Report on the State of Health + Urbanism: A Critique

Howard Frumkin, MD, DrPH, Richard Jackson, MD, MPH, AIA (Hon), Andrew Dannenberg, MD, MPH

In late 2013 the Center for Advanced Urbanism at MITs School of architecture and Planning issued a Report on the State of Health + Urbanism. The report described itself as groundbreaking and praised MIT as a center of cutting-edge research and innovation, and is handsomely produced and visually appealing, so readers may have had high expectations. Indeed the report raises some legitimate questions, and offers some potentially promising visualization methods. But it is mainly distinguished by surprisingly slapdash research, careless analysis, and unsupportable conclusions. Its important to set the record straight. For reference, the report can be found at http://cau.mit.edu/sites/cau.mit.edu/files/attachments/news/233987_TXT_Web.pdf, an interview with lead editor and author Alan Berger can be found at http://newsoffice.mit.edu/2013/3q-alan-berger-oncities-and-health-1121, and the Atlantics news coverage of the report can be found at http://www.theatlanticcities.com/neighborhoods/2013/12/much-what-we-know-about-public-healthand-urban-planning-wrong/7886/ . A summary of the report, with commentary The report consists of two major parts. The first part includes three opening chapters totaling about 30 pages; these lay out the background and conceptual approach, and offer conclusions. In the second part, nearly 100 pages are dedicated to reports of student projects in eight cities, which are collectively designated research. The reports conclusions appear at the end of the first section (pages 27-29), presented by authors Jocelyn Pak Drummond and Alan Berger. Tellingly, this chapter is entitled Current Limitations. As the name suggests, the organizing theme is what we dont knowpositioning limitations as the core finding of the report. No affirmative conclusions are drawn; in fact, almost nothing is said about what we do know. The authors bottom line seems to be that nothing is really known about the links between the built environment and health. There are five main conclusions. First the authors declare that research has not been able to prove causation. Its an oddly superficial discussion, without either a definition of causation or reference to the considerable literature on biomedical causation (e.g. Hill 1965; Susser 1973; Renton 1994; Kaufman and Poole 2000; Doll 2002). The authors then partially retreat from their position, with the following tortured construction: a combination of evidence-based practice and an application of what one can understand about the determinants of health allows for a less rigorous concept of association to move forward with recommendations. The effects of car congestion, air pollution and indoor air quality on the rate of respiratory diseases such as asthma, for example, can clearly be understood.

So if we do know enough to act, whats with the causation discussion? A semantic distraction? Plain sophistry? Why are the authors emphasizing the difficulty of proving causation rather than highlighting the actionable conclusions research has already yielded, and identifying the specific questions that still need answering? (Many such thoughtful articles are available, e.g. Srinivasan et al., 2003; Dannenberg et al., 2003; Northridge et al. 2003; Smit et al. 2011.) Next, the authors lament the lack of valid and reliable standard indicators for measuring urban health. There are numerous useful metrics in public health, which health officials and epidemiologists routinely use. Some indicators are longstanding (such as BMI, asthma symptoms, medication use, and survey data) and others are emerging (such as salivary cortisol and data capture from GIS-equipped asthma inhalers). Granted, there is more to learn, but we are certainly not without valid and reliable standard indicators. The third conclusion is that there is also a tendency in the design professions to create generalized guidelines that are based loosely on evidence and have little direct applicability to specific neighborhoods. This may well be a problem; in fact, this report exemplifies a loose relationship with empirical evidence. While the authors attribute this tendency to the lack of reliable indicators, one wonders if the problem doesnt run deeper, reflecting professional paradigmsa question very much worth considering as design and health professionals increasingly collaborate. Fourth, the authors note that The design and public health fields also face the challenge of the lack of a shared vocabulary to completely engage with each other on health issues. No argument there. Finally, the authors write, it is important to recognize that a change to the urban environment that is meant to address one health concern may simultaneously worsen another health concern. A good point. Complex systems are complex. What should we make of these conclusions? Every one is a lamentation, a statement of whats wrong with our current knowledge and tools. In reaching these conclusions, the authors seem to opt for contrariness and nihilism instead of balanced analysis. Its hard to escape the conclusion that they were much more concerned with being provocative and edgy than with being careful, fair, and accurate. So what? Across the nation, cities are growing and reforming. Buildings are being built, neighborhoods transformed, metro areas re-envisioned. At the same time, the nations health is a pressing concern. While some trends are encouraging (for instance, heart disease mortality has been declining for two decades), other trendsrising obesity, autism, allergies, some mental illnessesare worrisome. The prevalence of diabetes has doubled in one generation, and now imposes an economic burden of $245 billion on the nation (American Diabetes Association 2013)1.5% of our GDP. One in 12 Americans now has asthma, and the proportion is higher among children, the poor, and members of some ethnic minorities (Akinbami et al., 2012). Antidepressants are the most frequently used medications among Americans aged 1844 years; over the last 20 years, antidepressant use in the United States increased

