Special Article

Public Health Reports

2018, Vol. 133(Supplement 1) 35S-43S
Building Healthy Community ª 2018, Association of Schools and
Programs of Public Health

Environments: A Public Health Approach All rights reserved.

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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, MPH4

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 challenges have shifted toward the prevention of chronic dis-
focused on eliminating major infectious diseases. Efforts to ease. Cardiovascular disease is the leading cause of mortality
improve sanitation, treatment of drinking water, food inspec- in the United States.7 Important risk factors for cardiovascular
tions, and vector control led to major progress in health and disease include environmental risks (eg, exposure to air pollu-
the quality of the environment.1 In the 1970s, major episodes tion8) and local built environment factors that discourage
of air and water pollution led to the establishment of the US
Environmental Protection Agency (EPA) and the adoption of
1
national laws focused on air, water, and soil pollution control Department of Environmental Health and Engineering, Johns Hopkins
and remediation. An unintended consequence of creation of University, Baltimore, MD, USA
2
Vital Strategies, New York, NY, USA
the EPA was the disengagement of traditional public health 3
Our Planet, Our Health, Wellcome Trust, London, UK
agencies from environmental protection.2 4
Department of Health Policy and Management, Johns Hopkins Bloomberg
Now, the broad environmental and public health effects of School of Public Health, Baltimore, MD, USA
air pollution, the built environment, and global climate change
are becoming increasingly evident,3-6 and our understanding Corresponding Author:
Thomas A. Burke, PhD, MPH, Johns Hopkins Bloomberg School of Public
of the relationship between the environment and human health Health, Department of Health Policy and Management, 615 N Wolfe St,
is evolving. Whereas environmental health once focused on Baltimore, MD 21205, USA.
infectious disease prevention, now the environmental health Email: [email protected]
36S Public Health Reports 133(Supplement 1)

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 hol- disease and quality-of-life effects of exposure to poor air
istic view than that behind current regulatory approaches. quality. This underestimation is due to the fact that the recent
We must move beyond regulating smokestacks and dis- estimates of the global burden of disease do not include the
charge pipes toward an inclusive consideration of the role evolving research on cognitive, metabolic, and mental health
of the built environment in environmental quality and public outcomes associated with exposure to air pollution.20
health. The built environment is the human-made or modi- The built environment has an effect on many factors related
fied structures where we live, work, and play, from the large to public health, including obesity, physical activity,21 and
scale of metropolitan areas to the small scale of individual mental health.22 Air quality, which is associated with many
buildings. It includes neighborhoods, roads, utility systems, health outcomes, is strongly influenced by the built environ-
and transportation systems.11 In this article, we examine the ment. Car-centered development adopted since the 1950s
relationship between the built environment and health and required more roads, highways, and parking lots, leading to
present a conceptual framework for building healthier less green space, less availability of public transit or walkable/
communities. bikable transport, more traffic-related air pollution, and more
injuries. Vehicles have a major effect on air quality, including
The Relationship Between Environment a 17.5% contribution to fine particles (PM2.5) emissions in
New York City.23 Improvements in the built environment can
and Health result in substantial improvements to both ambient and indoor
The quality of the environment is a powerful determinant of air quality.24 The 1990 Clean Air Act Amendments brought
human health. The World Health Organization (WHO) esti- about many policy changes relevant to the built environment,
mated that 22% of the total global burden of disease in 2012, including vehicle emissions standards, promotion of low sul-
including 12.6 million deaths each year, was due to environ- fur fuels for power generation, and energy conservation. These
mental risks, including exposure to air pollution, chemicals, changes not only are cost effective but also greatly improve
or radiation; inadequate water quality; and poor sanitation.12 health: a prospective study of the Clean Air Act Amendments
The effects on children are even greater; 26% of all deaths of 1990 found that their benefits will outweigh the costs of
worldwide among children aged <5 in 2012 were attributable compliance by about 30:1 and will save 230 000 lives annually
to environmental risks.13 by 2020.25 Furthermore, improvements to the built environ-
The environmental burden of disease is an estimate of the ment frequently are associated with other co-benefits, includ-
proportion of the global burden of disease that could be pre- ing reducing greenhouse gas emissions.26
vented by changes to the environment. The United States has Environment-related disease has enormous economic
the highest environmental burden of disease among compar- effects. In 2008, the annual US cost of environment-related
ably high-income countries.14 Today, most diseases caused by pediatric disease (including lead poisoning, asthma, child-
environmental factors in the United States are highly prevalent hood cancer, and neurobehavioral disorders) was estimated
chronic illnesses with broad effects on mortality and disability to be $76.6 billion, representing 3.5% of total health care
across all age groups. In 2012, the US burden of chronic costs.27 State studies have shown similar effects on health
disease attributable to environmental risks amounted to 8.8 care costs.28,29
million disability-adjusted life years, a measure of overall Not all populations are affected equally by environmental
disease burden expressed as the number of life years lost to risks. A 2018 study found that population-weighted exposures
illness, disability, and early death.15 These estimates are dom- to air pollution in Massachusetts were highest among urban
inated by cardiovascular disease, neuropsychiatric disorders, non-Hispanic black populations and that the inequities, partic-
cancer, asthma, and chronic obstructive pulmonary disease.16 ularly for NO2 exposures in urban areas, increased from 2005
According to WHO, environmental risks related to these dis- to 2010.30 Nationally, population-weighted exposures of NO2
eases include air, water, and soil pollution; ultraviolet and for nonwhite people were 4.6 parts per billion higher than for
ionizing radiation; the built environment; electromagnetic white people in 2006, and reducing the exposure levels of
fields; occupational risks; anthropogenic climate change; eco- nonwhite people to the exposure levels of white people would
system degradation; noise; and not washing hands or contam- save 7000 lives per year that are lost due to ischemic heart
inating food with unsafe water or dirty hands. These estimates disease.31 The environmental justice movement has increased
do not include injury due to road traffic (responsible for an the public’s awareness of the combination of increased expo-
estimated 34 000 fatalities in the United States in 2013)17 and sures to environmental risks and social inequities that result in
other factors that can be influenced by the built environment. more disease related to such exposures in disadvantaged com-
Despite major improvements in air quality since the munities compared with wealthier, less exposed areas.32 The
1970s, air pollution is the largest environmental health risk increased environmental exposures faced by disadvantaged
in the United States.18 Exposure to particulate matter air communities are due, in large part, to decisions made around
pollution was the sixth-leading risk factor for death in the the built environment, including industrial siting, roadway
Koehler et al 37S

