Environmental Research 182 (2020) 109088

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Environmental Research
journal homepage: www.elsevier.com/locate/envres

Forecasting health effects potentially associated with the relocation of a T

major air pollution source
Dani Broitmana,∗, Boris A. Portnovb
a
Faculty of Architecture and Town Planning, Technion - Israel Institute of Technology, Technion City, Haifa, 32000, Israel
b
Department of Natural Resources & Environmental Management, University of Haifa, Mount Carmel, Haifa, 31905, Israel

ARTICLE INFO ABSTRACT

Keywords: Epidemiological studies often focus on risk assessments associated with exposures to specific air pollutants or
Air pollution proximity to different air pollution sources. Although this information is essential for devising informed health
Health impact policies, it is not always helpful when it comes to the estimation of potential health effects associated with the
Risk assessment introduction or relocation of local health hazards. In this paper, we suggest a novel approach to forecasting the
Childhood asthma
morbidity-reduction impact of hypothetical removal of a major air pollution source from a densely populated
Metropolitan area
Industrial transition
urban area. The proposed approach is implemented in three stages. First, we identify and measure the strength of
association of individual environmental factors with local morbidity patterns. Next, we use the estimated models
to simulate the impact of removal of the pollution source under analysis and its replacement by green areas.
Using this assessment, we then estimate potential changes in the local morbidity rates by mutually comparing
the observed risk surface of disease with the risk surface simulated by modelling. To validate the proposed
approach empirically, we use childhood asthma morbidity data available for a major metropolitan area in Israel,
which hosts a large petrochemical complex. According to our estimates, relocation of the petrochemical complex
in question is expected to result in about 70% drop in the childhood asthma morbidity rate area-wide. To the
best of our knowledge, the present study is the first that suggests an operational approach to incorporating
epidemiological assessments as an input for urban development plans related to local sources of air pollution.

1. Introduction relocation of existing ones.

Population living near major air pollution sources, such as petro-
chemical and other polluting industries, faces several health risks, in-
cluding respiratory and cancer morbidity (Axelsson et al., 2013; Cirera
et al., 2013). A typical feature of such pollution sources is that popu-
lation living close them is exposed to a mix of chemicals, which include
organic components, dioxins, heavy metals and other hazardous che-
mical substances (Hoek et al., 2018). To assess health risks associated
with residential proximity to such facilities, specific health outcomes
are typically estimated as relative risks or odds ratios associated with
prolonged exposure to different air pollutants (Logue et al., 2010;
Swartjes, 2015) or by using areal proximity to predefined air pollution
sources as proxies for unknown exposures (Pascal et al., 2013;
Alwahaibi and Zeka, 2016). Although this information is essential for
general risk assessments and for devising informed health policies, it
can be of little help for planners and decision-makers who want to as-
sess changes in the health status of the local population, potentially
associated with the introduction of new hazardous facilities or
The removal or relocation of existing sources of air pollution can
expectedly lead to the improved health of the local population, due to
well-established adverse effects of exposure to air pollution on popu-
lation morbidity (Renzetti et al., 2009; Perry and Lindell, 1997; Avol
et al., 2001; Turczynowicz et al., 2007). However, methods for fore-
casting the expected health effects of such land-use changes on the ex-
posed population are yet to be developed.
In this paper, we attempt to fill this lacuna by suggesting a novel
empirical approach to forecasting the impact of relocation of a major
air pollution source on local morbidity patterns. The proposed approach
is implemented in three consequent stages – risk factor modelling, risk-
change simulation, and risk-change assessment.
During the risk factor modelling stage, we perform a multivariate
analysis of the existing morbidity patterns, using the double kernel
density (DKD) smoothing, which transforms the observed morbidity
events into continuous disease rate surfaces. DKD is a recent enhance-
ment of the simple kernel density estimation (Bithell, 1990; Shi, 2009,
2010; Gerber, 2014), which is especially suitable for cases in which two

∗
Corresponding author.
E-mail addresses: danib@technion.ac.il (D. Broitman), portnov@research.haifa.ac.il (B.A. Portnov).