nearly 400% (Pratt et al. 2011). Our aging population will confront more health challenges. Health care costsnow at $2.5 trillion each year, or nearly 18% of GDPcontinue to rise. These two domainsthe built environment and human healthare linked. Mounting evidence shows that where we live, work, study, and play affects health and well-being in many ways. As we understand these connections better, we can design and build sustainable, resilient, and health-promoting places. This is serious business. It is vital that we get it right. While the Report on the State of Health + Urbanism is a deeply flawed document, we can learn much from it, in both positive and negative senses, as we work to advance human health and well-being through design. The major lessons, we submit, are the need for collaboration, the need for careful scholarship, the need to confront and manage complexity, and the need for balanced public discourse. The need for collaboration The intersection of the built environment and human health is highly interdisciplinary. It requires that built environment professionalsarchitects, urban planners landscape architects, developers, builders, and otherscollaborate with health and social science professionalsphysicians, epidemiologists, sociologists, and others. How did the MIT report do in this respect? The reports editor was Alan Berger, Professor of Landscape Architecture and Urban Design at MIT and Director of Research at that institutions Center for Advanced Urbanism, with Andrew Scott, an Associate Professor of Architecture at MIT. The other contributors are listed in two locations, on the acknowledgments page (page 1) and under contributors (page 10) (with considerable non-overlap between the two lists). But nearly all contributors other than professors Berger and Scott appear to have been MIT urban planning and architecture students. One contributor, Aparna Keshaviah, has a masters degree in biostatistics, but her professional experience (judging by her publications) is limited to cancer and psychological ailments, with no background in the built environment, social epidemiology, or broader issues of public health. There are no authors with expertise in epidemiology, medicine, environmental health, or other relevant health sciences, and no indication of pre-publication review by anybody with such expertise. As expected, a team this one-dimensional runs into trouble. Many statements are inconsistent with current knowledge in public health and biology. For example, on page 14, in the chapter entitled Health + Urbanism Primer, we read that Pythogenic theory (or filth theory) made it clear that disease was caused by the decomposition of organic matter. What? The filth theory was put to rest at more than a century ago (Chapin, 1902), along with bloodletting and leeches. On page 16 we read that infectious disease is no longer a major problem in developed countries. Really? Pneumonia and influenza kill over 50,000 Americans and cost the nation $40 billion each year, more than 1.1 million Americans are living with HIV, recent outbreaks of diseases such as SARS, Ebola, and West Nile virus have threatened the U.S. and dozens of other nations, and an estimated 1.7 million hospital-acquired infections occur each year in the United States. And on page 22, the section on air pollution begins with the declaration that High levels of carbon dioxide is [sic] linked to asthma-related deaths. Not only is this claim incorrect (carbon dioxide isnt linked to asthma mortality), but the reference cited to support 3

the claim (Galea and Vlahov 2005) says no such thing (in fact, it says nothing whatever on the health effects of carbon dioxide!). The report also misconstrues recent developments in the field, which a well-rounded team might have avoided. On page 16 we read: By the new millennium, the field of city planning had begun to deal with environmental issues again through the lens of sustainability, but without a direct focus on health. Its true that sustainability had emerged as a major current of city planning by the turn of the millennium. But health had emerged as well. By the early 2000s, there was enough literature that scholars were writing review articles and books summarizing contemporary efforts at the intersection of urban form and public health (a sampling: Sallis et al. 1995; Dub 2000; Handy et al 2002; Frumkin 2002; Morrison et al. 2003; Frumkin et al. 2004; Egan et al. 2003; Ogilvie et al. 2004. This growth is summarized in Jackson et al., 2013.) The report very sensibly calls for architects, planners, and designers to work collaboratively with health fields. And in his interview Professor Berger stated Were trying to get public health officials, designers, planners, and engineers in the same room to talk and come up with better solutions, and we want them all to be thinking across disciplinary boundaries. This is a fine idea. Such collaborations are underway across the country, and are bearing fruit. Many of the deficiencies of the report might have been avoided if the authors has collaborated with health experts.

