The uncontrolled, fractured, frenetic growth of a city away from its core is a drive toward disaster. Emory researchers and clinicians are leading the way in efforts to understand and deal with sprawl's unhealthy aftermath.

by Valerie Gregg

Metro Atlanta inhabits 20 Georgia counties like a lazy teenager lying on the couch, legs akimbo, dirty laundry flung about with reckless abandon. Often called the fastest growing settlement in human history, Atlanta now stretches about 100 miles north to south. No natural boundaries hem it in. Land is cheap. Taxes are low. Jobs abound -- 1 million created since 1980 and 1.3 million more predicted by 2025. Thousands of new residents arrive each year, the population jumping from 3 million to more than 4 million in the past 10 years.

Where to put these bodies? Since the 1950s, in cities like Atlanta, the answer has been the suburbs. Sprawling development has been fueled by white flight from the inner city, cheap gas, tax subsidies such as publicly funded highway construction, and the American yearning for independence, large houses, and land ownership. Here, the car is king. Cars, diesel trucks, and old coal-burning power plants are polluting the air of metro Atlanta at unprecedented levels, and the average Atlantan wastes about 52 hours a year in traffic jams, according to the Texas Transportation Institute.

This painful automotive reality presents more than mere inconvenience. It's bad for our health, says Emory's Howard Frumkin, who is at the forefront of efforts to influence local, state, and national policy on how to stem sprawl and deal with its unhealthy consequences. The facts he cites are grim. A motorist dies on the region's roads nearly every day. Pedestrians are killed at higher rates only in South Florida. During the five-month-long ozone fest that is summer in Atlanta, asthmatic patients flock to emergency rooms, and more cardiac patients die.

As Emory clinicians deal with the daily fallout from the American love affair with cars, researchers at the Woodruff Health Sciences Center are confronting the links between sprawl, illness, and death. They are pioneers in a new public health frontier, bringing the tools of epidemiology, community health education, political action, and clinical research to bear on this burgeoning problem.

Frumkin, who heads the department of environmental and occupational health of the Rollins School of Public Health, helps lead a sweeping effort involving the Centers for Disease Control and Prevention, Georgia Tech, environmental groups, state and local governments, and leaders across the Emory campus. The work of Frumkin and his colleagues is public health in action -- using science from many disciplines to sustain a healthy community.

Without action - and fast - Frumkin sees disaster on the horizon.

"It's extremely pressing that we address this problem now," he says. "The population is booming. Atlanta is estimated to have another million residents within 25 years. If Atlanta continues growing only at the same rate as the rest of the country, our population will reach 8 million within 100 years. We have to start thinking about the problems we're leaving our children and grandchildren."

Something in the air

Physician Howard Frumkin practices what
he preaches by cycling every day to his
job at the Rollins School of Public Health.
In his efforts to keep the issues of sprawl
and health before the public, Frumkin has
addressed many political and academic
groups, both local and national. Along
with Richard Jackson, director of the CDC
National Center for Environmental Health,
and Georgia Tech Professor Lawrence
Frank, he is co-authoring a book on
sprawl and public health.

Metro Atlanta has exceeded federal Clean Air Act maximum ozone levels since 1980, when the government began monitoring ground-level ozone. In 1998, the region lost all federal road building money because of it. While gridlock grows, and Atlanta's reputation as a livable city falters, the state is baby-stepping toward a solution.

Bus systems are in the works in Cherokee, Gwinnett, and Cobb counties, but the recently released Regional Transportation Plan puts much more emphasis on road-building than on mass transit, sidewalks, and bike paths. And since transportation depends heavily on land use, land-use changes are also needed -- but these are missing from the plan. Soon after his election, Governor Roy Barnes and the General Assembly gave the Georgia Regional Transportation Authority (GRTA) the power to set regional transportation policy, overriding local governments if necessary. Many hoped GRTA would force competing jurisdictions to work together for the good of the entire region, but the group has yet to flex its muscle. Now that federal road money has been restored, GRTA may lack the political "big stick" needed to do so.

Frumkin, a member of GRTA's executive policy council, is determined to keep sprawl's effects on health in the public eye regardless. He speaks about sprawl and health at every opportunity, chairs the technical committee of the Atlanta Clean Air Campaign, and is co-authoring a book on urban sprawl and public health. With Lawrence Frank, a Georgia Tech professor of urban and transportation planning, he is team-teaching an RSPH class on the subject next spring.