https://doi.org/10.1016/j.envres.2019.109088
Received 5 June 2019; Received in revised form 22 December 2019; Accepted 23 December 2019
Available online 24 December 2019
0013-9351/ © 2019 Elsevier Inc. All rights reserved.
D. Broitman and B.A. Portnov
related datasets are available: residential locations of the general po-
pulation, and a sub-set of the general population dataset, composed by
point locations of the events of interest, such as e.g., residential loca-
tions of disease-affected individuals. The DKD method normalizes the
kernel density of the latter by the kernel density of the general popu-
lation. The resulting ratios are comparable to disease rate estimates,
such as those commonly used in epidemiology and health geography
(Vanos et al., 2014; Vienneau et al., 2015). The main goal of the risk-
factor modelling phase is identification of statistical associations be-
tween the observed disease incidence and its underlying environmental
factors, including both locational disadvantages (such as e.g., proximity
to air pollution sources), and potential environmental benefits, such as,
e.g., proximity to green areas.
During the following, risk-change simulation, phase, we use the
models, estimated during the risk-factor modelling phase, to simulate
the impact of removal of the pollution source under analysis and its
replacement by health-benefitting environmental features, such as
green areas. Lastly, during the risk-change assessment phase, we estimate
potential changes in the morbidity rates by mutually comparing the
observed disease rate surface with the simulated one.
2. Materials and methods
2.1. Study area
The Haifa Bay area (HBA), used in the present analysis as a case
study, is located on the Mediterranean coast of Israel and consists of the
City of Haifa and several neighboring municipalities (see Fig. 1). HBA is
the third largest metropolitan area in Israel (after Tel Aviv and Jer-
usalem) and is home to about 500,000 residents (ICBS, 2015a). HBA
spreads over 300 km2 and hosts several large petrochemical facilities
(see dark gray areas in Fig. 1), a major power station, a seaport and
several smaller industrial facilities. Due to relatively high levels of air
pollution, HBA is characterized by elevated morbidity, including
cancer, and respiratory diseases (Goren et al., 1990, Zusman et al.,
Fig. 1. Map of the study area featuring residential location of all children in the database (left) and children diagnosed with asthma in 2014 (right). Note: Due to
privacy concerns the individual geocoded data are aggregated into statistical areas.
2
Environmental Research 182 (2020) 109088
2012, Zusman et al., 2016).
2.2. Childhood asthma data
The Clalit Health Services (CHS), data from which computerized
database was used for this study, is the largest health care organization
in Israel that provides health coverage to about 54% of the HBA po-
pulation (Cohen et al., 2010). In particular, we obtained medical re-
cords of 20,803 6-to-14-year-old children residing in the study area, of
whom 3820 children (18.4%) were diagnosed with asthma in 2014.
Although some children of the subject age group, residing in the study
area, are serviced by other, smaller health organizations, previous
studies (e.g., Svechkina and Portnov, 2017) found that the CHB data-
base represents fairly well the HBA metropolitan population in terms of
gender and age structure. Out of 20,803 records available in the data-
base, 18,397 records (88%) had accurate street addresses and were
geocoded using ArcGIS tools, including 3820 records of children diag-
nosed with asthma in 2014 (see Fig. 1). Our analysis found no sig-
nificant differences in the gender and age structure between geocoded
and non-geocoded subjects (P > 0.4).
2.3. Air pollution data
Among environmental factors associated with asthma, air pollution
is considered the most important and well-known contributor (Leikauf
et al., 1995). Specific air pollutants, known to be significantly asso-
ciated with asthma, include SO2 (Koenig et al., 1983; Huang et al.,
1991), NOx (Huang et al., 1991), particulate matter, PM (Dockery et al.,
1989), and ozone, O3 (Molfino et al., 1991).
To estimate air pollution levels at the places of child's residence, we
obtained data from stationary air quality monitoring stations located in
HBA - 15 stations for SO2, 18 stations for NOx, and 10 stations for PM2.5
(IMEP, 2017). First, we calculated air pollution averages from 2011 to
2013, that is for three years, preceding asthma incidence records. Next,
we attached these averages to the residential locations of the children in
D. Broitman and B.A. Portnov Environmental Research 182 (2020) 109088