The need for careful scholarship Careful, meticulous scholarship, and rigorous research, are fundamental academic standards. The MIT report falls short in this respect, making numerous claims that are unsubstantiated by the evidence presented, citing literature selectively and inaccurately, and presenting improvised student projects as research. Lets look at four detailed examples: the reports discussions of sprawl, urban density, food, and transportation mode. First, on sprawl. It is important, the authors tell us (on page 19), to avoid sweeping prejudices that have become prominent in the discussion of urban health over the last few decades. For example, there are many prevailing beliefs, even prejudices, about the negative health effects of the suburbs since they are associated with car dependence, sprawling parking lots, and a general lack of pedestrian amenities. This is a serious chargethat the health effects of suburbs are a matter of prejudice rather than fact. To support it, the authors cite three published papers at the end of those two sentences (Vandergrift and Yoked 2004; Lopez 2004; McCann and Ewing 2003). What can we say about these papers? First, they are a decade old, and a very large body of research has been published in the interim. One wonders why the authors didnt rely on a more comprehensive and up-to-date review of the literature before making sweeping claims about sweeping prejudices. Second, each of the papers is an empirical study, testing the hypothesis that urban sprawl is associated with inactivity or poor health outcomes, using primary data, and controlling for confoundersnot exactly the hallmark of prejudice. Third, remarkably, each of the papers reaches precisely the opposite conclusion from the one the authors 4

attribute to it. Its worth quoting the papers directly, to illustrate the inaccuracy of the authors statements. The first (Vandegrift and Yoked 2004), an analysis by an economist at the College of New Jersey and one of his students, concluded that new location patterns produced by suburban sprawl are an important cause of rising obesity rates. New location patterns are such that work, school and social activities are not as easily accessible by foot. Changes in sprawl then drive changes in the causes of obesity identified by medical researchers (e.g., low activity levels). The second (Lopez 2004), by an environmental health researcher at Boston University (with training in city and regional planning), found that Urban sprawl was associated with an increased risk for being overweight or obese when individual variables were controlled. While the level of effect of a 1-point change in the sprawl index is small, the cumulative effects may be large because of the range of potential sprawl index values. The third (McCann and Ewing 2003), written by a journalist specializing in the built environment and a professor of urban planning and published by two NGOs (Smart Growth America and the Surface Transportation Policy Project), showed a clear association between the type of place people live and their activity levels, weight, and health, finding that people living in counties marked by sprawling development are likely to walk less and weigh more than people who live in less sprawling counties. In addition, people in more sprawling counties are more likely to suffer from hypertension (high blood pressure). These results hold true after controlling for factors such as age, education, gender, and race and ethnicity.

So the MIT report, mischaracterizing the state of knowledge about urban health as pervaded by sweeping prejudices, supports this claim with a superficial and outdated review of the research literature, that misrepresents each paper it cites. A second example concerns urban density. On page 8 we read, Another conventional assumption is that dense urban settings lead to healthier lifestyles than sprawled suburban developments. The authors characterize that view as an assumption (although it is actually a data-based research finding), and set out to rebut it, citing just three of the scores of studies published in recent years on this topic (Lopez and Hynes 2006; Eid et al 2008; Zhao and Kaestner 2010). Again, the authors (Berger, Brown, and Keshaviah) misreport their sources, as two of the papers demonstrate the very opposite of what the authors are arguing. The first paper (Lopez and Hynes, 2006) states: Studies on sprawl and public health have found that increased levels of sprawl are associated with increased obesity, decreased physical active and poorer health, including the risk of motor vehicle and pedestrian fatalities.Evidence is mounting that the design and form of many, if not most, U.S. suburbs contribute to the growing prevalence of obesity and overweight among children and adults. Certain features of the built environmentsuch as the presence of sidewalks, streetlights, interconnectivity of streets, population density and use mixappear to encourage physical activity and thus reduce the risk of obesity and related health problems. Other factorssuch as cul de sacs, lack of parks, high

speed traffic and automobile focused transportmay function to discourage activity and ultimately increase obesity risk. The third paper (Zhao and Kaestner 2010), an economic analysis, concludes that sprawl is causally related to obesity, accounting for about one eighth of the growing obesity burden, but doesnt speak to the contribution of neighborhood design within cities.

The second paper (Eid et al 2008), another economic analysis, does support the authors point, finding reverse causation due to self-selectionthat individuals who are more likely to be obese choose to live in more sprawling neighborhoods, rather than that sprawl promotes overweight. This is regrettably sloppy scholarship. The existing literature isnt reviewed thoroughly, a very few articles are cherry-picked for citation, and two of these are misrepresented. A third example is the question of food access. On page 25, the authors state Despite intensive media and research interest in the effects of food access, little consensus has formed around this factors relationship to actual health outcomes. They define food deserts (which they call the so-called food desert problem) as areas with reduced access to large grocery stores and fresh food markets, and assert that their supposed overlap with unhealthy populations simply does not hold in large spatial analyses. Once again, they position themselves as the myth-busting authorities, out to set the record straight. Based on what? The authors cite just three sources to support their claims (Fleischhacker 1 et al. 2011; Lee 2013; Lee 2012), and once again their reliance on these sources deserves close scrutiny. The Fleischhacker et al. paper is a review of the literature on fast food access, current through 2009. Of the 21 studies reviewed, the authors concluded that 76% indicated fast food restaurants were more prevalent in low-income areas compared with middle- to higher-income areas. Ten of 12 studies found fast food restaurants were more prevalent in areas with higher concentrations of ethnic minority groups in comparison with Caucasians. Six adult studies found higher body mass index was associated with living in areas with increased exposure to fast food; four studies, however, did not find associations. This review found somewhat mixed results, but certainly did not overturn the notion that there are neighborhood disparities in fast food access, and associated health burdens. The two papers by Helen Lee include a peer-reviewed research article in Social Science and Medicine, and a subsequent opinion piece in the online Breakthrough Journal. The research article, based on a nationwide sample of 7730 children, found that children in poor and minority neighborhoods were indeed more likely to have greater access to fast-food outlets and convenience stores, but were also more likely to have access to grocery stores, and that patterns of exposure to food outlets werent related to patterns of weight gain over time. In the opinion piece, Lee cites her own work, and another study (Ruopeng and Sturm 2012), which

