Building Evidence for Health: Green Buildings, Current Science, and Future Challenges

Abstract

Civilizational challenges have questioned the status quo of energy and material consumption by humans. From the built environment perspective, a response to these challenges was the creation of green buildings. Although the revolutionary capacity of the green building movement has elevated the expectations of new commercial construction, its rate of implementation has secluded the majority of the population from its benefits. Beyond reductions in energy usage and increases in market value, the main strength of green buildings may be the procurement of healthier building environments. Further pursuing the right to healthy indoor environments could help the green building movement to attain its full potential as a transformational public health tool. On the basis of 40 years of research on indoor environmental quality, we present a summary of nine environment elements that are foundational to human health. We posit the role of green buildings as a critical research platform within a novel sustainability framework based on social-environmental capital assets. Expected final online publication date for the Annual Review of Public Health Volume 39 is April 1, 2018. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

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Annual Review of Public Health
Building Evidence for Health:
Green Buildings, Current
Science, and Future Challenges
J.G. Cede ˜
no-Laurent, A. Williams, P. MacNaughton,
X. Cao, E. Eitland, J. Spengler, and J. Allen
Environmental Health Department, Harvard T.H. Chan School of Public Health, Boston,
Massachusetts 02215, USA; email: memocedeno@mail.harvard.edu
Annu. Rev. Public Health 2018. 39:291–308
First published as a Review in Advance on
January 12, 2018
The Annual Review of Public Health is online at
publhealth.annualreviews.org
https://doi.org/10.1146/annurev-publhealth-
031816-044420
Copyright c
2018 J.G. Cede ˜
no-Laurent et al.
This work is licensed under a Creative Commons
Attribution 4.0 International License, which
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for license information
Keywords
health, indoor environmental quality, green buildings, sustainability,
human rights, built environment
Abstract
Civilizational challenges have questioned the status quo of energy and ma-
terial consumption by humans. From the built environment perspective, a
response to these challenges was the creation of green buildings. Although
the revolutionary capacity of the green building movement has elevated the
expectations of new commercial construction, its rate of implementation has
secluded the majority of the population from its benefits. Beyond reductions
in energy usage and increases in market value, the main strength of green
buildings may be the procurement of healthier building environments. Fur-
ther pursuing the right to healthy indoor environments could help the green
building movement to attain its full potential as a transformational public
health tool. On the basis of 40 years of research on indoor environmen-
tal quality, we present a summary of nine environment elements that are
foundational to human health. We posit the role of green buildings as a
critical research platform within a novel sustainability framework based on
social-environmental capital assets.
291
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ANNUAL
REVIEWS
Further
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INTRODUCTION
The relationship between habitation and human health dates back to the Middle Pleistocene (781–
126 kya). Early evidence of exposure to microcharcoal and soot in Lower Paleolithic hominis
from indoor cave smoke suggests that humans were affected by indoor environmental exposures
resulting from activities that were critical to civilization (e.g., control of fire) (53, 132). Since
then, we have faced unexpected consequences from modifying our interactions with the built
environment and buildings, such as the sanitation crisis at the end of the nineteenth century (75)
or the energy crisis in the 1970s and the subsequent onset of sick building syndrome (SBS) cases
(11, 46, 62). More recently, rapid urbanization and population growth have led to the extensive
use of natural resources for construction, adding to the significant greenhouse gas emissions from
existing and new buildings. This practice has made significant impacts on the health of ecosystems
and a changing climate. In response, ecological sustainability was developed as a field of study
to stop, and revert to the extent possible, the damages inflicted on planetary health by human
activities.
In buildings, sustainability has been driven primarily by green building rating systems (RSs).
The presence of green buildings now extends to more than 160 countries, assessed with more
than 40 building RSs as reported by the World Green Building Council. In principle, RSs share
a similar approach: a performance evaluation of a building based mostly on design parameters,
according to consensus-based criteria on domains such as energy and water consumption, use of
natural resources, and indoor environmental quality (IEQ). Similar to sustainability, RSs focused
initially on the reduction of energy and water use and waste. Green buildings have so successfully
galvanized a market transformation by offering sustainable solutions that, although the concepts
were initially considered cutting edge, many of these criteria are now standard and expected
minimum design criteria for new buildings in major real estate markets, regardless of whether the
buildings pursue RS credits.