the database, using the nearest monitor method (O'Connor et al., 2008).
2.4. Additional variables
The petrochemical industrial complex, located in the central part of
the HBA (Fig. 1), is the largest air pollution source in the study area
(Eitan et al., 2010). However, air pollution by organic compounds from
this source is not routinely monitored. Therefore, aerial distances be-
tween children's residences and this complex was included as an ex-
planatory variable for asthma prevalence, to serve as a proxy for un-
measured exposures.
Proximity to green areas is another potentially influential variable,
since green space is considered to be positively associated with less air
pollution and better health (Sbihi et al., 2015; Dadvand et al., 2014).
Following Villeneuve et al. (2012), Sarkar et al. (2015), and Sarkar
(2017), we used percent of green areas within a 500 m buffer around a
residence as a measure of greenness. The values of this variable for in-
dividual residences were calculated using satellite images, retrieved
from the MAARAG dataset (Maarag, 2014). This dataset describes the
herbaceous, forest and agricultural land cover at a spatial resolution of
25 × 25 m2.
Motor vehicles contribute to air pollution through the combustion
of fine particles smaller than 2.5 μm in aerodynamic diameter (PM2.5),
as well as by emission of volatile and semi-volatile organic compounds
– VOCs and sVOCs (US EPA, 1999; Price et al., 2012), many of which
are not routinely measured by local air quality monitoring stations.
Therefore, distance to the nearest main road was added as another, po-
tentially relevant exposure variable. The map of the main roads in the
study area was retrieved from the Survey of Israel's database (SOI,
2019).
Winds from the sea are potential transmitters of contaminants (Chan
et al., 1999; Busby and Parry, 2004; Waisel et al., 2008). Therefore,
distance to the sea coast was considered as an additional location-related
variable.
Altitude above the sea level is also known as a factor associated with
asthma prevalence, mainly due to air pollution inversion
(Gourgoulianis et al., 2001). Therefore, the topographical height of the
children's residences above the sea level was included as an additional
explanatory variable to account for this effect.
Socio-economic variables (such as poor residential conditions, low
socio-economic status of families, etc.) are well-established potential
risk factors for childhood asthma (Thakur et al., 2013; Strong and
Chang, 2014). To account for these effects, three additional variables
were introduced into the analysis. Since low socioeconomic level is
related to high population density (Crump, 2002), this measure was used.
The second variable was whether the family receives a welfare allowance
or not, a binary variable recorded in the CHS database, and the third
variable was the socio-economic status (SES) of the statistical area in
which a child's residence is located. Finally, since asthma risks are
known to differ by ethnicity (Shohat et al., 2000), the percent of the
Jewish population living in the neighborhood was used as a predictor.
The values of the neighborhood-level variables (such as SES, population
density and ethnicity) were obtained from the Israel Central Bureau of
Statistics (ICBS, 2015b) and linked to children's residences using the
“spatial join” tool of the ArcGIS™10. x software (ESRI, 2016). The same
tool was also used to calculate proximities to main roads and petro-
chemical industries. The descriptive statistics of the explanatory vari-
ables used in the analysis are reported in Table 1.
2.5. Asthma risk estimates
As previously mentioned, the dataset available for the analysis was
composed of individual residential locations of children diagnosed with
asthma (year-2014 prevalence). Since spatial concentrations of asth-
matic children in particular parts of the study area may simply be
caused by a high density of children residing in these loci, we used the
DKD technique (see inter alia Zusman et al., 2012, Zusman et al., 2016),
to generate a normalized continuous density surface of asthma rates.
First, we created a KD surface based on the childhood asthma pre-
valence dataset, featuring the home locations of 3820 children diag-
nosed with asthma, and, then, calculated the second KD surface based
on residential locations all children residing in HBA geocoded from the
CHS database (18,397 observations). Next, for each 3820 residential
locations of the children with asthma we calculated asthma rates, by
dividing the KD of asthmatic children in each location by the total
density of all children in that location. The resulting values were
asthma prevalence rates, measured as the number of asthmatic children
per 1000.
The most important parameter of the KD surface is the kernel
bandwidth, that is, a predefined search radius, in which the events of
interests are counted and weighted. Large bandwidths may result in
over-smoothed surfaces in which local variations are difficult to dis-