In case youre looking for this reference, the MIT report endnote misspells the first authors name as Rleischhacker. The correct citation appears in this critique.

found no association between the food environment at school or near home and childrens diets. What Drummond and Berger didnt cite was the very large body of evidence that reaches the opposite conclusionthat the food environment is associated with diet and health. These are summarized in numerous recent review papers. Here are a few examples. Larson et al 2009: Reviewed 54 studies. Research suggests that neighborhood residents who have better access to supermarkets and limited access to convenience stores tend to have healthier diets and lower levels of obesity. Beaulac et al. 2009: Reviewed 49 studies. We found clear evidence for disparities in food access in the United States by income and race. Sallis and Glanz 2009: Reviewed 21 studies. Numerous cross-sectional studies have consistently demonstrated that some attributes of built and food environments are associated with physical activity, healthful eating, and obesity. Residents of walkable neighborhoods who have good access to recreation facilities are more likely to be physically active and less likely to be overweight or obese. Residents of communities with ready access to healthy foods also tend to have more healthful diets. Walker et al. 2010: Reviewed 31 studies. factors within the built environment play a critical role in a persons diet, predominantly Black neighborhoods have fewer supermarkets compared to predominantly White neighborhoods, and the issue of poverty plays out in economic barriers in accessing food in low-income areas. Giskes et al 2011: Reviewed 28 studies. Weight status was consistently associated with the food environment; greater accessibility to supermarkets or less access to takeaway outlets were associated with a lower BMI or prevalence of overweight/obesity. However, obesogenic dietary behaviours did not mirror these associations; mixed associations were found between the environment and obesogenic dietary behaviours. Hilmers et al 2012: Reviewed 24 studies. Low-income neighborhoods offered greater access to food sources that promote unhealthy eating. The distribution of fast-food outlets and convenience stores differed by the racial/ethnic characteristics of the neighborhood.

The relationships among built environments, social and economic circumstances, diet, weight, and health, are complex. There is some variability in study results. But taken as a whole, currently available evidence supports the idea that food deserts are a real problem. The MIT team, in basing its conclusions on two studies and one opinion piece, which they apparently cherry-picked, provide an inaccurate and misleading picture of the current state of knowledge on this issue. Fourth, on the issue of transportation mode, Drummond and Berger state (page 20) Much has been written on the detrimental effects of automobile use in cities on urban health. Some of this research may involve causal mechanisms, but the majority repeats polemical positions. To support this broad statement, the authors cite a total of four papers. Remarkably, of the four, only one is actually about transportation mode! This is a parody of careful analysis.

Overall, this pattern of cursory literature reviews, misrepresentation of what the literature says, and polemical conclusions, reveals an unacceptably low level of scholarship. Careful scholarship extends beyond reading the literature, to conducting research. Research generally refers to a systematic, structured investigation or inquiry. In rigorous research, methods are carefully described, measures are selected for accuracy, precision, and validity, and data are analyzed carefully. The research section of this report falls short in many ways. On pages 31-33, authors Berger and Brown tell us how they selected the eight cities on which they focused. They cite several criteriainclusion on (unnamed) lists by (unnamed) organizations interested in climate and health, inclusion on the Clinton Global Initiative List, inclusion on a list of AIA case studies, and variation in geography, climate, and history. The selection process, however, is a black box. Eight cities emerge, including one (Atlanta) that does not appear on any of the lists the authors display (page 32) and two (Boston and Minneapolis) that appear on only one such list, and excluding one (Seattle) that appears on all the authors lists. The authors then proceed to use highly questionable research methods. They choose the County Health Rankings and Roadmaps (http://www.countyhealthrankings.org/) developed by the Robert Wood Johnson and the University of Wisconsin. While these rankings are one of the best available sources of nationwide county-level health data, they are no more finely scaled than the level of an entire county. Most counties are highly variable in their physical and social characteristics, down to the census tract and even block level. Atlantas Fulton County, for example, ranges from dense inner-city census tracts to loop-and-lollipop suburbs to bucolic rural areas. As a result, county-level data are largely inappropriate for studies that aim to link health with features of the built environment. Next, on pages 36-37, the authors create a combined metric for each county, simply adding nine parameters, such as the proportions of people with limited access to healthy foods, with no social-emotional support, who are living in poverty (children only), and who are physically inactive. Its unclear how these nine parameters were selected from among the 26 possibilities in the County Health Rankings. Moreover, adding unrelated parameters is an instance of the apples and oranges problem, illustrated by the classic New Yorker cartoon shown here. The authors proceed to perform analyses and draw conclusions based on these idiosyncratic measures. For instance, they remark that most striking, the majority of metros exhibit a U pattern where the best ranking (healthiest) counties are in the inner suburban belt just outside of the central city county.over 80% of the inner suburban counties rank better than the central city county in these major health metrics (bold type in original). In drawing this conclusion, the authors ignore the many other factors, such as age and socioeconomic status, that must be considered in making population 8