locations, and resulting traffic; pollution and toxic emissions; including zoning, energy exploration, redevelopment, hous-
lack of accessible green space; and poor building and housing ing, industrial siting, mass transit, and road construction.39,40
conditions.33 Reducing the burden of environmental disease Other tools that support environmental health decision making
depends on identification of the most vulnerable populations include quantitative and qualitative risk assessment tools,
and reducing disparities in exposure, disease outcomes, and mapping tools, and baseline data on environmental factors and
disease prevalence. 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 by A Framework for Healthy Communities
chronic diseases, coupled with a recognition of the role of the
We propose a framework for building healthy communities
environment in these diseases, requires an inclusive, cross-
that applies the aforementioned public health tools and
sector approach to improving the built environment for
approaches to strengthen the connections between public
healthier communities. The public health approach to solving
health and the built environment (Figure). The framework
environmental health problems is a stepwise process that
is adapted from WHO’s proposed road map for a global
includes:
response to the health effects of air pollution.46 Our frame-
 Defining the public health problem (identifying health work is intended as a road map for reducing the adverse
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 (tracking importantly, the approach includes ongoing health tracking
changes in community health)34 and environmental monitoring activities (evaluation metrics)
to evaluate the effect of improvements in the built environ-
This approach is built on epidemiologic evidence on ment and associated trends in the burden of environmental
health outcomes and risk; it integrates social considerations 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 of The following are examples of improvement decisions in the
these tools provide a new lens for examining the health impli- built environment that affect health and quality of life and
cations of all policies (eg, the Health in All Policies35 underscore the possibilities for broad stakeholder inclusion
approach, a collaborative approach that incorporates health in community development decision making.
considerations into architecture, urban planning, transporta-
tion, energy systems, and all policy decisions). For example,
an HIA uses a systems approach to integrate social, economic, Urban Planning
environmental, and health data and stakeholder input and to Multisectoral planning can help cities address existing and
characterize the potential health consequences of a proposed anticipated environmental health threats.47,48 Regions with
action or policy.36,37 Leischow and Milstein38 define the sys- urban sprawl have a higher carbon footprint, increased air pol-
tems approach as “a paradigm or perspective that considers lution emissions, an increased reliance on cars, reduced ability
connections among different components, plans for the impli- to walk or bicycle, and decreased community cohesion com-
cations of their interaction, and requires transdisciplinary pared with areas that have higher density development.24 Okla-
thinking as well as active engagement of those who have a homa City provides an example of how cities can address these
stake in the outcome to govern the course of change.” problems. With the participation of multiple city departments,
HIA complements other existing environmental health the city government developed comprehensive development
assessment processes, including environmental impact assess- plans that include an HIA49,50 to support urban infrastructure
ments. HIA is increasingly being applied by states, counties, development ranging from increasing opportunities for walk-
local communities, and nongovernmental organizations ing and cycling, to providing access to healthy food, to building
throughout the United States to inform a range of decisions, recreational facilities and improving the riverfront. The result
38S Public Health Reports 133(Supplement 1)