Table 1
Descriptive statistics of the research variables (N = 3820).
Variable Number (%) Mean SD Min Max

Asthma prevalence (cases per 1000) – 217.13 41.94 92.97 358.93

Family welfare allowance:
• yes 447 (11.7) – – –
• no
Topographical height of the place of residence above the sea level (m)
3373 (88.3)
– 74.94
–
96.73
–
0.00
–
435
Share of Jewish population in the neighborhood (%) – 86.85 26.89 0.00 99.9
High socio-economic ranking of the neighborhood (% of inhabitants in the top 7–10 SES deciles) – 41.38 14.75 0.00 74.64
Population density (per hectare) – 8.13 5.74 0.00 28.47
Distance to the sea (m) – 1675.00 843 89 4354
Distance to the nearest main road (m) – 100.00 126 0.00 991
Distance to the petrochemical industrial complex (km) – 5.20 1.90 0.78 9.12
PM2.5 exposure estimate, annual average (mg/m3) – 17.78 1.006 0.00 19.96
Percent of green areas within the walking radius of 500 m from the place of residence – 18.09 16.78 0.00 77.45

3
D. Broitman and B.A. Portnov
cern, while smaller bandwidths may produce spikes between close lo-
cations (Gatrell et al., 1996). In the analysis, we used the same band-
widths for the numerator of the DKD ratio (i.e., disease events) and for
its denominator (i.e., the population from which disease events are
drawn), considering that different bandwidths may result in biased rate
estimates, if the densities of the disease patients and of general popu-
lation are compared for areas of different size.
To define the optimal bandwidth, we used the cross-validation
technique. Cross-validation is a heuristic approach implemented for
selecting the smoothing parameter in the KD estimation (Bowman,
1984). The cross–validation test removes each data location once at a
time and predicts its value using all the remaining data points
(Johnston et al., 2001). The bandwidth was tested in the feasible range
between 100 and 1500 m, considering the overall size of the study area
(about 20 by 20 km). As measures of the goodness of fit, we used dif-
ferent parameters: the root mean square error, which indicates how
closely the model predicts the measured values (smaller errors imply
results that are more accurate), and the average standard error, which
estimates the variability of the predictions from the true values, and the
root mean square error. We also examined the root mean squared
standardized errors, expecting them to be as close as possible to 1 in
order to avoid overestimation or underestimation of the predictions'
variability.
Once we defined the optimal threshold for each dataset, we calculated
the KD surface for the children diagnosed with asthma (that is, the events
of interest) and for the total population (i.e., all children residing in Haifa
Bay metropolitan area and recorded in the CHS database). Finally, we
calculated the ratio between the two KD surfaces defining the DKD, and
assigned the values to the reference points, using the “Extract multi values
to points” tool in the ArcGIS™10.x software (ESRI, 2016).
2.6. Statistical analysis
In a spatial analysis, variables measured at neighboring locations
tend to be related (Anselin et al., 2006; Logan, 2012; Wikle, 2015). As
our observations were drawn from a continuous DKD asthma surface,
we thus expected to find a strong spatial autocorrelation of neighboring
residuals. Unless such autocorrelation is controlled, the resulting re-
gression estimates can suffer from an undesirable bias (Anselin and Rey,
1991; Anselin et al., 2006). To verify whether such autocorrelation is
present, we used the Moran's I spatial dependency test (Tiefelsdorf,
2006). Since a strong spatial dependence of neighboring residuals from
OLS models was detected, we ran spatial dependence models for dif-
ferent spatial proximity weight thresholds, to estimate and mutually
compare the models' performance.
Since we did not have any a-priori preference for any type of the
weight matrix, we used an Euclidian distance weight matrix, and tested
the model sensitivity to different distance choices, with a reasonably
small, a 100-m, increment and proceeded to spatial dependence re-
gressions. In these regressions, the DKD was the dependent variable and
the spatial effects were incorporated through the error term. Our ex-
pectation was that the ordinary least squares (OLS) regression will
perform poorly compared with the regressions weighted by neighbor-
hood proximity matrixes. Two types of spatial dependence models (of
spatial error and spatial lag families) were used in the analysis, but only
4
Environmental Research 182 (2020) 109088
spatial error models are reported in the following discussion as best
performing. The cross-model comparison was performed using three
measurements: The R2, log-likelihood and the Akaike criterion. The
analysis was performed in the GeoDA 1.x software (Anselin et al.,
2006).
2.7. Scenario testing