comparisons. Any findings based on invalid data and invalid analytical approaches are, of course, invalid. Next, the report presents descriptions of student projects in the eight cities. No systematic approach was used; we are told (page 34) that Student groups were given flexibility to choose a more detailed area to study within each city based upon the county level discoveries. While several investigations [sic] sought to describe the health performance and potential health threats for neighborhoods across the metro, others delved deeper [sic] into the disparities of the central city itself. The results are as variable as each citys unique demographic, geographic, economic, and physical makeup. It is no surprise that unstandardized study methods yield highly variable results. The individual student projects are for the most part impossible to evaluate. The descriptions of methods used are incomplete and erratic. Variables are not defined, analytical methods are not explained, confounding and bias are not addressed. The only firm statement that can be made is this: across the student projects, the conclusions and recommendations are unsupported by the data presented. The MIT report stands as a vivid reminder of the need for meticulous scholarship. Those who opine on a topic need to study the topic carefully, read deeply and broadly, pay close attention to what they read, learn from experts, ground their conclusions in evidence, and offer their opinions with appropriate limits and disclaimers. Those who undertake research need to learn and use rigorous methods, including clearly stated hypotheses, meaningful, validated measures, appropriate statistical methods, and disciplined, circumscribed conclusions. (These principles, by the way, are no less applicable to student projects than to professorial writing.) Careful study has already yielded important insights about the impact of the built environment on health, and further research, well conducted, will certainly extend these insights.

Complexity is a reality, not an excuse Health is a multifactorial phenomenon, determined by many factorsgenetics, diet, chemical exposures, physical activity, air quality, socioeconomic status, stress, and more. Epidemiologic studies, when testing specific hypotheses, therefore routinely rely on multivariate analysis, isolating the variable of interest while controlling for others. While this is not a perfect solution, it is well established, rigorous, and transparent. It permits conclusions to be drawn (McCormack and Shiell 2011). The authors of Health + Urbanism struggle with this concept. Consider this statement (page 7): Even though strong associations may exist, causality cannot be inferred from these alone. For example, many have postulated that the rise in obesity may be associated with urban form, transportation networks, and/or housing density. However, there are [sic] a multitude of confounding factors that could just as convincingly explain the association with obesitylack of exercise, genetics, education, income, stress, portion size and type of food. The relative impact 9

of urban design, planning, architecture, or landscape architecture over and above these other factors is simply unknown Claiming that causation cannot be inferred because many variables operate reflects a serious misunderstanding of science. It is akin to claiming that we cant know that drunk driving causes car crashes, because inexperience and rainy roads also cause car crashes. It is akin to claiming that we cant know that cigarettes cause lung cancer, because genetic factors and radon also contribute. Its incorrect. Scientific studies routinely control for such confounders in analyzing data. A special case of this misunderstanding is the ecological fallacy, which is well recognized in social science and epidemiology. It occurs when researchers draw conclusions about an association at the individual level, based on group data. Because groups are heterogeneous, associations seen at the group level dont necessarily hold at the individual level. Heres an example: Because automobile fatality rates are falling, and cell phone use is rising, cell phone use cant be associated with fatal car crashes. The authors fall into this trap on page 7 of the report: Despite the tremendous motorization of the American landscape from 1950 onward (three-fold increase per person) we have seen an increase in average U.S. life expectancy of 7.4 years. Not only is the nature of the association in the inverse direction from what has been suggested, but causality is also highly questionable. 2 This highlights the lack of epidemiologic expertise in the report. One rhetorical device for handling complexity is to advance an oversimplified straw man argument, and to take it down because its too simple. On page 8 we read, Another conventional assumption is that dense urban settings lead to healthier lifestyles than sprawled suburban developments. This is a classic straw man argument; no serious student of urban health makes such a simplistic claim (and the report offers no citation to such a statement). Some features of urban density, such as walkability, are associated with improved health behaviors and/or improved health outcomes. Some features of urban density, such as street-level air pollution, are hazardous. Other features of cities, such as poverty, are associated with a range of diseases. The truth is complex and nuanced, as researchers and practitioners working in this field understand well. So advancing, and then rebutting, such an artificial and simplistic claim, amounts to rhetorical chicanery. Another straw man argument appears on p 7: When it comes to the design and form of cities, our research suggests there are no silver bullets or universal solutions to urban health problems. To emphasize that point, Alan Berger said this in the interview that followed the release of the report: One of the reasons we wrote the report was to give people a sense that the silver-bullet mentality, from technological or policy perspectives, needs to stop. Really? In a field with numerous sophisticated researchers routinely dealing with complex problems, is there any evidence that the silver bullet mentality is endemic? Can Professor Berger cite even one example of somebody

