Bringing Public Health into Urban Revitalization: Workshop Summary (2015)

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2 Utilizing Green Technologies in Washington, DC The workshop’s first session focused on case studies from Washington, DC. Lynn Goldman, dean of the Milken Institute School of Public Health at George Washington University, introduced this session by noting that, as someone who works in Washington, DC, she has been struck by how easy it is to get around without an automobile, how convenient public transportation has become, and how every year it becomes easier to walk or to bicycle through the city. At the same time, she said, she has been struck by the huge disparities between those in the city who are very educated and very well off and those who have less education, lower incomes, and a harder time accessing the city’s opportunities for improving one’s health. She stated that Washington, DC, offers a number of important opportunities for improving public health and that it is those opportunities that the session’s two speakers would be addressing. GREEN BUILDINGS The session’s first speaker was Gregory Kats, president of Capital E, a national clean energy advisory and venture capital firm. He was previously the director of financing for energy efficiency and renewable energy at the U.S. Department of Energy; serves on the Washington, DC, mayor’s Green Ribbon Task Force, guiding the greening of Washington, DC; and chairs the Federal Council, guiding the greening of federal buildings. He spoke about green buildings and the role that they could play in Washington, DC. In the coming decades, cities will play a major role in determining not only the quality of people’s day-to-day lives but also the long-term quality of the global environment, Kats said. Cities are major sources of the carbon dioxide that is driving global warming, for instance, and cities have historically been far from environmentally friendly in many different ways, but it does not have to be that way. 5 

6 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION Kats described results synthesized from his book Greening Our Built World: Costs, Benefits, and Strategies, which examined the cost-effectiveness of green buildings (buildings designed to use fewer resources and support the health of inhabitants) through detailed building surveys and findings from other studies (Kats et al., 2010). The sponsors for his research include some groups not normally associated with this type of work, including the American Institute of Architects, the National Association of Realtors, and the National Association of State Energy Officials. He noted that no environmental groups sponsor his research to avoid it being tagged as something with a specific environmental objective. In his research, the benefit–cost ratio of constructing a green building versus a traditional building is about 2.5 to 1, just on the basis of utility bills. That is, for every additional $1 in cost, the green building will return $2.50 in cost savings over 20 years, on a net-present-value basis. Green building design1 also has a number of health benefits, in the sense that people living and working in them tend to be healthier in various ways, Kats said, but these benefits are generally difficult to quantify because of a paucity of evidence on the health and productivity benefits specifically attributed to green building design. He showed some results from one study carried out by the Seattle Housing Authority comparing the health of children and adolescents moved into a building that the authority worked to make healthy (naming it a “breathe-easy home”) with the health of those not moved into a different home. Over an average 14-day period, those living in the new home for 1 year had 12.4 symptom-free days, whereas those living in the old home had only 8.62 symptom-free days. The group in the new home had an average of 20.6 urgent clinical care visits over the course of 1 year, or just one-third the 61.8 urgent clinical care visits of those living in the old home (Kats et al., 2010). In other words, the difference was dramatic. In carrying out its research on green schools, his group was able to quantify various benefits for the students in such schools, as reported in 1 In this context, green building design refers to construction certified by the U.S. Green Building Council’s Leadership in Energy and Environmental Design (LEED) rating system or another similar rating system. LEED is a trademarked certification program used in 135 countries that guides the design, construction, operation, and maintenance of buildings that save money and resources, positively impact the health of their occupants, and promote renewable clean energy. For more information, see http://www.usgbc.org/leed (accessed March 19, 2015). 2 Although the slide showed 7.6 days, the data presented in the literature indicate 8.6 days (Takaro et al., 2011). 

UTILIZING GREEN TECHNOLOGIES IN WASHINGTON, DC 7 Greening America’s Schools: Costs and Benefits (Kats, 2006). These benefits included a 3 percent increase in learning ability, a 1.4 percent increase in lifetime annual earnings, a 25 percent decrease in asthma incidence, a 15 percent decrease in the numbers of cases of colds and flu, and a 3 percent reduction in teacher turnover (Kats, 2006). Although the effects according to the changes in percentages are relatively small, they result in large benefit–cost ratios because employee costs are significantly higher than building costs over the lifetime of a school. Moreover, when health and productivity benefits are added, the benefit–cost ratio of doing green buildings is substantially higher than the energy and water benefits alone (Kats et al., 2010). Kats next showed data from a study by the World Green Building Council that looked at the price of green buildings versus the price of conventional buildings over time in various countries in Asia, Europe, and North America. The data demonstrated that buyers were consistently paying a premium for green buildings (World Green Building Council, 2013). “So the market is really responding to the choice between a building that is designed to be deliberately healthy and efficient versus the conventional design strategy, which is to barely meet code at lowest cost,” he said. When the U.S. real estate market went into recession in 2008, Kats noted that there was some question whether green buildings would continue to thrive or whether people would choose to go back to basic building design and see green design as a superfluous option. “It turned out to not be the case,” he said. “The growth of green buildings has been very dramatic.” In 2012, 41 percent of nonresidential construction in the United States was certified by Leadership in Energy and Environmental Design (LEED), whereas a decade ago only about 2 percent of nonresidential construction was LEED certified (USGBC, 2015). The fact that the design of new nonresidential buildings has moved so decisively to green design has tremendous positive implications for health, he said. Comparison of Cool Roofs, Green Roofs, and Solar-Paneled Roofs Switching gears to his work in the District of Columbia, Kats said that he and his colleagues are collaborating with the District of Columbia Department of General Services in a study of the costs and benefits of cool roofs, green roofs, and solar-paneled roofs.3 The goal is to develop a 3 Green roofs (sometime referred to as “vegetated roofs”) are covered with soil (ranging in depth from 2 to 3 inches to 6 inches or deeper) and a variety of plants to reduce storm water runoff and promote cleaner air. Cool roofs use a white surface 