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 Council stakeholder views, vulnerable populations, policies, programs, or plans
Committee on Health Impact Assessment baseline health status, health effects, and
“Improving Health in the United States: The recommendations
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
Centers for Disease Control and Prevention Interactive mapping of environment, Spatial presentation of disease incidence
National Environmental Public Health Tracking exposures, health effects, and population and environmental risk factors
program41 characteristics
Cumulative Risk Assessment Data on multiple chemical and nonchemical Characterization of incremental risks to
 2009 National Academy of Sciences, stressors that interact to contribute to health from multiple agents or
Engineering, and Medicine report “Science health impacts stressors
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 and factors
community characteristics
EJSCREEN: EPA’s Environmental Justice Screening Demographic information including data on Mapping and screening results to identify
and Mapping Tool45 low-income, non–English-speaking, and environmental health risks, vulnerable
minority populations; and environmental populations, and environmental health
indicators of risk, including traffic, lead disparities
paint, air, water, and waste

has been an update of all zoning and planning codes, relocation Green Space and Blue Space
of a major highway, creation of a large downtown park in a
Parks and green space offer a range of health benefits, some
former industrial area, and development of trails to promote
of which are direct (eg, stress reduction, improved birth out-
active recreation.44 Such improvements can lead to more active
comes) and some of which are indirect (eg, reduced crime
lifestyles for residents, improved safety, strengthened commu-
rates56 and reduced mortality during heat waves due to the
nity bonds, and improved air quality,24 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 space”—
Housing draws people to congregate, exercise, and relax near such
Substandard housing and homelessness are risk factors for areas.60,61 Many cities are enhancing their green and blue
poor health.51-53 Racial/ethnic and economic segregation is spaces. For example, areas such as the Baltimore Inner Har-
also associated with poor health outcomes for racial/ethnic bor and San Antonio River Walk feature broad walkways and
minority groups.54 Some housing authorities have combined have become centerpieces of each city’s economic develop-
healthy housing features, such as asthma-free housing and ment, its commercial and social life, and its tourist appeal.
low-allergen housing. A leading example is the Mariposa Targeted tree planting, focusing on areas with low tree cov-
Healthy Living Initiative, a 900-unit mixed-income develop- erage,62 increases green space and may improve health
ment near downtown Denver.55 In addition to healthy hous- through direct pathways (eg, trees filter out air pollutants,
ing units, the Mariposa Healthy Living Initiative features reduce the urban heat island effect) and indirect pathways
“campaigns for action” that focus on social connectedness, (eg, aesthetic improvements that encourage walking and
physical activity promotion, healthy eating, health care viewing vegetation for a restorative effect that improves
access, and educational programs. mental health).63
Koehler et al 39S

Current State Tools and Guidance Health-Informed Pracce Evaluaon Metrics Desired State
• Health Impact • Zoning that permits mixed-use, high-density Environment
Americans have a high ↑ Ambient air Improved health for all
Assessment (HIA) development
burden of environmentally Americans through
• Public Health Tracking • Investment in parks, greenspace, waterfronts quality
related disease due, in part, ↑ Indoor air quality enhanced community
• EPA EnviroAtlas and C- • Cross-sectoral planning for disaster
to poor community design. ↑ Water quality design. Public health is
FERST preparedness
Public health is disengaged ↓ Noise included in built
• Cumulave Risk • Healthy housing requirements
from built environment environment decision
Assessment • Limited car use in urban centers (eg, tolling,
decision making. Behaviors making.
congeson pricing)
• Aging, substandard, • Complete streets requirements ensuring safety ↑Physical acvity • Walkable and bikable
unaffordable housing for pedestrians, cyclists, and drivers ↑ Healthy diet cies with mixed land
Cross-sector • Investments in transit systems ↑Social capital
• Sprawl (eg, low-density use
Collaborators • Investments in power grid to support use of
development) • Plenty of parks,
• City/regional planners renewable energy Health
• Inadequate greenspace greenspace, and social
• Architects ↓ Cardiovascular
• Disaster suscepbility gathering spots
• Landscape architects disease
• Automobile-centered • Ample healthy,
• Developers and builders ↓ Respiratory
transportaon systems affordable housing
• Small businesses disease
• Inadequate, poorly • Disaster resiliency
• Housing agencies Educaon Research ↑ Mental health
maintained transit, • Integrated public
• Parks and recreaon • Internships for public • Transdisciplinary ↑ Safety
pedestrian, and cycling transit systems that
• Civil society health students in other approaches to ↓ Heat-related
infrastructure promote acve transport
• Transportaon planners, sectors evaluate the health illness and mortality
• Reliance on pollung • Reliance on renewable
engineers, and agencies • Training in outreach, impacts of built ↓ Obesity
energy sources energy
• Elected officials communicaon, and environment policies ↓ Asthma
• Energy-, land-, water-, and • Sustainable, local food
• Community and cizen science • Advancement of ↓ Cancer
chemical-intensive food systems
nongovernmental • Policymaking and quantave methods
systems
organizaons evaluaon processes for HIA