Actually, life expectancy increasd by 9.9 years from 1950 to 2008, as the authors would have learned from a quick check of readily available CDC vital statistics data (Arias E. United States Life Tables, 2008. National Vital Statistics Report, Vol 61, No 3, September 24 2012. Table 19. Available: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_03.pdf).

10

advocating a simplistic silver bullet? Again, this is a straw man argument, mischaracterizing the state of the field, and pretending to offer a solution. Complexity is not just a challenge for researchers; it is a challenge for practitioners. When a doctor diagnoses an illness and prescribes a treatment, she routinely has to weigh the side effects of treatment. The same is true for design professionals. Yes, improving walkability and transit access improves health. Yes, exposure to air pollutants from traffic degrades health. Yes, poverty is a powerful predictor of poor health. The report raises legitimate questions about the dangers of exposure to highway emissions; designers need to balance these with the benefits of physical activity and of job access for low-income communities, in considering whether to encourage suburban development patterns or when and where to build density and/or TODs. Built environment professionals, like health professionals, need to be thoughtful about the collateral impacts of their interventions. The authors are unquestionably correct in noting that the relationship between the built environment and human health is complex. Unfortunately, their response is unhelpful: they suggest that complexity precludes reaching firm conclusions, they abjure the use of appropriate analytical methods, and they engage in straw man arguments. A better path forward is to embrace the complexity, to identify the important variables (including but not limited to the built environment) that affect health, and to work to understand their impact using appropriate analytical methods.

The need for balanced public discourse When the report was issued, in November, 2013, MITs News Office promoted it, publishing an interview with Professor Berger. He opened the interview with the following statement: The number one thing Ive learned is: You cannot prove causality easily, because the issue is so complex. His second statement began as follows: One of the main things we learned from this study is that there is no silver bullet for urban health. At only one point in the interview, buried in a later statement, did he refer to a solutionseparating buildings from highways. Its true that reality is complex, but its equally true that solid evidence currently supports many policy conclusions. By choosing to frame the issue as one of uncertainty, Professor Berger largely defined the narrative that would follow. Neither Professor Berger nor the rest of the team is responsible for how their work is reported in the media. But the way they frame their work does have influence. The Atlantic Cities covered the report a few weeks after its release, in a story headlined We Dont Know Nearly as Much about the Link between Public Health and Urban Planning as We Think We Do. The story parrots, and amplifies, Professor Bergers narrative, unburdened by critical thinking or even fact-checking. For example: the MIT report knocks down many of the assumptions that have become entrenched in how we think about health and cities: namely, that walkable cities are healthier than auto-oriented

11

suburbs, that cars are a primary cause of our expanding waistlines, that too much fast food and too little fresh fruit are to blame for inner-city obesity. After lionizing the MIT report this way, the Atlantic reporter proceeds to make statements seemingly grounded in evidence (or the lack of it), such as: There's no evidence to suggest that sprawl causes obesity What? There is extensive evidence that sprawl contributes to obesity, readily available to anyone who looks it up (or who interviews an expert). The story includes no comments from experts in the field who might have provided countervailing views. And stories such as this have legs; they live on in the blogosphere. Weeks later, a Seattle Bike Blog post on air quality along bike routes included this statement: Urban planners have assumed interventions like walkable transit-oriented development and bike networks hold positive health outcomes for communities, but a ten-year study from the MIT Center for Advanced Urbanism shed a not so fast warning on the above assumptions, according to The Atlantic Cities. 3 By now, the MIT student projects had become a ten-year study from MIT! With each successive wave, accuracy falls, and false statements gain a veneer of reality. Seeking evidence, interviewing experts, and presenting opposing views, are standard practices among skilled journalists. Unfortunately, far too many journalists, bloggers, and other commentators fail to observe these conventions, as in the Atlantic Cities piece. Those who speak to the press therefore have a special responsibility to be well informed, and to present their views accurately, with balance, and with context, to help advance public discourse.