8 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION rigorous and broadly applicable cost–benefit model and tool kit that will help builders make decisions about these different building options. Determining the benefits of these green options can be complex, Kats said. Cool roofs, for example, have a variety of potential benefits, both direct and indirect. Because a cool roof reflects a large percentage of sunlight back into space, it prevents the building from heating up in summer and also helps reduce the heat island effect, which causes urban areas to be hotter than the surrounding areas. Keeping urban areas cooler reduces the amount of ozone buildup, which in turn reduces some negative health effects. It also helps decrease the rates of heat-related mortality in the city during the hot summer months. Green roofs retain water and release it gradually through the presence of plants growing on the roof. They also help reduce the heat island effect, reduce the level of ozone, and reduce heat-related mortality, but in addition, they help reduce storm water management costs. The placement of solar cells on roofs to produce power helps reduce the negative effects of generating power by burning fossil fuels—in particular, by reducing the particulate matter, heavy metals, and greenhouse gases that result from the burning of fossil fuels. Kats said that he and his group have worked very closely with the U.S. Environmental Protection Agency (EPA) to map out the health implications of these various design choices, and they are now able to point to quantifiable benefits of green buildings. For instance, particulate matter—in particular, fine particles with a diameter of 2.5 micrometers or less (PM2.5)—is known to have major health effects, such as increasing the rates of asthma, lung cancer, cardiovascular disease, various respiratory diseases, and premature mortality. It turns out that while green roofs help decrease PM2.5 concentrations, they accomplish this mainly by decreasing building temperatures and thus lowering energy use, Kats said. The model also takes into account the benefits accrued by green roofs from the reduced amount of heat-related morbidity and mortality. The effects of heat on health range from the mild (discomfort, skin eruptions, heat fatigue) to the moderate (heat cramps, heat exhaustion) and the severe (heat stroke, conditions requiring emergency medical care) and even death. “In Europe, a decade ago, there were 50,000 premature deaths in one severe heat incident during one summer,” Kats said. He added that the greatest material to increase light reflection, reduce heat absorption, and cool the building interior. Solar roofs are covered with photovoltaic array solar power installations, which can produce energy for the building (Environmental and Energy Study Institute, 2012). 

UTILIZING GREEN TECHNOLOGIES IN WASHINGTON, DC 9 effects of heat are generally seen on the top floors of low-income apartment buildings with dark, flat roofs. The model that Kats and his colleagues developed provides estimates of the costs (in dollars) and benefits associated with the three roof choices as installed on buildings in Washington, DC. The most expensive roof to install and maintain is the green roof, as it requires people to plant and take care of an expanse of greenery; cool roofs are not significantly more expensive to install and maintain than conventional roofs. All three types of roofs have energy benefits—energy savings by keeping a building cooler for cool and green roofs and energy generation from solar-paneled roofs— and in the case of cool roofs and the solar-paneled roof, these benefits already outweigh the costs, even when no other benefits are taken into account. A major benefit of the green roof is the savings associated with storm water accommodation, and the savings are enough to more than balance the cost of the roof. All three types of roofs have health benefits as well. By far the greatest health benefits come from the reduction in particulate matter that would result if the power generated by solar-paneled roofs had been generated by conventional methods. When all of these costs and benefits are added up, the model predicts that a cool roof costs about $0.73 per square foot to install and maintain, while its total benefits (net present value calculated over a 20-year period) are $5.45 per square foot. The corresponding values are $22.52 and $60.78 per square foot for a green roof and $0.00 and $77.45 per square foot for a roof on which photovoltaic (PV) arrays are installed. All of the costs are additional costs compared with the cost of a conventional roof. Noting that the cost premium for a cool roof is less than $1 per square foot and that the health benefits of such a roof are nearly $3 per square foot, Kats noted that this sort of simple and inexpensive change to a roof more than pays for itself. “Just looking at the health benefits from a city perspective leads you to say this should be our standard design policy,” he said. These are just preliminary results,4 Kats cautioned, but their implication is that cities have the opportunity to save a lot of money, improve the quality of life, reduce health care costs, and reduce energy costs by, for example, changing how buildings face the sun and modifying the albedo— or reflectivity—of the buildings to change how much sunlight the buildings absorb. 4 An updated analysis of Washington, DC, cool roofs, green roofs, and solar roofs is available in a recent report by Kats and Glassbrook (2015). 

10 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION Other Building Technologies to Reduce the Impact to the Environment Kats then spoke about two emerging technologies that can help cities reduce their costs to the environment. The first is a way to reduce “embedded carbon dioxide,” which refers to the carbon dioxide from material, such as cement, used in the construction of a building, road, or other structure. Embedded carbon dioxide accounts for 6 percent of the world’s production of carbon dioxide and also a large percentage of the District of Columbia’s carbon footprint, he said. Indeed, it can take up to 10 years of operating a building—with all of the energy consumption that that entails—to produce the same amount of carbon dioxide that was created in the building’s construction. Kats said that a company, Blue Planet, on whose board of directors he serves, has developed a technology that captures 80 percent of the carbon dioxide coming out of flue stacks and turns it into cement products, such as aggregates used for highway construction. In this way, the amount of embedded carbon dioxide can actually be negative; that is, the amount of carbon dioxide stored permanently in the materials—and kept out of the atmosphere—is more than the amount generated in their production. The materials are also very reflective, so they do not absorb as much heat from the sun as typical building materials, lessening the heat island effect in cities. The materials were scheduled to undergo at-scale testing in December 2014, Kats said, and his group will soon be getting test results back from that testing. The second project that he described is a partnership between BrightFarms and the District of Columbia Department of General Services to grow food in a 120,000-square-foot greenhouse in Anacostia in the southeastern section of DC, with the first harvest expected in 2016. “This will employ 25 to 30 people, full-time equivalent, and produce more than 1 million pounds of green produce per year,” Kats said. “It will be harvested in the morning, sold in the afternoon, and eaten in the evening rather than shipped across the country.” It is expected to decrease the carbon dioxide emissions associated with food production and distribution by 97 percent, helping the environment and also increasing the availability of fresh food in places that do not normally get it. Kats also mentioned a technology called NEST, which is a learning system for controlling residential heating and air-conditioning in a smart way. By shifting when a home’s air-conditioner is operating, for instance, it can significantly reduce residential power consumption, thus decreasing power bills. It can also move much of the power usage to off-peak hours, 