This significant shift in building practices has resulted in benefits to human health at different
scales (84). At the societal level, green buildings may reduce pollutant emissions by consuming less
energy. Although the benefits of green buildings to the broader society are a compelling argument
for certification and government mandates for their use, return on investment for property owners
as well as improvements in occupants’ health, satisfaction, and productivity are presumably the
most tangible benefits and are therefore the greatest motivation for building owners and tenants
to pursue green building certification. As green building elements that promote energy efficiency
have become the norm, we have seen a shift in the market toward designing, operating, and
maintaining “healthy buildings.”
In this review, we focus on this last aspect—human health, satisfaction, and productivity—and
aim to provide a brief summary of the scientific evidence related to buildings and health. We divide
this review into nine foundational elements that constitute a healthy building (indoor air quality,
ventilation, thermal health, water quality, dampness and mold, dust and pests, noise, light and
views, and safety and security), which were chosen on the basis of evidence of a causal or strongly
suggestive relationship between each foundational element and health outcomes. Studies from all
types of buildings (green and conventional) were considered, allowing us to draw on reliable study
designs from four decades of IEQ research and larger samples of buildings and study participants
rather than exclusively relying on green buildings. As a result, the nine foundational elements are
not particular to any specific rating system; rather, they represent the foundational components
of any healthy, green building. Finally, we present our views on how green buildings should
evolve to become an effective public health tool to address current and future challenges of indoor
environments and human health.
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FOUNDATIONAL ELEMENTS OF A HEALTHY BUILDING
Indoor Air Quality
Indoor air quality (IAQ) is a simplified term that is used to describe the complex topic that explores
how the air in indoor environments impacts human health, comfort, and productivity. The term
IAQ includes all the chemical, radiological, biological, and physical pollutants to which we are
exposed via indoor air (131). Therefore, it is a subset of overall IEQ, which includes water, dust,
and lighting, among others. IAQ is too broad of a topic to be adequately described within the
scope of this paper. Here we present a succinct description of IAQ for readers unfamiliar with
the topic, and we direct readers to the many excellent and thorough reviews that cover by now
well-established exposure-response functions for common pollutants (3, 95, 117, 122).
IAQ is influenced by three primary factors: pollutants generated indoors, for example from
building products (e.g., formaldehyde), consumer products [e.g., volatile organic compounds
(VOCs)], animals (e.g., human bioeffluent, animal allergens), and human activity (e.g., cook-
ing, spraying pesticides); pollutants generated outdoors that penetrate indoors (e.g., radon, diesel
exhaust); and the building systems and conditions that can act to mitigate or exacerbate these
exposures (e.g., ventilation, filtration, moisture). Poor IAQ has been associated with both acute
effects such as asthma, fatigue, irritation, and headache, as well as chronic effects such as cancer,
depending on the pollutant, pollutant concentration, and exposure duration.
Quantifying the economic costs and benefits of IAQ remains a critical research area because
these types of analyses influence government policy and policy makers, as well as building own-
ers and designers who are often making trade-offs to save building costs without accounting for
the health ramifications of those decisions. Poor IAQ is associated with increased absenteeism
(93), increased sick building symptoms (119), and increases in infectious disease transmission
(44, 58, 70), all of which have associated economic impacts. A 2008 meta-analysis evaluated
the monetary and societal costs of indoor air pollutant–related damages and observed a range
of reported damages associated with poor IAQ, including productivity loss, health care costs,
and building damages (from moist air and mold development). Each study estimated upwards of
$10 million in annual “air pollution costs” (101). There are also significant economic benefits from
cleaner indoor environments. In the United States alone, the cost savings and productivity gains
from improved indoor environments have been estimated at $25 billion to $150 billion per year
(47).
IAQ is a multidisciplinary phenomenon and serves as the basis and cross-point for all the foun-
dational elements reviewed in this article. Singular strategies may not be effective in responding
to the deterioration of IAQ by climate change (CC), energy conservation, and social develop-
ments. Rather, holistic solutions geared toward a better IAQ are preferable, including innovations
in air distribution, air cleaning, and indoor environmental devices/systems, and should leverage
smart technologies and sensing systems with user management that optimizes IAQ on the basis
of real-time health performance indicators (122).