He insists that controlling Atlanta's runaway growth is possible. "Transportation is only one piece of the picture," he says. "To make any difference in the sprawl situation, we must address land use, energy consumption, and transportation as a package. Major land-use changes alone are very difficult to achieve among competing political jurisdictions. GRTA doesn't have the authority to do that. Massive efforts to educate the public are necessary."

Emory goes feet first

A foul stench

The unhealthy relationship between air
pollution and illness and death has been
suspected for quite some time. In the 14th
century, King Edward II of England ordered
people who fouled the air with smoke to
be tortured. In 1952, a "killer fog" hovered
over London for five days, smothering res-
idents in the smoke of factory smoke-
stacks and their own coal-burning furnaces
and fireplaces. A record 3,000 people died
during those five days, mostly of respira-
tory and cardiopulmonary failure, at a rate
five times higher than normal. Death rates
returned to normal soon after the fog lifted.

Closer to home, smog is a fixed part of the
Atlanta skyline during the summer months,
when a palpable cloud of gases and grit
envelops the city. The hot Georgia sun
cooks up a noxious mess of gases and
soot from cars, power plants, and diesel-
fueled trucks.

When heated, two components of emis-
sions - volatile organic compounds and
nitrogen oxides - combine to form ozone,
which irritates and inflames lung tissue.
Shortness of breath, coughing, choking,
wheezing, chest pains, headaches, and
eye irritation are symptoms of excess
ozone exposure. It affects everyone, but
children, the elderly, and those with
chronic respiratory illnesses are the
most vulnerable.

Cleaner fuels, regional mass transit, and "smart growth" - policy decisions favoring public transportation and high-density, multi-use development - are some solutions, and Emory's pedestrian campus concept sets a good example. Roads have been transformed into pedestrian avenues. Shuttle buses help eliminate the need for cars. Careful planning integrates green space into the landscape as growth continues. The Atlanta Clean Air Campaign recently recognized Emory President William Chace with its Pace Setter Award for leadership in reducing traffic and improving air quality.

Emory has also adopted an environmental plan that integrates smart growth concepts into long-range campus planning. Frumkin says the WHSC is morally obliged to lead the way.

"Academia has a lot of catching up to do," he wrote recently in a scathing editorial in Emory Report. "The challenge is especially compelling at universities like Emory that have medical centers. The EPA reports that medical facilities, by incinerating disposable plastics, are second only to the paper industry in emitting dioxins. We create large volumes of solid waste…. And just count the gas guzzlers in the doctors' parking lot!"

Granted, improving the situation on a citywide scale is a different story. The health effects of sprawl are insidious, severe, and diverse. Air pollution aggravates asthma and heart and lung disease. Obesity is epidemic in part because the car culture, long commutes, and the cul-de-sac structure of suburbia discourage walking and biking as part of daily life. The city - recently named the second most dangerous area in the nation for pedestrians - loses between 50 and 70 people in pedestrian fatalities each year.

Minorities and the poor bear a disproportionate burden of these problems. Nationwide, African-Americans are four times more likely to die of asthma attacks than others. In metro Atlanta, the pedestrian fatality rate is 4 per 100,000 people for African-Americans, 10 for Hispanics, and less than 2 for Caucasians.

While sprawl spawns complex social, political, and health issues, Frumkin is convinced that good science can drive change. Epidemiologic studies at Emory are examining how air pollution affects heart and lung disease among the population at large. Emory is the champion of community-based interventions that teach inner city parents how to manage their children's asthma. And Emory clinical scientists are looking at individual patients to answer questions about bad air that have been with us for centuries.

Zapping asthma

Zap Asthma's summer day camp taught
children how to manage their asthma.
By blowing up balloons, the "High Steppers"
learned how the alveoli and bronchi in the
lungs react during an asthma attack.

Asthma is epidemic in inner city communities, affecting millions of children nationwide and racking up annual medical costs in the billions. Inner city children are four times more likely to be hospitalized for asthma, and 80% of child deaths from asthma are among those living in urban areas.

"In Atlanta, asthma is the leading cause of school absenteeism," says Joyce Essien, director of the RSPH's Center for Public Health Practice. "These poor outcomes result from a complex array of factors. The data fail to capture the full consequence and impact of this disease on the family and the community."

Essien helped found ZAP Asthma, a partnership between health providers, schools, and community organizations. ZAP Asthma's community health workers educate and support inner city families with asthmatic children, making sure they have the resources and knowledge to prevent asthma attacks.

Such programs are more important now than ever. Indeed, asthma has become the most prevalent chronic pediatric illness, with asthma rates for all Americans jumping 75% in 15 years. Whether high ozone levels contribute to the development of asthma is unknown, but it's well documented that ozone triggers asthma attacks.