UTILIZING GREEN TECHNOLOGIES IN WASHINGTON, DC 11 lessening the overall load on the electric utility. It also helps enable renewable energy. Because solar power is generated only when the sun is shining, it will be helpful to be able to reshape power usage so that more is used during daylight hours and less is used at night, and NEST can do this. It is a very interesting kind of emerging area for energy and comfort control, Kats said. The final technology that Kats described was an initiative called Places, in which his company, Capital E, is a minority partner. The idea behind Places is to use data on locations and their characteristics to help determine the risk involved with a mortgage loan. Kats described the idea behind it as follows. A person might not keep up payments on a mortgage for a variety of reasons. One is because the value of the home has dropped below how much was owed on the mortgage. “It turns out,” Kats said, “if I live in a walkable, mixed-use TOD [transit-oriented development]-type neighborhood, the value of my home declines much, much less in an economic downturn.” A person who has a home in a walkable, mixed-use neighborhood with good transportation and a FICO5 score of 600 turns out, according to the group’s analysis, to be less likely to default on a mortgage than someone who has a FICO score of 700 and a higher income and who lives in a neighborhood with sprawl. Another reason a person may default on a mortgage is if he or she loses his or her job and is not able to get another job nearby. “That is much less of a problem in a walkable neighborhood with access to public transit,” Kats noted. Furthermore, because the cost of buying, maintaining, and using a car is about $8,000 per year, a person living in a walkable neighborhood is more likely to be able to make do with one less car, making it more likely that the person could apply that money to keeping up payments on a mortgage. When the location-specific data are combined with the additional neighborhood characteristics related to transportation and employment, the Places model turns out to be a far better predictor of whether a person will default than a conventional FICO score, Kats said. To test the Places program, it was used to analyze a 100,000-loan portfolio evaluated and invested in by AIG. “They went back and applied the metrics that we developed, and it turns out they would have saved $250 million to $300 million by not giving loans to certain people who had relatively high FICO 5 A FICO score is a type of credit score that makes up a substantial portion of the credit report that lenders use to assess an applicant’s credit risk and whether to extend a loan. 

12 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION scores but were in a sprawl and therefore had systematic risk along the risk attributes we talked about.” More importantly, Kats said, “they would have done another $5 billion to $6 billion in loans to individuals who did not have high enough FICO scores but whose homes were in neighborhoods that were associated with walkability, flexibility in terms of jobs, and flexibility in terms of transportation.” Thus, Kats said, the program represents a powerful new method that cities can use to think systematically about exposure to risk in a way that drives recognition of value toward walkability and away from sprawl. A PLAN FOR SUSTAINABILITY The second speaker was Brendan Shane, chief of the Office of Policy and Sustainability at the District of Columbia Department of the Environment. He is a principal staffer for the mayor’s Sustainable DC initiative who works with various segments of the District government and community stakeholders to define and implement the mayor’s vision of making the District of Columbia the greenest city in the nation. Today, Shane began, sustainability is defined by the three Es: environment, economy, and equity. Here “equity” refers broadly to the community fabric, the public health, and the overall equitable nature of the community. Sustainable DC The Sustainable DC plan6 took about 18 months to develop, Shane said, although it was originally intended to be finished in 6 months. “We ended up with a very ambitious set of goals [and] a big document, which is available online.” The main goal of the plan is that within a generation the District of Columbia should become the healthiest, greenest, and most livable city in the country. The past decade has seen a burst of activity in the area of green building, Shane said, specifically in healthy buildings, green roofs, storm water management, cleaner water programs, and green power. Among all the cities in the United States, the District of Columbia ranks near the top in the number of green and energy-efficient buildings, both in absolute numbers and in numbers per capita. “We are only a city of 650,000,” he 6 More information about Sustainable DC is available at www.sustainabledc.org (accessed April 16, 2015). 