Conclusion While the Report on the State of Health + Urbanism is a deeply flawed document, we can learn much from it, in both positive and negative senses. First, the links between the built environment and health are keenly important, and are a topic of growing interest. This is a good thing. With many opportunities for designing and building, and with many health challenges facing the nation, approaching the intersection proactively offers great promise. The MIT team is to be congratulated for focusing on the human dimensions of design. Second, real collaboration is essential. As the report points out, the design professions and the health professions use different languages, and draw on different knowledge bases. Further, people in many other arenas also have a stakefrom elected office to law enforcement, from parks and recreation to utilities, and, of course, the public, in all its diversity. Collaboration needs to be broad-based. This report suffered considerably from the absence of health science expertise, an object lesson for such efforts going forward.

http://www.seattlebikeblog.com/2014/02/24/some-seattle-bike-routes-have-healthier-air-than-others/#more248688

12

Third, intellectual rigor is essential. This is achieved by including the right expertise on project teams; by thorough, careful review of available evidence; by the use of appropriate measures; by the use of rigorous analytical methods; by careful editing and peer review of work products; and by identifying study limitations in research reports (to name a few). In classes, studios, and student projects, students deserve to be taught the elements of intellectual rigor. Again, this report suffered in these regards, a basis for improvement in the future. In fairness to MIT, a proper report of the scope attempted here requires a significant investment in time and money. AIA is to be commended for sponsoring this work, but funding is needed at levels far beyond those that support student projects. We need to build, refine, and validate data sets, invest in innovative study designs, and educate architects and planners to make informed decisions. Fourth, as the report emphasizes, this is an area of considerable complexity. Many factors determine the health of individuals and populations, many factors determine the quality of buildings, neighborhoods, and cities, and many factors determine the choices people make. Research design, data analysis, and conclusions must acknowledge this complexity. No evidence is ever perfect, partly owing to the complexity of the world, but that complexity must not be allowed to foster nihilism or paralysis. Casting gratuitous doubt is not only irresponsible; it can be dangerous (Michaels 2008). We know a great deal, we can act on what we know, and as we do, we can and should continually test our assumptions and improve our knowledge. Finally, public discourse is an essential element of creating healthy places. If researchers and other opinion leaders frame this topic primarily in terms of what we dont know; if the urge to be provocative, edgy, and iconoclastic trumps the need to be balanced, thoughtful, and accurate; if pedantry eclipses the need to solve real problems for real people in real time; and if nihilism erodes constructive engagement; then the public will suffer. Opinion leaders, from academics to industry leaders to professional associations, need to lead, based on the responsible and accountable use of our best data and our best judgments. This is essential to achieving a healthy, sustainable built environment for all people in all communities.

References
Akinbami LJ, Moorman JE, Bailey C, et al. Trends in Asthma Prevalence, Health Care Use, and Mortality in the United States, 20012010. National Center for Health Statistics Data Brief Number 94. May 2012. Available: http://www.cdc.gov/nchs/data/databriefs/db94.htm. American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care 2013; 2013;36:103346. Beaulac J, Kristjansson E, Cummins S. A systematic review of food deserts, 1966-2007. Prev Chronic Dis. 2009 Jul;6(3):A105. Chapin CV. The end of the filth theory of disease. Popular Science Monthly 1902;60:234-39. Cummins S, Flint E, Matthews SA. New neighborhood grocery store increased awareness of food access but did not alter dietary habits or obesity. Health Aff (Millwood). 2014 Feb;33(2):283-91. Dannenberg AL, Jackson RJ, Frumkin H, et al. The impact of community design and land-use choices on public health: a scientific research agenda. Am J Public Health 2003;93(9):1500-08. Doll R. Proof of causality: Deduction from epidemiologic observation. Perspect Biol Med 2002;45:499-515. Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clinical Nutrition 2004;79(1):6-16. Dub P. Urban health: an urban planning perspective. Rev Environ Health. 2000 Jan-Jun;15(1-2):249-65.

