The way society uses land is no longer of interest only to developers, politicians, architects, road builders, and urban planners. When preventable illness and death are involved, it 

becomes a matter of public health. Howard Frumkin, his RSPH colleagues, and collaborators from other universities are at the forefront of this new frontier in public health.
Taming Urban Sprawl

RSPH faculty member Howard Frumkin
speaks to community and legislative
groups about sprawl's effects on health
at every opportunity. A member of the
Georgia Regional Transportation
Authority's Executive Policy Council,
he is working on a book and plans to
teach a class on the subject next fall.

 'Much of the public concern about sprawl centers on quality of life. That's important, but it leaves out a dimension of sprawl based firmly in evidence: human health.' -- Howard Frumkin

by Valerie Gregg

Gabina Chavez didn't stand a chance. The 32-year-old Mexican immigrant was walking to a Burger King near her home in Gwinnett County to work the morning shift. She died while trying to cross Steve Reynolds Bou levard -- struck once by a garbage truck, and then again and again by four or five cars in the heavy early-morning traffic.

Only two of those who hit Chavez, the mother of two young children, remained at the scene. The hit-and-run drivers and several witnesses drove away before police arrived. The day after Chavez died, her husband had to hitch a ride from friends to buy a new dress for her burial, The Atlanta Constitution reported.

About 6,000 pedestrians are killed and 10,000 injured in the United States every year. Metro Atlanta was recently named the second-most dangerous area for pedestrians in the nation by the Surface Transportation Policy Project. Indeed, a 1999 study by t he Centers for Disease Control and Prevention found that Atlanta's pedestrian fatality rate increased 13% from 1994 to 1998, while the national rate declined by 9.6%.

Howard Frumkin, chair of the Department of Environmental and Occupational Health, blames urban sprawl -- the unplanned, uncontrolled, fractured growth of a city away from its core.

"This sprawling type of development is largely an American phenomenon," he says. "It brings more drivers and more traffic. We have built our roads for cars alone, and they are unfriendly to pedestrians. "In metro Atlanta, we lose between 50 and 70 peop le to pedestrian fatalities each year. It's gone up in the past 10 years as the region has grown."

Minorities and the poor bear a disproportionate burden of sprawl-driven health threats nationwide. 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. "That say s worlds about who has to walk on roads that are unwalkable, who gets to drive, and how we designed the region," says Frumkin.

Chavez's story is not an isolated case. There are entire communities in metro Atlanta unable to afford the approximately $6,000-a-year cost of car ownership. Many live in suburban areas with limited public transportation, crosswalks, or sidewalks. Othe rs live in the congested inner city. On any given day, they can be seen dashing through gaps in the traffic across Jimmy Carter Boulevard, Buford Highway, Peachtree Road, Simpson Street, and Ralph D. Abernathy Boulevard.

Frumkin says the Gabina Chavez tragedy has disturbing social implications.

"Perhaps the drivers and potential witnesses were late for work or felt no human bond with the person lying on the road," says Frumkin. "This disconnection may be related to sprawl. Spending long hours driving on crowded roads can be anonymous and soci ally isolating, aggravated by a sense of urgency and wasted time, causing anger and frustration. One symptom of this social pathology may be road rage, behavior people wouldn't dream of doing face-to-face with another person. Hit-and-run behavior - a chil ling manifestation of social disconnection, mistrust, and lack of responsibility - may reflect the same forces."

The impact of sprawling development on public health goes far beyond car-related accidents. When air pollution is high, more people die of heart and lung diseases, and asthmatic children flock to hospital emergency rooms. Long commutes and the cul-de-s ac structure of suburban neighborhoods discourages walking and biking as transportation. Obesity has become epidemic.

"These problems are preventable," says Frumkin. "They don't have to happen. Much of the public concern about sprawl centers on quality of life. That's important, but it leaves out a dimension of sprawl based firmly in evidence: human health."

The way society uses land is no longer of interest only to developers, politicians, architects, road builders, and urban planners. When preventable illness and death are involved, it becomes a matter of public health. Frumkin and his RSPH colleagues ar e at the forefront of this new frontier.

