment [HIA]) identifies research and education needs. Finally, and most
● Implementing and evaluating policy choices importantly, the approach includes ongoing health tracking
(tracking changes in community health)34 and environmental monitoring activities (evaluation
metrics) to evaluate the effect of improvements in the built
This approach is built on epidemiologic evidence on environ- ment and associated trends in the burden of
health outcomes and risk; it integrates social considerations environmental disease.
into policy recommendations and includes monitoring and
health surveillance to evaluate policy impacts.
Numerous emerging tools and information resources are Examples of Incorporating Health Into the
helping to advance the public health approach and offering Built Environment
new ways to inform environmental decision making. Some
The following are examples of improvement decisions in
of these tools provide a new lens for examining the health
the built environment that affect health and quality of life
impli- cations of all policies (eg, the Health in All
and underscore the possibilities for broad stakeholder
Policies35 approach, a collaborative approach that
inclusion in community development decision making.
incorporates health considerations into architecture, urban
planning, transporta- tion, energy systems, and all policy
decisions). For example, an HIA uses a systems approach to Urban Planning
integrate social, economic, environmental, and health data Multisectoral planning can help cities address existing and
and stakeholder input and to characterize the potential anticipated environmental health threats.47,48 Regions with
health consequences of a proposed action or policy.36,37 urban sprawl have a higher carbon footprint, increased air
Leischow and Milstein38 define the sys- tems approach as “a pol- lution emissions, an increased reliance on cars, reduced
paradigm or perspective that considers connections among ability to walk or bicycle, and decreased community
different components, plans for the impli- cations of their cohesion com- pared with areas that have higher density
interaction, and requires transdisciplinary thinking as well development.24 Okla- homa City provides an example of
as active engagement of those who have a stake in the how cities can address these problems. With the
outcome to govern the course of change.” participation of multiple city departments, the city
HIA complements other existing environmental health government developed comprehensive development plans
assessment processes, including environmental impact that include an HIA49,50 to support urban infrastructure
assess- ments. HIA is increasingly being applied by states, development ranging from increasing opportunities for
counties, local communities, and nongovernmental walk- ing and cycling, to providing access to healthy food,
organizations throughout the United States to inform a to building recreational facilities and improving the
range of decisions, riverfront. The result
Table. Examples of public health tools for environmental health decision making

Environmental Health Assessment Data, Methods, and Applications Tool’s Outputs for Environmental
Tools and Related Resources Used by the Tool Health Decision Making
Health Impact Assessment Integrates data on proposed policy, Evaluation of health consequences of
● 2011 report of the National Research stakeholder views, vulnerable policies, programs, or plans
Council Committee on Health Impact populations, baseline health status, health
Assessment “Improving Health in the effects, and recommendations
United States: The Role of Health
Impact Assessment”37
● 2014 US Environmental Protection
Agency’s (EPA’s) “A Review of Health
Impact Assessments in the U.S.: Current
State-of-Science, Best Practices, and
Areas for Improvement”39 Interactive mapping of environment, Spatial presentation of disease incidence
Centers for Disease Control and Prevention exposures, health effects, and population and environmental risk factors
National Environmental Public Health Tracking characteristics
program41 Data on multiple chemical and Characterization of incremental risks to
Cumulative Risk Assessment nonchemical stressors that interact to health from multiple agents or
● 2009 National Academy of Sciences, contribute to health impacts stressors
Engineering, and Medicine report “Science
and Decisions: Advancing Risk
Assessment”42
● EPA Framework for Human Health
Risk Assessment to Inform Decision
Making43
EPA EnviroAtlas44 National data for mapping of pollution Community maps for screening and
sources, environmental concentrations, prioritizing environmental health risk
exposures and risks, and demographic factors
and community characteristics
EJSCREEN: EPA’s Environmental Justice Demographic information including data Mapping and screening results to
Screening and Mapping Tool45 on low-income, non–English-speaking, identify environmental health risks,
and minority populations; and vulnerable populations, and
environmental indicators of risk, environmental health disparities
including traffic, lead paint, air, water,
and waste

has been an update of all zoning and planning codes, Green Space and Blue Space
relocation of a major highway, creation of a large
downtown park in a former industrial area, and Parks and green space offer a range of health benefits, some
development of trails to promote active recreation.44 Such of which are direct (eg, stress reduction, improved birth out-
improvements can lead to more active lifestyles for comes) and some of which are indirect (eg, reduced crime
rates56 and reduced mortality during heat waves due to the
residents, improved safety, strengthened
24
commu-
nity bonds, and improved air quality, and they may have
economic and climate benefits. urban heat island effect, which is the buildup of heat in
urban areas compared with surrounding rural areas because
of human activities 57-59). The aesthetic appeal of water—
coastal and riverfront areas sometimes called “blue
Housing space”— draws people to congregate, exercise, and relax
near such
Substandard housing and homelessness are risk factors for social connectedness, physical activity promotion, healthy
poor health.51-53 Racial/ethnic and economic segregation is eating, health care access, and educational programs.