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
became the first US city to achieve this goal, and it now
Public transit ridership continues to grow in the United
produces more electricity than it uses. A 2018 study found
States; 10.5 billion public transportation trips were reported
that if 17% of the electricity production in the eastern United
in 2015, an increase of 30% from 1995.64 The greater Seattle
States during summer 2006 were replaced with solar photo-
area has invested in bus and light rail systems, resulting in a
voltaics, PM2.5 would be cut by almost 5%, saving more than
nearly 6% increase in ridership from 2016 to 2017, to a
1400 lives and $13 billion.73
record 122 million riders in 2017.65 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 program will require changes to public health practice, research, and
saw the percentage of students who walked or biked to education. HIAs should be adopted as a core tool and com-
school in the morning or afternoon roughly double from petency for environmental health practitioners. HIAs should
8% to 16%.69 Transit and cycling both reduce air pollution be increasingly quantitative, both in terms of health conse-
emissions and provide exercise opportunities, such as walk- quences and benefits and in terms of economic costs and
ing to and from transit stations or riding a bicycle.70,71 benefits. Informed by these tools, public health officials 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-
Renewable Energy plishing these goals will require (1) an examination of cur-
Some towns have committed to being powered completely rent organizational structure and support, (2) capacity
by renewable electric energy (excluding transportation). building for managing information 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
40S Public Health Reports 133(Supplement 1)

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 cities United States as we build healthy community environments.
use digital technology and design to ensure that cities pro-
vide healthy living conditions, have infrastructure needed for Acknowledgments
high-quality jobs, and are sustainable (smartcitiescouncil.
The authors acknowledge the following people: Shelley Hearne,
org). Similarly, expanded data, information, and communi- Big Cities Health Coalition; Jennifer Orme-Zavaleta, US Environ-
cation tools (ie, Twitter, Facebook) will drive the evolving mental Protection Agency (EPA); Gina Solomon, University of
public health communication landscape. California, San Francisco; Clifford Mitchell, Maryland Department
Researchers should develop partnerships with commu- of Health; Jim Dwyer, Department of Transportation Port Admin-
nities across multiple disciplines, agencies, and sectors so istration; Emily Fisher, Johns Hopkins University (JHU); Jerry
that their research aligns with community needs. Cross- Taylor, Niskanen Center; Tim Whitehouse, Chesapeake Physicians
disciplinary research teams should aim to fill critical gaps for Social Responsibility; Suzanne Condon, Massachusetts Depart-
in the data to assess the links between environment and ment of Health (retired); Jon Links, JHU; Keshia Pollack Porter,
health, improve the quantitative measures of HIAs, advance JHU; Dan Costa, EPA; Pat Breysse, Centers for Disease Control
exposure science, identify vulnerable populations, and inte- and Prevention; and Sarah 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 improvements to the research, authorship, and/or publication of this article.
in the built environment. Researchers should integrate citizen
science, whereby the public participates voluntarily in the Funding
scientific process to address real-world problems, into the
The authors disclosed receipt of the following financial support for
evidence base (citizenscience.gov). Research should priori-
the research, authorship, and/or publication of this article: This
tize evaluation of citizen science tools that allow citizens to article was produced with the support of the Bloomberg American
collect, analyze, and interpret data to ensure their quality and Health Initiative, which is funded by a grant from the Bloomberg
applicability, develop best practices for the use of these tools, Philanthropies. Partial support for Koehler and Hobbs also provided
and ensure comparability with current monitoring and sur- by an Air Climate & Energy (ACE) Center Grant funded by US
veillance programs. Systems-based research can provide an Environmental Protection Agency Assistance Agreement No.
upstream perspective, moving from individual pollutants and RD835871.
pathways to integrated prevention strategies. Policy and
implementation research should include longitudinal evalua- ORCID iD
tion of the health effects of environmental policies.
Kirsten Koehler, PhD http://orcid.org/0000-0002-0516-6945
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