UTILIZING GREEN TECHNOLOGIES IN WASHINGTON, DC 13 said, “but in terms of real numbers, we have as many energy star buildings as Los Angeles. . . . We have as many LEED-certified buildings as Chicago and New York and cities which are 5 and 10 times our size.” The District uses 100 percent green power, which has required a significant investment from both the public and private sectors, he said. “The government is not buying all this power and it is not building all these buildings; this is the private sector adopting market greening in a significant way.” Another green initiative is the District’s 5-cent fee for disposable bags supplied at a grocery or other store, which has led to an 80 percent decrease in bag usage and a corresponding drop in the number of bags that end up in the Potomac River. The District also has more than 2 million square feet of green roofs, and, Shane said, over the past several years the District has been installing more green roofs by square footage than any other city in the United States. Furthermore, the first major bike-sharing system in the United States was in the District of Columbia, and that program is still one of the most active in the country. Although the bike-sharing programs in New York City and Chicago, Illinois, are larger, the DC program is still growing at a remarkable rate, Shane said. Moving to how DC defines “sustainability,” Shane offered four characteristics. First, it is about creating options: “options about where you live, how you can get to work, what kind of power you buy, what kind of job you can have, all sorts of things.” Second, it is about long-term vitality for the city. Third, it is affordability. “If you asked what the number one issue in the mayor’s election we just had last week, affordability might be it,” he said. And, fourth, it is healthier families. The Sustainable DC framework has 32 goals, 31 targets, and 143 actions, but they are all organized around four broad areas: (1) jobs and the economy, (2) health and wellness, (3) equity and diversity, and (4) climate and the environment. Similarly, the solutions proposed fall into seven broad areas: the built environment, energy, food, nature, transportation, waste, and water. Some of the metrics and targets are still being defined, Shane said, because it is not always easy to measure progress. In the area of health, DC is focusing on two core challenges: obesity and asthma. One in three DC children is at risk of becoming overweight or obese, and the risk is much higher among lower-income groups (especially residents in Southeast DC). The risks of asthma are spread more equitably around the city. At this point, Shane acknowledged, the plans for dealing with these health issues are not particularly detailed or sophisticated, in part because 

14 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION this is the first time that the city has focused on these issues. The first goal in the area of health and wellness is to “inspire healthy, active lifestyles for all residents, regardless of income, ability, or employment.” An associated target is to cut the citywide obesity rate by 50 percent by 2032. “Anyone who works with that field would know that is pretty aggressive,” he said. “The goals throughout this plan are very aggressive and they tend to be round numbers—we are going to cut energy use in half; we’re going to cut obesity in half.” Among the actions identified to be needed to meet this goal are expansion of access to public parks and programming to promote healthy lifestyles through physical exercise and to investment in a public health campaign to promote the benefits of healthy eating and active living. The second health and wellness goal is to “create safe environments that are conducive to healthy living.” The associated target is to “require all new housing projects in the District to meet Healthy by Design standards.” To meet this goal, the District will develop a Healthy by Design program for new affordable housing projects that focuses in particular on low-income and underserved neighborhoods. The idea, Shane explained, is that housing needs to be designed with health in mind. “Transit-oriented access, all of the green elements you expect to see in new buildings should be embodied there.” A second action will be to assess the various environmental, economic, and social barriers to healthy lifestyles specific to DC. Climate Goals in the Sustainable DC Plan On a larger scale, the Sustainable DC plan also has what Shane called “big-picture goals for climate.” One is to “advance physical adaptation and human preparedness to increase the District’s resilience to future climate change.” However, the goal is aimed at more than dealing with events that may occur several decades from now. “We need to do it for the climate we have right now,” Shane said. “[Hurricane] Sandy is an example of that.” The target associated with this goal is to require that all new buildings and infrastructure undergo a climate impact analysis. “This is a building or road or other public infrastructure that is going to be there for 50 years, maybe longer, so we need to plan for the climate 50 years in advance.” Various impacts of climate change must be planned for, Shane said. The average temperature is increasing, sea levels are expected to rise, and habitats are changing, so various species are on the move. For instance, the Asian tiger mosquito was not found in the DC area some years back; now it is. Sustainable DC is now working on a climate resiliency and adaptation plan. The first step is a three-part study that is analyzing climate impacts, 

UTILIZING GREEN TECHNOLOGIES IN WASHINGTON, DC 15 assessing risks and vulnerabilities, and identifying and prioritizing solutions. Expected temperatures are particularly important, Shane said. “You can get out of the way of a flood most of the time, . . . but heat is what kills in numbers and kills the most vulnerable people more than others.” Among the potential solutions that have been studied is the expansion of cool roofs. What would happen if the cool roofs were to spread across the system until they were on a substantial percentage of the city’s roofs? “When you start increasing the reflectivity of the city,” Shane said, “you start seeing decreases in morbidity—in this case, reducing the number of deaths on an average of 6 percent if we increased by 10 percent the urban reflectivity” (Kalkstein et al., 2013). One of the complications that the study revealed was that if the District increased its number of cool roofs, the majority of the benefit would actually be to Prince Georges County in Maryland, which lies to the east of the District, because that is the predominant direction in which the wind blows. “This isn’t something that we can solve alone,” Shane said. “We really want Virginia to cool down [Virginia is to the east of the District], to be more reflective, because if they are cooler, then we are cooler.” Other Health-Related Initiatives in the District Shane described a number of health-related initiatives that the District is currently carrying out. First, he mentioned Capital BikeShare. “I think it’s one of our best examples of a rapid change,” he said. The program has grown so rapidly that the District is now working on increasing the number of places where people can ride bikes. “We need more bicycle tracks, we need safer bicycle tracks, we need more trails, and things like that.” A related program, called Bank on DC, provides discounted access to bikes to residents of Ward 7 and Ward 8 (the city’s two poorest wards) who do not have credit cards (which is a requirement of Capital BikeShare). Play DC is a 10-year, citywide initiative aimed at rebuilding the city’s playgrounds and parks. It is about half done now, Shane said. For instance, 40 of the District’s 75 playgrounds have been renovated. The new designs were done in partnership with the community, and the goal has been to provide more opportunities for people to play in a safe place. Live Well DC is an initiative to increase public awareness of the importance of making healthy decisions in terms of both physical exercise and diet. Lead-Safe Washington is focused on reducing risks from lead- based paint hazards. It does not stop with lead-based paint, however. The ultimate goal is to develop a more comprehensive approach because homes 