also associated with poor health outcomes for racial/ethnic
minority groups.54 Some housing authorities have combined
healthy housing features, such as asthma-free housing and
low-allergen housing. A leading example is the Mariposa
Healthy Living Initiative, a 900-unit mixed-income
develop- ment near downtown Denver.55 In addition to
healthy hous- ing units, the Mariposa Healthy Living
Initiative features “campaigns for action” that focus on
areas.60,61 Many cities are enhancing their green and blue
spaces. For example, areas such as the Baltimore Inner
Har- bor and San Antonio River Walk feature broad
walkways and have become centerpieces of each city’s
economic develop- ment, its commercial and social life,
and its tourist appeal. Targeted tree planting, focusing on
areas with low tree cov- erage, 62 increases green space
and may improve health through direct pathways (eg,
trees filter out air pollutants, reduce the urban heat island
effect) and indirect pathways (eg, aesthetic improvements
that encourage walking and viewing vegetation for a
restorative effect that improves mental health).63
 Current State Tools and Guidance Health-Informed Practice Desired State Evaluation Metrics
Health
Americans have a high burden of environmentally related disease due, in part, to poor community design. PublicImpact
healthAssessment
is disengaged(HIA)
Zoning that permits
from mixed-use,
built Improved
high-density
environment decision health for allEnvironment
development
making. Americans through
Aging, substandard, unaffordable housing Public Health Tracking
Investment in parks, greenspace, waterfronts Walkable and bikable cities↑ Ambient air qual
with mixed lan
Sprawl (eg, low-density development) EPA EnviroAtlas andCross-sectoral
C- FERST planning for disaster preparedness ↑ Indoor
Plenty of parks, greenspace, andair quality
social gat
Inadequate greenspace Cumulative Risk Assessment
Healthy housing requirements Ample healthy, affordable ↑ Water quality
housing
Disaster susceptibility Disaster
Limited car use in urban centers (eg, tolling, congestion pricing) ↓ Noise
resiliency
Automobile-centered transportation systems Complete streets requirements ensuring safetyIntegrated
for pedestrians, Behaviors
public transit systems
cyclists, that
and pro
drivers
Inadequate, poorly maintained transit, pedestrian, and cycling infrastructure Investments in transit systems Reliance on renewable↑Physical
energy activity
Reliance on polluting energy sources Investments in power grid to support use Sustainable,
of renewablelocal food ↑
energy Healthy diet
systems
Energy-, land-, water-, and chemical-intensive food systems ↑Social capital
Health
Cross-sector Collaborators ↓ Cardiovascular di
City/regional planners ↓ Respiratory disea
Architects ↑ Mental health
Landscape architects ↑ Safety
Developers and builders ↓ Heat-related illn
Small businesses ↓ Obesity
Housing agencies ↓ Asthma
Parks and recreation Education Research ↓ Cancer
Civil society InternshipsTransdisciplinary
for public health students
approaches
in other
to evaluate
sectorsthe health impacts of built env
Transportation planners, engineers,
Training inand
outreach,
Advancement
agencies
communication,
of quantitative
and methods
citizen science
for HIA
Elected officials Policymaking and evaluation processes
Community and nongovernmental organizations

Figure. A framework for improving community health through better environment decision making. The current state presents baseline
health and defines built environmental challenges. The desired state presents public health and environmental goals for a healthy community.
The core components of the public health approach are shown indicating the path toward the desired state. Adapted from the World
Health Organization.46 Bulleted items may differ for various communities and applications. Abbreviations: EPA, US Environmental
Protection Agency; C-FERST, Community-Focused Exposure and Risk Screening Tool.

Public Transit, Walking, and Bicycling of wind and hydroelectric energy. 72 In 2008, Rock Port
Public transit ridership continues to grow in the United became the first US city to achieve this goal, and it now
States; 10.5 billion public transportation trips were reported produces more electricity than it uses. A 2018 study found
in 2015, an increase of 30% from 1995.64 The greater that if 17% of the electricity production in the eastern
Seattle area has invested in bus and light rail systems, United States during summer 2006 were replaced with solar
resulting in a nearly 6% increase in ridership from 2016 to photo- voltaics, PM2.5 would be cut by almost 5%, saving
2017, to a more than
65
1400 lives and $13 billion.73
record 122 million riders in 2017. Cities that make bicy-
cling safe and convenient help promote this healthy and
sustainable form of transportation while minimizing the risk Recommendations for Practice, Research,
of injuries.66,67 Programs such as Safe Routes to School68 and Education
encourage students to use active transport by ensuring that
safe places are available for children to walk and bike. In a Enabling public health practitioners to promote and support
case study of 6 schools during a 3-year period (2007-2009), innovative collaborations for a healthy built environment
schools that implemented the Safe Routes to School will require changes to public health practice, research, and
program saw the percentage of students who walked or education. HIAs should be adopted as a core tool and com-
biked to school in the morning or afternoon roughly double petency for environmental health practitioners. HIAs should
from 8% to 16%.69 Transit and cycling both reduce air be increasingly quantitative, both in terms of health conse-
pollution emissions and provide exercise opportunities, such quences and benefits and in terms of economic costs and
as walk- ing to and from transit stations or riding a benefits. Informed by these tools, public health officials
bicycle.70,71 must be prepared to engage with cross-agency, cross-sector,
and community stakeholders from the early stages of
problem formulation through evaluation of policy decisions.