A study published in the April 15, 2000 American Journal of Epidemiology found that the number of asthmatic children visiting hospital emergency rooms in Atlanta was 20% higher following days when ozone levels were highest. The study evaluated 6,000 asthma-related pediatric visits at seven metro Atlanta emergency rooms during the summers of 1993, 1994, and 1995. "On a public health scale, there are serious implications," says RSPH epidemiologist Paige Tolbert, the lead author.

Ozone isn't the only problem. Polluted urban air also contains microscopic particles of everything from tire rubber, to combustion by-products from cars and power plants, to mold. This "particulate matter" is thought to trigger acute asthma attacks, heart arrhythmia, and other cardiac and respiratory problems. Just how it does so is not well understood.

Tolbert and collaborators at Emory, Georgia Tech, and other institutions around the country hope the Study of Particulates and Health in Atlanta (SOPHIA) will help change that. Sophisticated equipment at an air pollution monitoring "superstation" in downtown Atlanta produces daily measurements of air contaminants, including pollen, mold, acidity, metals, sulfates, carbon, and particulates as small as 10 nanometers in diameter. The station, run by the Electric Power Research Institute and Georgia Tech, is producing the most detailed air pollution data ever collected.

Cardiac conundrum



P. Barry

Tolbert - principal investigator for SOPHIA - is correlating particulate matter data with patient visits to 33 Atlanta-area hospital emergency rooms. The study includes patients of all ages with several ailments, mostly heart and lung diseases. The incidence of cardiac arrhythmia in people with implanted automatic defibrillators is also being compared with the air quality data.

"We hope this will help us understand what drives the associations seen in other studies between particulates and heart and respiratory problems," says Tolbert.

So far, SOPHIA is yielding interesting results. "Our findings show air pollution to be associated with all kinds of heart problems, including specific ailments like arrhythmia," she says. "There was little scientific evidence of this connection 10 years ago. Evidence is building, but there is still much that we don't understand."

In another study, P. Barry Ryan, an environmental chemist at RSPH, is investigating air pollution's effect on recent heart attack victims and people with chronic obstructive pulmonary diseases like emphysema and asthma. Coordinated by Harvard, the study is also ongoing in Boston and Los Angeles.

In fall 1999, Ryan's research group collected data on 24 subjects and repeated the study on 22 subjects in the spring of 2000. The information is extremely detailed and specific to each person. For seven days, the air inside and outside of the subject's home is analyzed, while subjects undergo electrocardiograms during different levels of activity.

"We're trying to link exposure to particulate matter and other gases with heart problems," he says. "We're finding that fine particulate matter and ozone seem to spread evenly throughout the city. With certain gases and larger, coarse particulates, that's not the case. It may be that these different levels of pollutants cause the effects or maybe the mix of the pollution causes the effects."

Theories on how particulate matter causes heart problems abound. "In the past we thought these particles got into the lungs and caused localized irritation and inflammation," says Ryan. "But new research shows that breathing particulate matter could change blood chemistry and affect the nervous system as well."

Driving change

Combating the health effects of urban sprawl will be a tough road. Cleaning up the air alone requires taking on several powerful lobbies -- electric power companies, interstate trucking, developers, and auto makers. Academic health care workers must lead the way, Frumkin says. He urges doctors, nurses, physician's assistants, and health professionals from across the spectrum to become environmental activists.

"As a physician, I would care a great deal if a rogue destroyed vaccines, blew up a hospital, or infected a water supply," says Frumkin. "These are acts of health terrorism. But pumping persistent organic chemicals into the atmosphere, overusing resources, and contributing to global warming are equally harmful…."

He believes "smart growth" is the answer.

"Sprawl is not a necessary by-product of urban growth and economic development," he says. "Growth can be planned and managed. To continue down our current road is too costly when a healthy community is the price we pay. Sprawl-related threats like pedestrian fatalities, car accidents, and lung and heart disease can be prevented. They don't have to happen."

Valerie Gregg is editor of Emory's Public Health magazine.


Kellen Bolden was only 10 when he died. He was boarding the school bus after a day at Pointe South Elementary School in Clayton County when he suddenly collapsed, unable to breathe. The school nurse performed CPR, and an ambulance rushed him to a local hospital. He was pronounced dead at 3:10 pm, around the time he was due to arrive home from school. Cause of death: asphyxia due to asthma.

"He probably got a big whiff of diesel exhaust from the buses, and he died on the spot," says Gerald Teague, a pediatric pulmonologist at Emory. "His asthma probably had been acting up all day, and the response to the bus exhaust took away what little reserve he had left."

