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Report on the State of Health + Urbanism: A Critique

Report on the State of Health + Urbanism: A Critique

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Published by architectmag
By: Howard Frumkin, MD, DrPH, Richard Jackson, MD, MPH, AIA (Hon), Andrew Dannenberg, MD, MPH
By: Howard Frumkin, MD, DrPH, Richard Jackson, MD, MPH, AIA (Hon), Andrew Dannenberg, MD, MPH

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Published by: architectmag on Apr 11, 2014
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01/07/2015

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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 MIT’s 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. It’s 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-on-cities-and-health-1121, and the
 Atlantic’s
 news coverage of the report can be found at http://www.theatlanticcities.com/neighborhoods/2013/12/much-what-we-know-about-public-health-and-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 report’s 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
don’t 
 know—positioning 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. It’s 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.”
 
2 So if we do know enough to act, what’s 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 doesn’t run deeper, reflecting professional paradigms—a 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 what’s wrong with our current knowledge and tools. In reaching these conclusions, the authors seem to opt for contrariness and nihilism instead of balanced analysis. It’s 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 nation’s health is a pressing concern. While some trends are encouraging (for instance, heart disease mortality has been declining for two decades), other trends—rising obesity, autism, allergies, some mental illnesses—are 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 18–44 years; over the last 20 years, antidepressant use in the United States increased
 
3 nearly 400% (Pratt et al. 2011). Our aging population will confront more health challenges. Health care costs—now at $2.5 trillion each year, or nearly 18% of GDP—continue to rise. These two domains—the built environment and human health—are 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 professionals—architects, urban planners landscape architects, developers, builders, and others—collaborate with health and social science professionals—physicians, epidemiologists, sociologists, and others. How did the MIT report do in this respect? The report’s editor was Alan Berger, Professor of Landscape Architecture and Urban Design at MIT and Director of Research at that institution’s 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 master’s 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 isn’t linked to asthma mortality), but the reference cited to support

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