To investigate a potential effect of the hypothetical relocation of the
petrochemical complex, which is the main environmental hazard lo-
cated in the study area, and its replacement by an alternative land use,
on childhood asthma morbidity, we performed the analysis in several
stages. First, we used the best performing model estimated for the
childhood asthma prevalence (see Subsection 2.6) and applied the ac-
tual values of all the variables for each location, to compare our pre-
dictions with the observed asthma rates. After we determined that our
model predicts the observed rates of childhood asthma quite well, we
proceeded to simulate the hypothetical removal of the petrochemical
industry complex from the study area. For this purpose, map pixels,
currently occupied by the petrochemical industries, were arbitrarily
replaced by greenery. For simplicity's sake, we used binary values to
define green areas (that is, green or not), assuming that future studies
may use more advanced metrics, differencing between types of green
areas and intensity of their use. In the following up simulation, the
values of all explanatory variables (except for the proximities to the
petrochemical complex and percent of greenery) were set to their area-
wide averages. The distance to the petrochemical industries was not
considered, since the industrial complex was hypothetically relocated
elsewhere, and percent of greenery was recalculated for all residential
locations. During the next step, the estimated values were input into the
selected model and asthma rate predictions were calculated.
3. Results
3.1. DKD bandwidth calibration
Fig. 2 shows the results of cross-validation of the kernel bandwidth,
which was the first step required for DKD calculation and analysis. As
Fig. 2 shows, for both datasets (i.e., for the total population of children
and for children with asthma), the values of the root mean square error
and of the average standard error are minimal at 1000 m. In addition,
for 1000 m, the root mean squared standardized errors is close to 1 for
both datasets, thus defining 1,000 m as the optimal bandwidth for both
datasets.
In the next step, we performed a further validation of the bandwidth
by randomly partitioning each dataset into two groups: 80% of the
observations used for training, and the remaining 20%, called the test
group, used for validating the model (Villa-Vialaneix et al., 2012). The
results of the analysis are reported in Fig. 3. As Fig. 3 shows, there is a
very high correlation between the predicted values of the test group and
the observed original values in both datasets (R2 = 0.993 and
R2 = 0.967 for all children's population and for asthma prevalence
cases, respectively), thus leading us to conclude that the chosen 1000 m
bandwidth for both datasets is optimal.
D. Broitman and B.A. Portnov Environmental Research 182 (2020) 109088

Fig. 2. Cross-validation of the KD bandwidth using root mean square, average standard errors and root mean square standardized under incremental kernel's
bandwidth for all children's population (upper graphs) and for asthma prevalence cases (lower charts).

Fig. 3. The observed vs. predicted values for all children and asthma case datasets.

3.2. Calibration of the neighborhood proximity matrix
Table 2 reports regression results for two different models: The OLS
regression (Model 1) and the spatial error dependence model with the
best performing neighborhood weight threshold of 400 m (Model 2).1
In both cases, the dependent variable is the DKD rate of asthma per
1000.
As Table 2 shows, Model 1, which does not consider spatial auto-
correlation (OLS), has a relatively low explanatory power (R2 = 0.392).
Concurrently, Model 2, which is a spatial error model that accounts for
spatial autocorrelation of the residuals, explains a larger share of the
DKD variability around its mean (R2 = 0.976). In fact, such a high fit is
unsurprising, considering that DKD observations are drawn from a
continuous surface and the model fit thus improves significantly after
error terms, observed in neighboring locations, are factored in as an
additional explanatory variable.
The explanatory variables, which emerged as statistically significant
in both models, and with the expected signs, are: distance to the sea,
distance to the petrochemical industries (both linear and quadratic
terms), and the index of greenness around individual places of re-
sidence (P < 0.01).2 In both models (see Table 2), childhood asthma
rates decrease with increasing distance from the sea (p < 0.01).
Fig. 4(a) and (b) shows the observed childhood asthma rate and
predicted childhood asthma rate calculated by the spatial error model
(Model 2), respectively. As a mutual comparison of these maps shows,
the model predictions are not only accurate (as shown in Table 2), but
also visually consistent.