16 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION with peeling lead paint often have mold, energy use, or other issues. Park Prescription is a pilot program in which family physicians hand out prescriptions for exercise and time at prescreened locations. “They don’t just say go do some exercise,” Shane explained. “They say go to this playground, use this track or this pool, giving people a more specific prescription to try to get them to understand their opportunities as well as the importance of health initiatives.” The Age-Friendly DC Initiative is doing a survey of every block in the city to find out how friendly it is for older citizens to walk or get access to transit or other things that they need. DISCUSSION Goldman started the discussion session by saying that a great deal of concern about gentrification exists in DC.7 “On the one hand, you want people who work in the city . . . [and] to be living in the city, and . . . no city can thrive if none of the people in the city generate income,” she said. “On the other hand, some of the traditional neighborhoods are concerned as development is moving out through the city, even with the proposals to create new amenities.” So she asked Kats and Shane to comment on gentrification. “It’s a very challenging issue,” Shane said. “Often, when we put out our goals and challenges and we’re looking at economic growth and health and wellness and equity, the first question you get is, How are you going to keep the community equitable? How are you going to keep it affordable if we have bike lanes everywhere and every millennial across the country wants to move here? There is no simple answer.” The District is trying various things to keep housing affordable. In particular, the current mayor is looking at major investments—$100 million per year or more—to preserve and increase affordable housing. And even with that kind of money, Shane said, it is challenging, in the face of the market transformation that is now taking place in the District, to keep 7 According to the Centers for Disease Control and Prevention, “gentrification is often defined as the transformation of neighborhoods from low value to high value. This change has the potential to cause displacement of long-time residents and businesses. Displacement happens when long-time or original neighborhood residents move from a gentrified area because of higher rents, mortgages, and property taxes. Gentrification is a housing, economic, and health issue that affects a community’s history and culture” (CDC, 2013). However, gentrification can help return middle-class families to disinvested areas, as well. 

UTILIZING GREEN TECHNOLOGIES IN WASHINGTON, DC 17 housing affordable. Recent news reports indicated that in the past year there had been a 34 percent increase in median home prices in one neighborhood in Southeast DC, from $250,000 to $350,000. “Those are the kinds of market forces you’re battling against,” he said. “The people are arriving, and the prices are going up.” But the issue of where the real estate market is going should be kept separate from the issue of improving the various communities in the District, Shane said. “The idea that you have a walkable neighborhood, a healthy neighborhood, is independent of whether someone is new, moving into the area, or has been here for a while, whether they paid $50,000 for their house or whether they paid $1 million for it.” Thus, he and his colleagues focus on improving the quality of the community citywide, including the affordable housing, and on developing new assets that will improve the lives of everyone in the city. “You need to understand that the community will be changing, will be growing, and you need to build these assets in and make sure they are accessible to people at all levels of income,” he said. Kats added that he thought that DC had done a great job in terms of engaging all parts of the community in discussions about the future of the city. “I think every ward feels like they have been listened to . . . and not just listened to, but their input has been really important.” Concerning gentrification and equity issues, Kats said that the District’s efforts to affect the cost of transportation, reduce energy costs, and improve health will have major effects on the city’s low-income citizens, who are disproportionately affected by health issues and the cost of energy and transportation. “Low income is very concentrated in areas with few trees, very low albedo [i.e., reflectivity], meaning excess heat, excess smog, and excess respiratory problems,” he said. “So the systematic solutions that the city is putting in place to bring down temperature and to make these buildings more affordable . . . are going to have measurable positive benefits. It doesn’t offset the rise in value, but I think the city has really been admirable in how well it has addressed this and is addressing it.” Next, Jack Spengler of Harvard University mentioned two innovative programs being carried out by cities elsewhere. Vancouver, British Columbia, Canada, has a program that is mapping indicators of happiness, thriving, and social ability down to the level of census tracts as a way of understanding factors affecting the cohesiveness and health of a community. A second program called One Science in Washington State is looking to use family services to reduce various stresses on children because these stresses 

18 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION have been shown to predict risky behaviors, health, income, and various other outcomes later in life. John Balbus of the National Institute of Environmental Health Sciences asked Shane a question about how the effects of the various analyses that he was talking about are measured. For example, in saying that a 10 percent increase in reflectivity would result in a 6 percent decrease in heat deaths, how is that measured? Is that done completely according to a model, or are there programs looking at actual health effects? Specifically, Balbus spoke about the difficulty of tying effects to causes in an environment where the effects may be mediated by very small scale phenomena and the variables are constantly changing. “If you have a neighborhood and you increase the value of the homes 200 percent and you change the people in the neighborhood, you will change the health in that neighborhood,” he said. He then asked, “how do you evaluate the program in light of the population changes that may be occurring as well? Are you tracking the original residents?” Shane answered that he could only speak in generalities and that others were more familiar with the specific details. But, in general, he said, many of these programs are only getting started now. “Ideally, we would be doing the baseline assessments and have that information now. Then, as we move to cooler roofs in residential neighborhoods, as we plant a tree and then wait a decade for it to actually be big enough to do anything, as we make changes that are long term, some of these need to be looked at long term.” However, he added, he does not know for sure that anyone is actually planning to look systematically at the effects in a way that will deal with the various complications. Kats expanded on the answer to Balbus’s question. “John Davies Cole, who is the state epidemiologist for DC, has been helping us as well,” he said. “We’ve gotten health data by ward, including hospital visits. Somebody who suffers from asthma or allergies goes to the hospital. They can’t pay for it, but somebody pays for it and it ends up being a real cost. Mapping those costs has taken quite a long time, and I think we are at least taking a step in that direction. Those are quantifiable, and they do vary by income, they vary by location, so you can begin to map things which are triggered by or contributed to by excess temperature due to the urban heat island. . . . I think we’re starting to use that data in a way that’s constructive in terms of shaping policy and quantifying in a fairly rigorous way what this means.” Bernie Goldstein of the University of Pittsburgh had two questions. First, what is being done about education? In Pittsburgh, Pennsylvania, once 