Accom- plishing these goals will require (1) an examination
Renewable Energy of cur- rent organizational structure and support, (2)
Some towns have committed to being powered completely capacity building for managing information
by renewable electric energy (excluding transportation). technology, and
From 2008 to 2015, Aspen, Colorado; Burlington, Vermont; (3) cross-agency workforce training. Political and agency
Greensburg, Kansas; and Rock Port, Missouri, achieved leaders at the federal, state, and local levels should reward
100% renewable electricity sourcing, primarily in the form cross-cutting solutions that encourage collaboration among
officials from various sectors. Partnerships among research- emphasizing translation of science for diverse audiences and
ers, public health practitioners, and public health associa- communicating uncertainty and risk.
tions should lead to the creation of technical assistance This is a time of transition for environmental health. The
teams that can boost the capacity of practitioners, conduct changing global environment presents an opportunity and
HIAs, and integrate data on health with data on the environ- urgent need for public health leadership to move beyond
ment. Finally, technological innovations should be adapted traditional roles and reduce the burden of disease in the
to promote public health. For example, emerging smart United States as we build healthy community environments.
cities use digital technology and design to ensure that cities
pro- vide healthy living conditions, have infrastructure
needed for high-quality jobs, and are sustainable Acknowledgments
(smartcitiescouncil. org). Similarly, expanded data, The authors acknowledge the following people: Shelley Hearne,
information, and communi- cation tools (ie, Twitter, Big Cities Health Coalition; Jennifer Orme-Zavaleta, US Environ-
mental Protection Agency (EPA); Gina Solomon, University of
Facebook) will drive the evolving public health
California, San Francisco; Clifford Mitchell, Maryland
communication landscape.
Department of Health; Jim Dwyer, Department of Transportation
Researchers should develop partnerships with commu- Port Admin- istration; Emily Fisher, Johns Hopkins University
nities across multiple disciplines, agencies, and sectors so (JHU); Jerry Taylor, Niskanen Center; Tim Whitehouse,
that their research aligns with community needs. Cross- Chesapeake Physicians for Social Responsibility; Suzanne
disciplinary research teams should aim to fill critical gaps Condon, Massachusetts Depart- ment of Health (retired); Jon
in the data to assess the links between environment and Links, JHU; Keshia Pollack Porter, JHU; Dan Costa, EPA; Pat
health, improve the quantitative measures of HIAs, advance Breysse, Centers for Disease Control and Prevention; and Sarah
exposure science, identify vulnerable populations, and inte- Vogel, Environmental Defense Fund.
grate social and behavioral influences on health risks.
Research should document the economic effects of the built Declaration of Conflicting Interests
environment’s influence on health outcomes to provide a The authors declared no potential conflicts of interest with respect
sound basis for balancing costs and benefits of to the research, authorship, and/or publication of this article.
improvements in the built environment. Researchers should
integrate citizen science, whereby the public participates
voluntarily in the scientific process to address real-world Funding
problems, into the evidence base (citizenscience.gov). The authors disclosed receipt of the following financial support for
Research should priori- tize evaluation of citizen science the research, authorship, and/or publication of this article: This
article was produced with the support of the Bloomberg American
tools that allow citizens to collect, analyze, and interpret
Health Initiative, which is funded by a grant from the Bloomberg
data to ensure their quality and applicability, develop best
Philanthropies. Partial support for Koehler and Hobbs also
practices for the use of these tools, and ensure comparability provided by an Air Climate & Energy (ACE) Center Grant funded
with current monitoring and sur- veillance programs. by US Environmental Protection Agency Assistance Agreement
Systems-based research can provide an upstream No. RD835871.
perspective, moving from individual pollutants and
pathways to integrated prevention strategies. Policy and
ORCID iD
implementation research should include longitudinal evalua-
tion of the health effects of environmental policies. Kirsten Koehler, PhD http://orcid.org/0000-0002-0516-6945
With respect to education, discipline-based siloes in
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