1
Model results for other neighborhood proximity matrices are not reported
here and can be obtained from the authors upon request.
2
This result suggests that there is an initial increase in asthma rates with
distance, and, then, decrease, which can be interpreted as a downward para-
bola.

5
D. Broitman and B.A. Portnov Environmental Research 182 (2020) 109088

Table 2 3.3. Scenario testing

Factors affecting the observed prevalence rates of childhood asthma (Method –
OLS (Model 1) and Spatial error (SE) regression with weight threshold distance The main conclusions that can be drawn from the results of the
of 400 m (Model 2); dependent variable – DKD rate of asthma per 1000). previously described asthma prevalence modelling are as follows: First,
Predictor Model 1 Model 2 the asthma rates increase with distance from the petrochemical in-
B (t)a B (t)a dustries up to 4–5 km range, and, second, the amount of greenery
around children's residences decreases asthma rates. Both variables are
(Constant) 103.52 126.55
(8.23)*** (28.47)***
robust and statistically significant (p < 0.05), which is fairly con-
Welfare allowance (no = 0, yes = 1) 4.53 0.69 sistent with the literature (Sbihi et al., 2015; Cilluffo et al., 2018). Based
(1.67)*** (0.33)** on these relationships, we simulated the hypothetical removal of the
Topographical height of the place of residence (m) 0.09 −0.02 petrochemical industries from the study area, and their replacement by
(9E-03)*** (8E-03)**
green areas, that is, by a large metropolitan park or other recreation
Jewish population in the neighborhood (%) 0.19 −0.016
(0.02)*** (0.01) facility (see Subsection 2.7 on scenario testing).
High socio-economic ranking (% of inhabitants in high −0.19 -9E-03 Fig. 4(c) shows that the predicted asthma rates, under the “industry
SES deciles 7–10) (0.05)*** (0.02) relocation” scenario, drop drastically, compared to both actually ob-
Population density (per hectare) −0.25 −0.05
served asthma prevalence rates (see Fig. 4(a)), and the model simulated
(0.11)** (0.04)
Distance to the sea (m) −0.017 −0.02
rates (Fig. 4(b)). In particular, as Table 3 shows, the relocation of the
(9E-04)*** (1E-03)*** petrochemical industry complex in question is expected to lead to about
Distance to the nearest main road (m) −0.014 -2E-03 a 70% drop in the childhood asthma morbidity area-wide, from 217.13
(5E-03)*** (2E-03) cases per 1000 children, to 64.15 cases per 1000 in the simulated in-
Distance to the petrochemical industries complex, 32.48 49.29
dustry relocation scenario.
linear term (km) (1.84)*** (4.23)***
Distance to the petrochemical industries complex, −2.1 −4.46
quadratic term (km2) (0.17)*** (0.36)*** 4. Discussion
PM2.5 exposure estimate, annual average (mg/m3)c 1.62 −1.23
(0.46)*** (1.11) Planning for a better and more sustained urban environment re-
Percent of green areas within the walking radius of −0.22 −0.05
500 m from the place of residence (0.04)*** (0.02)**
quires, among other things, knowledge about potential health effects
λb 0.99 associated with introduction, relocation or removal of local health ha-
(1E-03)*** zards. In addition, every industrial activity needs to undergo a sig-
No of obs. 3820 3820 nificant transition (often called the industrial transition), to achieve
R2 0.389 0.976
globally agreed environmental aims, specified in the United Nations'
R2-adjusted 0.388
2030 Agenda for Sustainable Development (UN, 2016).
Notes. In this paper, we suggest an empirical approach aimed at forecasting
(*) Indicates a two-tailed 0.1 significance level; (**) Indicates a two-tailed 0.05 the impact of relocating (or removal) of a major air pollution source on
significance level; (***) Indicates a two-tailed 0.01 significance level. morbidity patterns in surrounding residential areas. Unlike traditional
Model 1: OLS regression (special weight threshold distance is zero). health outcome estimates, typically calculated as relative risks or odds
Model 2: Spatial error model with the spatial weight threshold dis- ratios (Logue et al., 2010; Swartjes, 2015), the proposed approach
tance = 400 m (i.e., optimal threshold according to the regression fit (log- adopts a more complex heuristic, which defines its novelty, and is im-
likelihood and the Akaike criterion – See text and Appendix 1).
a
plemented in three stages. The first step is risk modelling, performed by a
Unstandardized regression coefficient and its t-statistic in the parentheses.
b multivariate analysis of environmental factors affecting the local mor-
Spatial errors coefficient.
c
Different combinations of air pollutant variables were tested but only the
bidity patterns. The second step is a risk-change assessment, simulating
best performing models are reported. Others air pollution variables (such as the expected impact of the pollution source removal on the observed
SO2, NOX and O3) were either insignificant or negatively related to childhood morbidity patterns. The next step is cross-case analysis which estimates
asthma, which is at odds with the literature and may suggest a variable mis- potential changes in the morbidity rates by mutually comparing the
specification. Due to a multicollinearity consideration, these air pollution observed disease risk surface with the simulated one. In this paper, we
variables were introduced separately into the models; alternative model spe- tested the proposed approach using childhood asthma morbidity data
cifications can be obtained from the authors upon request. available for a major metropolitan area in Israel, which hosts a large
petrochemical complex. The analysis demonstrates the utility of the
proposed evaluation method. The main contribution of the present