UTILIZING GREEN TECHNOLOGIES IN WASHINGTON, DC 19 young professionals start having children, they tend to move out of central Pittsburgh because the inner-city schools are not good enough, and he said he suspected that the same thing is true in Washington. “How are you going to keep people in these areas that you are building up unless you improve the schools? Why isn’t that part of your system?” Second, Goldstein noted that the city population with the greatest public health problems is the collection of homeless people, yet he had heard nothing about plans to improve their situation. What, if anything, is planned for the homeless? Shane answered that these two areas are indeed being addressed by the District. For instance, great progress in being made in improving the schools. “The city is seeing a turnaround,” he said, “so the public school enrollments are increasing year by year and they are increasing faster each year.” This indicates that young people are moving into the District and staying as their children become school age, he said, although he acknowledged that inequities remain and that not all District schools are doing so well. Part of the success is due to the District’s public charter school program, which is one of the most robust in the country, he said. “About 40 percent of public school students in the District are now in a public charter school, which are all over the city with a whole variety of focus areas.” The city has also instituted universal prekindergarten that is available for all 4- year-olds and will likely be made available to 3-year-olds as well. “I think we are starting to see the statistics which show that families are staying, the numbers of enrollments are rising,” he reiterated. “The problem is that the families that are staying and the schools that are bursting at the seams tend to be in pretty affluent areas. Diversity is decreasing in some of these schools, as they are made up more and more of people living in that neighborhood, as opposed to kids moving around the city to these schools.” In other words, problems remain, but the city has been working hard to improve its schools and make the District a place that young people with families want to live. There is less success to report with homelessness, Shane said, but the city is working on it. “It’s a very high visibility issue right now as the city is trying to figure out how to move people into permanent housing, to move people into transitional housing, and, frankly, getting away from debacles of recent years where the city has just been overrun by the numbers,” he said. “As the affluence increases, the housing prices are going up. In recent years, especially last year’s cold winter, it all converged when you had more and more people not being able to afford housing and colder and colder winters, 

20 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION which led to the city having to mobilize in a way it never had before around hypothermia and homelessness.” Currently, a range of homelessness programs is in place, and the District administration is trying to figure out which approaches to addressing homelessness will be the most effective. Linda Birnbaum, director of the National Institute of Environmental Health Sciences, spoke next. She commented that health is not simply a personal issue but that it is affected by factors over which individuals have little or no control. For example, she mentioned that in March 2015 the Roundtable will be sponsoring a workshop on how environmental exposures, such as chemicals and air pollution, can increase the risk of obesity. Given that, she asked whether abandoned areas inside the city are being tested for the presence of cadmium and other heavy metals before they are transformed into places where food is grown. She also asked if anyone has done life-cycle analyses of materials, including solar panels, that are used in the construction of green buildings. Kats answered that he was familiar with one urban agriculture site in the District that is scheduled to produce 1 million pounds of food per year. “That is actually hydroponic,” he said, “and it is extremely tightly measured, so the quality of produce is very high. It’s very fresh; there are no contaminants.” Concerning the life cycle of green buildings, he said that the LEED certification program has done a good job with paying attention to the upstream and downstream environmental effects (that is, the effects related to the production and disposal of the building materials). “We invested a lot in large-scale photovoltaics,” he said. “There are some nasty metals in some of the PV options, like cadmium and telluride. Those are much more carefully monitored. The whole move has been toward upstream and downstream life-cycle assessment.” As another example, he mentioned PVC, or polyvinyl chloride, which is a widely used building material. “It’s great as long as you don’t have to manufacture it,” he said. “It’s great as long as you never have a fire. It’s great as long as you never have to dispose of it. But if you think about the front end [production] of PVC and the back end [disposal], there are some real health questions,” and so the LEED standards are weighted against the use of PVC because of these life-cycle considerations. 

UTILIZING GREEN TECHNOLOGIES IN WASHINGTON, DC 21 Because the District has adopted not just LEED standards but LEED Gold and LEED Platinum standards,8 which are even more stringent, it is doing a better job of addressing upstream and downstream issues than most cities, he said. Shane added to that answer by noting that although the District is not treated as a state in terms of having representation in Congress, it is a state in terms of EPA regulations and so it has a very robust environmental program. “We have 300 people in our agency, and that includes toxics and clean air and clean water programs,” he said. “We regulate use of soils and clean-up very rigorously here and have very high standards.” Thus, anyone looking to develop a site—even those who are not planning on growing anything in the soil—must have the soil tested and, if necessary, clean it up. Furthermore, the University of the District of Columbia has a laboratory that offers free soil testing for people who may be doing agriculture at their homes or in community gardens. Finally, he added that the large-scale growing programs in the District are generally not soil based. “We don’t have that much space,” he said. “There are a lot of aquaponics programs developing, fish and plants together, as well as hydroponics.” Faiyaz Bhojani, from Royal Dutch Shell, asked two questions. The first concerned how best to quantify the benefits of various programs aimed at improving people’s health, productivity, and environment. Shell has various such programs and has resorted to speaking about “value on investment” rather than “return on investment” because of the difficulty of quantifying such returns. Second, he asked in general terms about developing partnerships between the private and public sectors. “Employers cannot do this all by themselves, nor can the NGOs [nongovernmental organizations], governments, et cetera,” he said. “We have to develop partnerships in figuring out how we can help each other because the ultimate goal is still the same thing: thriving people, better environment.” Shane answered that partnerships are crucial. In terms of controlling carbon dioxide emissions, for example, the government is a relatively small player. About 6 percent of the District’s emissions are from the government, while 94 percent of the emissions are under private control. “You could use similar numbers probably for making people healthier or getting them to exercise,” he said. “The ability to achieve any of our big-picture goals 8 To receive LEED certification, building projects satisfy prerequisites and earn points to achieve different levels of certification. These levels are Certified, Silver, Gold, and Platinum. There are different standards for residential buildings and commercial buildings, for example. 