13

Egan M, Petticrew M, Ogilvie D, Hamilton V. New roads and human health: a systematic review. Am J Public Health 2003;93, 1463-71. Eid J, Overman HG, Puga D, Turner MA. Fat city: Questioning the relationship between urban sprawl and obesity. J Urban Econ 2008;63(2):385404. Fleischhacker SE, Evenson KR, Rodriguez DA, Ammerman AS. A systematic review of fast food access studies. Obesity Reviews 2011;12:e460-e471. Frumkin H. Urban sprawl and public health. Public Health Rep. 2002;117(3): 20117. Frumkin H, Frank L, Jackson RJ. Urban Sprawl and Public Health. Washington: Island Press, 2004. Galea S, Vlahov D. Urban Health: Evidence, challenges, and directions. Annu Rev Public Health 2005;26:341-65. Giskes K, van Lenthe F, Avendano-Pabon M, Brug J. A systematic review of environmental factors and obesogenic dietary intakes among adults: are we getting closer to understanding obesogenic environments? Obesity Reviews 2011;12:e95-e106. Handy SL, Boarnet MG, Ewing R, Killingsworth RF. How the built environment affects physical activity: Views from urban planning. Am J Prev Med 2002; 23 (2 Suppl 1): 64-73. Hill AB. The environment and disease: Association or causation? Proc Royal Soc Med 1965;58:295-300. Hilmers A, Hilmers DC, Dave J. Neighborhood disparities in access to healthy foods and their effects on environmental justice. Am J Public Health. 2012;102(9):1644-54. Jackson RJ, Dannenberg AL, Frumkin H. Health and the built environment: 10 years after (Editorial). Am J Public Health 2013;103(9):1542-44. Kaufman JS, Poole C. Looking back on Causal Thinking in the Health Sciences. Annu Rev Public Health 2000;21:101-19. Larson NI, Story MT, Nelson MC. Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med. 2009;36(1):74-81. Lee H. The role of local food availability in explaining obesity risk among young school-aged children. Soc Sci & Med 2012;74(8):11931203. Lee H. The making of the obesity epidemic: how food activism lead public health astray. Breakthrough Journal, Spring 2013. Available: http://thebreakthrough.org/index.php/journal/issue-3/the-making-of-the-obesity-epidemic/ Lopez R. Urban sprawl and risk for being overweight or obese. Am J Public Health 2004;94(9):157479. Lopez RP, Hynes HP. Obesity, physical activity, and the urban environment: public health research needs. Environmental Health 2006;5:25. McCann BA, Ewing R. Measuring the Health Effects of Sprawl: A National Analysis of Physical Activity, Obesity and Chronic Disease. Washington: Smart Growth America and Surface Transportation Policy Institute, 2003. Available: http://www.smartgrowthamerica.org/research/measuring-the-health-effects-of-sprawl/. McCormack GR, Shiell A. In search of causality: a systematic review of the relationship between the built environment and physical activity among adults. Int J Behav Nutr Phys Act. 2011:13;8:125. Michaels D. Doubt is Their Product: How Industry's Assault on Science Threatens Your Health. New York: Oxford University Press, 2008. Morrison DS, Petticrew M, Thomson H. What are the most effective ways of improving population health through transport interventions? Evidence from systematic reviews. J Epidemiol Community Health 2003;57:327-33. Northridge ME, Sclar ED, Biswas P. Sorting out the connections between the built environment and health: A conceptual framework for navigating pathways and planning healthy cities. J Urban Health 2003;80(4):557-68. Ogilvie D, Egan M, Hamilton V, Petticrew M. Promoting walking and cycling as an alternative to using cars: systematic review. BMJ 2004;329:763. Pratt LA, Brody DJ, Gu Q. Antidepressant Use in Persons Aged 12 and Over: United States, 20052008. National Center for Health Statistics Data Brief Number 76. October 2011. Available: http://www.cdc.gov/nchs/data/databriefs/db76.pdf. Renton A. Epidemiology and causation: A realist view. J Epidemiol Community Health 1994;48(1):79-85. Ruopeng A, Sturm R. School and residential neighborhood food environment and diet among California youth. Am J Prev Med 2012;42(2):129-35. Sallis JF, Bauman A, Pratt M. Environmental and policy interventions to promote physical activity. Am J Prev Med 1995;15:37997. Sallis JF, Glanz K. Physical activity and food environments: solutions to the obesity epidemic. Milbank Q. 2009;87(1):123-54. Smit W, Hancock T, Kumaresen J, et al. Toward a research and action agenda on urban planning/design and health equity in cities in low and middle-income countries. J Urban Health 2011;88(5):875-85. Srinivasan S, OFallon LR, Dearry A. Creating healthy communities, healthy homes, healthy people: initiating a research agenda on the built environment and public health. Am J Public Health 2003;93(9):1446-50. Susser M. Causal Thinking in the Health Sciences. New York: Oxford University Press, 1973. Vandegrift D, Yoked T. Obesity rates, income, and suburban sprawl: an analysis of US states. Health & Place 2004;10(3):22129.

14

Walker RE, Keane CR, Burke JG. Disparities and access to healthy food in the United States: A review of food deserts literature. Health & Place. 2010;16(5):876-84. Zhao Z, Kaestner R. (2010). Effects of urban sprawl on obesity. J Health Economics, 2010;29(6):779-87.

15