Things Fall Apart

RSPH faculty members P. Barry Ryan and
Paige Tolbert are studying the effects of
air pollution on a variety of health prob-
lems, including asthma and heart disease.

' Sprawl concentrates poverty, and poverty exacerbates many public health problems.' -- Robert Bullard, Clark Atlanta University

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 has nearly doubled its size in the past 10 years and now stretches 110 miles north to south. No natural boundaries hem it in. Land is cheap. Taxes are low. Jobs abound -- with 1 million created since 1980 and 1.3 million more predicted by 2025. Th ousands of new residents arrive each year, jumping the population from 3 million to 3.5 million between 1990 and 1996.

Where to put these new residents? Since the 1950s, in cities nationwide, the answer has been the suburbs. Sprawling suburban development has been fueled by white flight from the inner city, cheap gas, and the American yearning for independence, large h ouses, and land ownership. Federal housing loans for builders have strongly favored single family homes over apartments for the past 50 years. And local zoning laws continue to sharply divide shopping, residential, industrial, and business areas.

The car, therefore, is king. According to the Texas Transportation Institute, the average Atlantan drives 35 miles per day and wastes 52 hours in traffic jams per year -- more than residents of any other American city.

"We have expanded land use faster than our population. We build larger houses that require more energy use per person farther away from the urban core," Frumkin says. "In Atlanta, cars and trucks produce much of the air pollution mix, because in the su burbs, you can't get anywhere on foot."

Smog is a fixed part of the landscape during the summer months, when a palpable cloud of gases and grit envelopes the city. On any given weekday, something falls off a truck on Interstate 85, backing traffic up for miles. Fatal car accidents regularly turn a 30-minute commute into a four-hour ordeal. Cars idle throughout the city as drivers negotiate Atlanta's tangle of congested arteries -- back and forth, from home to school, to work, to the store.

In the summer, 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 emissions - volatile organic compounds and nitrogen oxides - combine to form ozone, which irr itates 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 illness es are the most vulnerable.

Something in the Air

Sociologist Robert Bullard of Clark Atlanta
University has studied the societal impact
of urban development patterns for 20 years.
His recent book, Sprawl City, examines
sprawl in Atlanta. He frequently collabor-
ates with RSPH faculty on research and

 'The people who build, shape, zone, and regulate our environment are public health colleagues of ours even though they don't think of themselves as such. We need to sit at the table with them, so that health is cons

idered when decisions are made.' -- Howard Frumkin

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

Epidemiologists have consistently found that more people are hospitalized and die of respiratory and cardiac failure when the air is polluted.

Asthma has become the most prevalent chronic pediatric illness, and the CDC reports that asthma rates for all Americans have jumped 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 le vels 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. Paige Tolbert, epidemiologist and RSPH associate professor of environmental and occupational he alth, was the lead author.

"We found clear evidence of an exposure-response relationship to air pollution and children's emergency room visits for asthma," says Tolbert. "On a public health scale, there are serious implications."

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, he art arrhythmias, and other cardiac and respiratory problems. Just how they do 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 do wntown Atlanta produces daily measurements of many 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 Te ch, is producing the most detailed air pollution data ever collected. The US Environmental Protection Agency and many air pollution researchers are using these data.

Tolbert -- the 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. T he 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 is driving the associations seen in other studies between particulates and heart and respiratory problems," says Tolbert.

So far, SOPHIA is yielding interesting results. "In our interim analyses, we've seen significant positive associations with air pollution for all cardiac events combined as well as for more specific outcomes like arrhythmias," she says. "Ten years ago, there was little evidence for an association of cardiac outcomes with air pollution. Evidence supporting this relationship is accumulating, but much remains to be understood."

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 stud y is also ongoing in Boston and Los Angeles.

In the fall of 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 s ubject's home is analyzed, while subjects undergo electrocardiograms during different levels of activity.

"We're trying to link some exposure variables for particulate matter and other gases with potential variability in heart rate," 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. "New research is showing that breathing particulate matter could c ause changes in blood chemistry and the viscosity of the blood and could affect the sympathetic and autonomic nervous systems."