22 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION comes down to working with private sector, motivating private-sector business and institutions and individuals to move.” Sometimes, of course, the government uses “the regulatory hammers,” Shane said. It sets standards that the private sector must follow. For instance, in summer 2014 the District banned the use of polystyrene for take-out food containers. “The idea is that it is replaced by alternative products that are combustible and more easily recyclable,” he said. “We want to reduce the risk and create an opportunity there. We will use some of the tools where we can force an action and make a change.” On the other hand, the District is also interested in working with the private sector in various areas on a voluntary basis. For instance, the District has a voluntary program called the Smarter DC Challenge that challenges businesses to be smarter about the way in which they operate. “We provide incentives where we can,” Shane said, “but it’s about networking, about leadership from the private sector in the workplace.” As for quantifying benefits, Shane said that when a clear business case for green power exists—with data showing that green power is in businesses’ best interests—real movement will take place in the market on a larger scale. “So we need to be working to make those connections and have it be something that pencils out as a business case,” he said. “We don’t do it enough yet, and we are working and hoping, through some partnerships with local universities, to start ramping up that kind of research effort, at least for the DC market.” On the quantification issue, Goldman said that when George Washington University built a LEED Platinum building, people from the university administration often questioned the cost and whether it was worth it—even down to the issue of installing the more expensive but more energy-efficient LED lights. “We were fortunate enough to have a sustainability office in the university that could come up with the cost savings for the electricity and help us do the comparison so we could justify the lights,” she said. “That happened over and over again.” Unfortunately, she said, many businesses are not so lucky and do not have someone who can quantify the benefits of such decisions. Shane added that at the moment a number of researchers are working to quantify the benefits of energy- and health-related choices, “but the case isn’t always there and the research isn’t as robust as it needs to be.” Richard Jackson from the University of California, Los Angeles, commented that it is important to document the benefits of the various programs being put into place. “There is supposed to be 1 percent set aside for art in many places, there is supposed to be 1 percent set aside for 

UTILIZING GREEN TECHNOLOGIES IN WASHINGTON, DC 23 evaluation in public health programs, and I would assert there needs to be the funding to really document these impacts that you are having,” he said. “This can’t be done by a busy epidemiologist or public health researcher who has already got 50 other things to do and doing it out of good will; it has to be supported.” He also asked Shane what “flipped the switch” in the District. “Why did this place go from completely dysfunctional to really a paradigm and a model?” Shane responded that there were a number of different switches. Part of it was that the DC mayor made sustainability a major focus “and invested in it and provided the bully pulpit that helped so much of the rest of us in the government, staff folks, move things forward.” Another part of it was that the U.S. Green Building Council is headquartered in the District, and thus, the council could influence thinking in the District. Finally, he said, the development of the D.C. Green Building Act in 2005 and 2006 was the result of a coming together of the private sector—particularly the District’s builders—and government to say, “Yes, this is the future. We’re going to move this way.” Once the standards were passed, even though they would not go into effect for the private sector for a few years, people recognized that this was the direction the market would be going, and the result was a huge upswing in the adoption of green building practices in the city. Jackson also made reference to the graphs that Kats showed indicating that mortgage lenders face fewer risks lending to people in more livable, walkable parts of a city and noted that this could have serious implications for the nation’s suburbs in the future. “It’s just a mind-boggling question,” Shane said. “We are in now a wealthy, dynamic city, . . . and I think we have an opportunity to lead. We need to be leading because we have the resources to lead, and we are transit oriented and we have a lot of the benefits. But if you start looking at how to move these concepts to suburban America and to 90 percent of the rest of the world, it is extremely difficult. You run into the fact that we are still very much building the old way. If you just go 15 miles from here, you will find the exact same type of housing that was being built 10 and 20 years ago. Maybe it’s a little denser, maybe there are a few more townhouses instead of single-family homes, but there’s a big disconnect.” Groups like the Urban Land Institute are looking at how to retrofit housing—how to take a system that was built around the car and suburbanization and make it into something different—but no clear answers exist yet. Kats offered a different perspective. “People point to Manhattan as a fantastic model of walkability,” he said, “but there are parts of the five boroughs that are just completely unwalkable.” What is important is 