Fig. 4. The observed childhood asthma rates (A); rates estimated by spatial error regression (B); and asthma rates simulated under the petrochemical industries
relocation scenario (C). Note: Due to privacy concerns the geocoded data are aggregated into statistical areas.

6
D. Broitman and B.A. Portnov
Table 3
Simulation test of the potential effect of petrochemical industries' relocation on childhood asthma rates (see text for explanations).
Dataset/development scenario
Observed asthma DKD prevalence rate (cases per 1000)
Asthma prevalence rate (cases per 1000) predicted by Model 2
Asthma prevalence simulated for the petrochemical industries relocation scenario (cases per 1000)
study is that, to the best of our knowledge, the present study is the first
that suggests an operational approach to incorporating epidemiological
assessments as an input for future urban plans related to local pollution
sources.
The statistical significance of both linear and quadratic terms of the
petrochemical industry proximity variable, which the present analysis
detected, suggests that there is an initial increase in asthma rates with
distance (roughly up to 4–5 km proximity range), and then a decrease,
as reflected by the negative coefficient of the quadratic term
(b = −4.47, t = 0.36, p < 0.01 in Model 2), which implies that the
relationship between aerial proximity to the petrochemical complex
and childhood asthma prevalence can be interpreted as a downward
parabola. Apparently, this effect is attributed to air pollution dispersion
from industrial smokestacks, which lands at some distance from the
emission source. For example, it is well known that petrochemical in-
dustries release volatile organic compounds (VOCs) originated in the
production, storage and waste management stages (Cetin et al., 2003).
These VOCs are associated with human morbidity (Hakim et al., 2012),
including asthma (Norbäck et al., 1995; Dales and Raizenne, 2004).
Unfortunately, these VOCs emissions are not routinely recorded by the
monitoring stations apparently due to the absence of adequate equip-
ment and high monitoring costs.
Our results are generally in line with the results of several previous
studies which revealed a positive effect of residential proximity to green
area and parks on the reduction in childhood asthma rates (Sbihi et al.,
2015; Dadvand et al., 2014). Additional studies support the hypothesis
of the protective effect of urban greenness, reporting that low exposure
to urban greenness by children is associated with higher risk of nasal
symptoms (Cilluffo et al., 2018) and that higher tree density is asso-
ciated with lower childhood asthma prevalence (Lovasi et al., 2008). I
should be noted, however, that in our test case all the residences are
located at distances greater than 500 m from the petrochemical facility.
Therefore, the green areas that replaces the facility in the simulation
have no effects of the expected asthma rates, since our measure of
greenness was a 500 m buffer around a residence. In that sense, the
replacement of the petrochemical facility by any non-polluting activity
would have yielded the same results.
It should also be noted that in the present study, we have analyzed
only the “most extreme” scenario, in which the main pollution source
was replaced by greenery. However, future studies can use our ap-
proach for assessing less “extreme” cases, such as e.g., replacement of a
pollution source with non-polluting or low polluting industries. In this
sense, the proposed method can be used for assessing multiple devel-
opment scenarios, which can be of help for both decision-makers and
physical planners.
7
Environmental Research 182 (2020) 109088
Mean SD Min Max
217.13 41.94 92.97 358.93
217.13 26.18 120.21 268.53
64.83 18.89 3.54 101.27
Although we analyze a specific test case of a hypothetical removal of
a local source of air pollution, represented by petrochemical industries,