The Right to Breathe

Emory's pedestrian campus concept is
one approach to solving sprawl-related
problems: Roads can be transformed into
pedestrian avenues. Shuttle buses eliminate
the need for cars. Careful planning inte-
grates green space into the landscape.
The Atlanta Clean Air Campaign recently
recognized Emory President William M.
Chace (below) with its Pace Setter Award
for his leadership in reducing traffic and
improving air quality.

Epidemiologists have consistently found that more people are hospitalized and die of respiratory and cardiac failure when the air is polluted.

Robert Bullard wants the students in Reuben Warren's RSPH class on minority health issues to get angry.

"Who has the highest level of asthma in the country?" he asks during a guest lecture. "Black children. We have laws on the books that are supposed to make sure no one has to breathe unhealthy air. Asthma attacks can be prevented. Not only is it illegal and immoral, it's downright criminal to allow a defenseless child, a vulnerable kid, to be poisoned. This is a matter of justice. The law should be enforced equally -- whether it's in white suburbs or the black inner city."

Metro Atlanta has exceeded federal Clean Air Act maximum ozone levels since 1980, when ozone monitoring began. In 1998, the region lost all federal road-building money because of it. The road money won't flow again until the region develops a workable plan to improve air quality.

The slow progress on improving air quality is compromising the health of city children, says Bullard, sociologist and director of the Environmental Justice Center at Clark Atlanta University. He has studied every angle of urban sprawl for the past 20 y ears in Los Angeles, Houston, and Atlanta. He'd like to see more inner city residents involved in making the vast public policy changes necessary to make real environmental improvements.

"Some communities are invisible although they're present in large numbers," he says. "Urban African-American communities are more likely to receive unwanted land uses like highways, freeways, landfills, dumps, and warehouses for city buses that pump ou t carcinogenic diesel fumes. These things follow the path of least resistance."

Air pollution is not the only problem that sprawl causes inner city residents. The economic boom times that drive urban sprawl create unequal opportunities. Suburban business and retail development often mean empty storefronts in the urban core. Withou t public transportation to the suburbs, new jobs created by suburban business development are out of reach to city residents without cars.

"Sprawl concentrates poverty," says Bullard, "and poverty exacerbates many public health problems."

Bullard joins Frumkin in an urgent call to action. Cleaner fuels, regional mass transit, and "smart growth" are some solutions. Smart growth means local government decisions that favor public transportation and high-density, multi-use development -- pl aces where people can live close enough to shopping and work to walk.

Georgia Governor Roy Barnes took an important step by giving the Georgia Regional Transportation Authority (GRTA) the authority to make regional transportation decisions, overriding local governments if necessary. Frumkin, a member of GRTA's Executive Policy Council, is the only health expert on board. He also chairs the Technical Committee of the Atlanta Clean Air Campaign.

"The people who build, shape, zone, and regulate our environment are public health colleagues of ours even though they don't think of themselves as such," Frumkin says. "We need to sit at the table with them, so that health is considered when decisions are made."

Frumkin speaks about sprawl's effects on health at every opportunity. He has addressed the National Conference of State Legislators, the State Legislative Leaders Forum, GRTA, the Atlanta Regional Commission, and many other groups. So far, the reaction has been positive. "People generally haven't considered sprawl as a health issue, and they are interested in the possibilities this offers," he says. "These include health funding for sprawl initiatives, the involvement of medical and public health group s as advocates for smart growth, and public education."

Collaborating with a professor of urban planning at Georgia Tech, Frumkin plans to teach a class on urban sprawl and public health in the fall of 2001. The two are also working on a book on the subject.

The road to preventing sprawl-related health problems is bound to be bumpy, says Bullard. "Smart growth is a three-legged stool, with economic development, environmental quality, and equity holding equal importance," he says. "The equity piece is the m ost difficult, because it means facing hard issues of income, school quality, jobs, and race."

Frumkin feels "smart growth" will lead to a healthier community on many fronts.

"Sprawl is not a necessary by-product of urban growth and economic development. Growth can be planned and managed," he says. "To continue down our current road is too costly when an unhealthy community is the price we pay."

Spring 2001 Issue | Dean's Message | Taming Urban Sprawl | Rites of Passage
Resistance Fighter | Epi in Action | The Big Picture

Copyright © Emory University, 2001. All Rights Reserved.
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Web version by Jaime Henriquez.