Kellen, who suffered from severe, unstable asthma, was Teague's patient several years ago. Teague, who sees asthmatic patients almost every day, was chastened by his death. "Apparently his asthma was in good control, but any death from asthma should be prevented. Unfortunately, there's only so much we can do as doctors to control environmental factors that trigger asthma attacks."

Asthma is now the most prevalent chronic disease among children in the United States, afflicting about 11% of Georgia's children, according to a state Department of Community Health study. Since Teague began practicing in Atlanta in 1989, he has seen air quality deteriorate and the number of asthmatics skyrocket.

"We now have a summer wheezing season, which corresponds to the annual smog season from May through September," he says. "Traditionally, physicians have focused on respiratory infections and allergens as asthma triggers. But research in the past 10 years has shown that many people are particularly sensitive to ozone."

During the 1996 summer Olympic Games, metro Atlanta traffic declined 22.5%, ground ozone levels fell by 28%, and hospital visits for asthma fell by 42%, according to a study by Teague and collaborators at the Centers for Disease Control and Prevention. The study, published in the February 2001 issue of the Journal of the American Medical Association, showed that ER visits for reasons other than asthma actually increased slightly.

Understanding the link between ozone and asthma is just the first step, says Teague. Cars and power plants throw a plethora of other contaminants into the air, including soot (hydrocarbons), nitrogen oxides, and volatile organic compounds. Summer heat and sunlight plus these components create ozone.

"For all we know, ozone may not be the biggest problem," says Teague. "But physicians now can identify patients who are sensitive to ozone just by asking them the right questions. Ozone sensitivity can be treated."

Teague chairs a committee of the Atlanta Clean Air Campaign that's writing an advisory on smog and outdoor exercise. Breathing ozone damages the lung tissue of healthy people as well as those with lung disease.

"The question in Atlanta is: should people exercise outdoors? At certain times of day, during certain times of year, along busy roads, the answer is no," he says.

During the summer months, joggers should exercise early in the morning, before the sun fuels the chemical reaction with air pollution that creates ground-level ozone. At high levels, ozone can damage anybody's lungs. At low levels, it can affect unusually sensitive people, indoors and out.

"Jogging along a busy road at 6 p.m. is not a good idea," says Teague. "You inhale incredible amounts of ozone as well as particulates, which stay at a constant level all year."

In August 2000, metro Atlanta had 30 straight days when ozone levels exceeded federal standards. This year, the wheezing season began early, with ozone exceeding the legal standard on May 4 and 5. One of Teague's patients, a 14-year-old asthmatic girl from Marietta, even had trouble breathing indoors on those two days.

"She described chest tightness, and her pulmonary function fell significantly," says Teague. "One of the cardinal features of ozone sensitivity is a diminished capacity to breathe deeply."

This patient is the first to enroll in a study Teague is conducting in collaboration with researchers at Georgia Tech and the American Lung Association. The Georgia Tech Research Institute is providing seed funding for the study. The air quality inside and outside patients' homes is monitored and compared against patients' pulmonary function.

Asthma: Not child's play

Pulmonologist Gerald Teague instructs
a teenager with chronic lung disease
how to measure his pulmonary function.

"My patient was exposed to ozone outdoors and indoors those two days," says Teague. "People think by staying inside, they'll be protected. That's partly true, but indoor ozone is about 20% of the outdoor level. That can still be high enough to cause trouble for an asthmatic."

Levels of suspended particulate soot inside homes are even worse -- about 80% to 90% of the level outside. All year round, SUVs, trucks, and school buses kick out extraordinary amounts of soot into the air. As with high ozone, elderly people with lung or heart disease and children with asthma are most at risk. Teague advises Atlantans to watch air quality advisories and take precautions when ozone is high. They should also shorten their daily commutes, avoid speeding, and support legislation to limit emissions from trucks, buses and SUVs.

However, the power, auto, and trucking industries have fought against stricter standards for years, claiming that catalytic converters and high-tech smokestack scrubbers are too costly.

But if you ask a respiratory therapist at Hughes Spalding, a case worker at ZAP Asthma, an ER doc at Grady, or anyone who knew Kellen Bolden, they'll disagree. The life of a child like Kellen is the price that's too high.

In this Issue

From the Director  /  Letters


How to remake a hospital


Moving Forward  /  Noteworthy

On point: Healer or line worker?

Nation at a crossroad


Copyright © Emory University, 2001. All Rights Reserved.
Send comments to the Editors.
Web version by Jaime Henriquez.