24 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION whether walkable areas are emerging through integrated mixed-use dense and walkable design. When such areas do emerge, he added, it is typically the result of an intentional construction effort involving a combination of public and private incentives and investment. One key is flexibility in zoning to allow retail below and residential above in multistory buildings, or even vice versa. The fastest growth in the past 5 years, Kats said, has been in suburbs and areas that have intentionally developed walkable spaces, and those places often serve low-income people extremely well. Al McGartland from EPA noted that, according to the National Air Toxic Assessment Program, the Washington, DC, area has various automobile-related air pollutants because of the large numbers of people who drive in the area, even with the presence of an excellent public transit system. He asked if any policies to get people to drive less are being considered. Shane said that there are. For instance, the recently passed Sustainability Act required that transit benefits be given to a much larger swath of private-sector employers than had previously been the case. Within the federal government, there are efforts to reduce the amount of free parking that agencies provide to their employees. The District of Columbia Department of Transportation has a sustainability office that has been involved in developing a long-term master transportation plan for the District that is called Move DC. A number of other transportation-related initiatives also exist, such as performance parking, expanded bus routes, and various efforts to increase the attractiveness of cycling. In 2013, Shane said, the District passed Los Angeles as the U.S. metropolitan area where people spend the most time in their cars, so the issue has assumed even greater urgency. “There are a lot of reasons [why] and ways you can improve people’s lives by getting them out of their cars,” he said. “The city is working on a number of those.” Paul Sandifer from the National Oceanic and Atmospheric Administration asked about the program that encourages physicians to write prescriptions for physical activity. In particular, he noted that exposure to biologically diverse environments has been shown to be beneficial for children with asthma, and he wondered if there is any screening of the green spaces that prescriptions are written for. Shane answered that the District of Columbia Department of Health is working with the District of Columbia Primary Care Association to determine the most effective approaches to such prescriptions. Furthermore, he added that the population of District is fortunate to have access to more 

UTILIZING GREEN TECHNOLOGIES IN WASHINGTON, DC 25 biologically diverse environments than the populations of many other urban areas because it is a federal district with a number of areas that are part of the National Park System. “We also have a number of city parks that are wild spaces that allow people to go into nature, even though you are in the middle of the city,” he said. “The mayor talks a lot about taking the paddle ride down from the Maryland line on the Anacostia River coming down through the city. You just would not know you are in Washington, DC. So some really fabulous opportunities exist, and connecting people to those is one of our efforts.” Ann Carroll with the Office of Brownfields and Land Revitalization of EPA asked about the possibility of paying for health programs through the use of tax increment financing (TIF), which is a way of devoting future gains in taxes—for instance, gains caused by increasing property valuations—to pay for current programs, generally with the expectation that the current programs will lead to increases in the tax base and thus eventually pay for themselves. Health departments in many areas have been getting less and less funding in recent years, she said, and it will be important to once again build up these departments. Shane replied that the District has used TIFs quite a lot for the general economic revitalization of neighborhoods, although not for financing health programs. “The landowners agree that as improvements are made, some of the increased tax value will be dedicated back to the city or the value will be captured,” he explained. There have also been a number of examples of green TIFs around the country. To his knowledge, he indicated, no health TIFs have been put into effect, but, he added, “I would think that some of those green TIFs may well have a number of health-focused outcomes very well integrated in them. It would be interesting to see where those are.” Kats spoke briefly about a green affordable housing example led by Enterprise Community Partners and called the Green Communities initiative. The goal of the initiative is to provide green affordable housing and end housing insecurity. He noted that after 15 years, “the occupants can then own that property, and if that property is green, it has a much higher value than nongreen both because the neighborhood is more attractive, better maintained, is more flexible, is better designed. For many low- income families, it’s the single largest opportunity they have to get significant equity,” he said. Generally, he noted, when developers are required to include low- income housing in their developments, there is a stigma associated with that housing. However, when it is green affordable housing, the stigma is much less, to the point that the affordable housing is more likely to be integrated 

26 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION with the rest of the housing development rather than kept to itself. “In other words,” he said, “the aesthetics and the [design] quality associated with green design offset the stigma of affordable and make affordable a more attractive—or less undesirable—build-out requirement for conventional developers.” REFERENCES CDC (Centers for Disease Control and Prevention). 2013. Healthy places: Health effects of gentrification. Atlanta, GA: CDC. Available at http://www .cdc.gov/healthyplaces/healthtopics/gentrification.htm (accessed April 16, 2015). Environmental and Energy Study Institute. 2012. Fact sheet: Cool roofs. Washington, DC: Environmental and Energy Study Institute. Available at http://www.eesi.org/files/cool_roofs_072412.pdf (accessed April 15, 2015). Kalkstein, I., D. Sailor, K. Shickman, S. Sheridan, J. Vanos. 2013. Assessing the health impacts of urban heat island reduction strategies in the District of Columbia. Available at http://www.coolrooftoolkit.org/wp-content/uploads/2013/10/DC- Heat-Mortality-Study-for-DDOE-FINAL.pdf (accessed September 16, 2015). Kats, G. 2006. Greening America’s schools: Costs and benefits. A Capital E report. Washington, DC: U.S. Green Building Council. Available at http:// www.usgbc.org/Docs/Archive/General/Docs2908.pdf (accessed March 19, 2015). Kats, G., and K. Glassbrook. 2015. Washington, DC smart roof cost–benefit report. Washington, DC. Available at http://cap-e.com/wp-content/uploads /2015/04/DC_SmartRoofReport_2015-04-16.pdf (accessed December 1, 2015). Kats, G., J. Braman, and M. James. 2010. Greening our built world: Costs, benefits, and strategies. Washington, DC: Island Press. Takaro, T. K., J. Krieger, L. Song, D. Shaify, and N. Beaudet. 2011. The breathe- easy home: The impact of asthma-friendly home construction on clinical outcomes and trigger exposure. American Journal of Public Health 101:55–62. USGBC (U.S. Green Building Council). 2015. Green building facts. Washington, DC: USGBC. Available at http://www.usgbc.org/articles/green-building-facts (accessed June 22, 2015). World Green Building Council. 2013. The business case for green building: A review of the costs and benefits for developers, investors and occupants. World Green Building Council. Available at http://www.worldgbc.org/files/ 1513/6608/0674/Business_Case_For_Green_Building_Report_WEB_2013-04- 11.pdf (accessed April 9, 2015).