the same approach can be used for other pollution sources, for example,
facilities that produce soil or water pollution. In addition, the proposed
approach can be used not only for relief assessment, but also for ex-ante
assessments of the health impact expected from the construction or
relocation of potentially hazardous industries within or nearby popu-
lation centers. The proposed approach can therefore find applications in
the field of infrastructure planning in general, and in urban planning in
particular.
A practical advantage of the suggested approach is that it does not
rely on assessments of particular pollutants, which may be difficult to
collect and analyze, but on the health status of the local population
regarding specific morbidity. The relative simplicity of the approach
can also help to analyze a wide range of “what-if” scenarios, common in
physical planning practices (Klosterman, 1999; Afzalan et al., 2017).
This is the reason why the assessment of specific pollutants, as PM2.5, is
not explicitly included in this analysis. Although emissions of this
pollutant are expected to be lower once the local pollution source under
analysis is removed, we have no information on the share of PM2.5
emission attributable to this source, and therefore assume that area-
wide pollution levels remain constant.
Additional contributions of the present study are results related to the
positive palliative influence of green areas on childhood asthma pre-
valence, compared with sometimes contradictory and not always con-
clusive results reported in the literature (Fuertes et al., 2016; Alcock et al.,
2017; Goyal and Singh, 2018). The fusion of individual level morbidity
estimates, greenery data, locational attributes and distances to potentially
harmful sources of air pollution (which levels are not routinely mon-
itored), and statistical data about predefined areal units can be considered
another methodological contribution of the present study.
A potential limitation of the present study is that we cannot infer
causality due to its ecological nature, since conclusions for individuals
cannot be drawn from the analysis of aggregated data. In addition, the
present study focuses on one type of illnesses affecting a specific age
group living in the study area, which may limit the generality of the
study's results. If wider and more precise morbidity datasets are avail-
able, future studies should test the applicability of the proposed method
to other epidemiological datasets at a different range of scales.
5. Policy and ethics
This study does not involve human subjects in clinical trials and is
solely based on the analysis of existing data sources. Therefore, the
work described here is in accordance with the Code of Ethics of the
D. Broitman and B.A. Portnov Environmental Research 182 (2020) 109088

World Medical Association (Declaration of Helsinki) for experiments Acknowledgements

involving humans,3 the EC Directive 86/609/EEC for animal experi-
ments4 and the uniform requirements for manuscripts submitted to The authors' gratitude is due to Prof. Khaled Karkabi of the Clalit
Biomedical journals.5 Health Services for providing data for this research.

Declaration of competing interest

None.

Appendix 1

The performance of the OLS and SE models estimated using different weight distance matrixes using R2 (A), log likelihood (B) and the Akaike
criterion (C). [The best results are reported for the neighborhood weight matrix of 400 m].

3
https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-
principles-for-medical-research-involving-human-subjects/.
4
https://eur-lex.europa.eu/legal-content/EN/ALL/?uri=CELEX
%3A31986L0609.
5
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3142758/.

8
D. Broitman and B.A. Portnov
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.envres.2019.109088.
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