Ventilation
Ventilation plays a crucial role in creating healthy IAQ by regulating the air velocity, temperature,
relative humidity, and airborne contaminant concentrations (33). Ventilation in buildings brings
in fresh air from outside and dilutes occupant-generated pollutants (e.g., CO2, odors) and product-
generated pollutants (e.g., VOCs) (77). Although a mechanically ventilated building system filters
outdoor air, outdoor pollutants such as PM2.5 can penetrate indoors if the mechanical system
does not properly filter the air stream. Because people spend approximately 90% of their time
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indoors, the main exposure to outdoor air pollution may occur indoors (31, 79). Even with proper
ventilation, the concentration of pollutants indoors can be higher than concentrations found
outdoors (116).
Occupants in poorly ventilated spaces often report symptoms such as headache, fatigue, short-
ness of breath, sinus congestion, cough, sneezing, dizziness, and nausea, as well as eye, nose,
throat, and skin irritation (91). Lower indoor ventilation rates are associated with higher rates of
short-term sick leave, asthma, and respiratory infection (120). This collection of symptoms stem-
ming from extended exposure to poorly ventilated spaces has been deemed sick building syndrome
(SBS) (39, 128). Studies have also found an association between the ventilation of buildings and
the transmission of airborne infections (77, 83, 111). Ventilation has also shown strong associa-
tions with cognitive function; a 400-ppm increase in indoor CO2levels has been associated with
a 21% decrease in performance on a cognitive task (4, 84, 85). In primary schools, low classroom
ventilation rates resulted in significant decreases in academic achievement (54). Many studies have
suggested that green buildings with increased ventilation generally have lower levels of pollutants
(e.g., VOCs, nitrogen dioxide, particulate matter) (64, 98) and that occupants have reported the
perception of improved IAQ and fewer health problems (34, 86).
To ensure better IAQ in building spaces, current ASHRAE (American Society of Heating,
Refrigerating, and Air-Conditioning Engineers) standards require a minimum ventilation of 20
cubic feet per minute per person (12) and recommend regular maintenance of heating, ventilation,
and air conditioning (HVAC) systems, as substandard ventilation often occurs in buildings where
HVAC systems are either neglected or inadequately maintained (52). The current ventilation
standard, by definition, is a minimum standard designed to provide merely “acceptable” IAQ,
despite decades of research showing benefits of higher outdoor air ventilation rates. Doubling
ventilation rates resulted in an increase in productivity that offset the associated energy costs (84).
However, changes in ventilation raise concerns about the size and capacity of ventilation ducts, so
decisions must involve all relevant stakeholders.
These health-promoting ventilation findings should be considered in future standards for all
building types. As society prioritizes reducing energy use to mitigate future global challenges,
such as CC and rapid urbanization, additional research on advanced ventilation systems with high
outdoor air pollution filtration rates (i.e., increased global ambient CO2levels, increased ambient
pollution from energy sources in developing countries) will be necessary to lower ventilation
energy costs for zero–low-energy designs (28). Areas that rely on natural ventilation will need to
be considered in relation to changing climates [e.g., increased temperatures, increased humidity
(45)] because buildings in these areas must still meet adaptive thermal comfort standards as well
as mitigate further health and environmental damages (34).
Thermal Health
Traditionally, thermal comfort has been defined as “the condition of mind that expresses satis-
faction with the thermal environment and is assessed by subjective evaluation” (13, p. 3) and is
influenced by air temperature, mean radiant temperature, air speed, humidity, personal metabolic
activity, and clothing-induced thermal insulation (41). Thermal health, a new term that goes
beyond just comfort, encompasses effects on health, performance, and well-being.
Unfavorable heat, humidity, and ventilation conditions in the workplace have been associated
with increased reports of itchy, watery eyes, headaches, throat irritation, respiratory symptoms,
increased heart rate, negative mood, SBS symptoms, and fatigue (23, 73). Low humidity and low
temperatures alter the disease transmission of infectious disease particles, such as the influenza
virus (81). Alternatively, warm and humid indoor environments encourage mold and fungal growth
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(117). Thermal conditions of indoor environments can also impact performance and learning,
such that task and cognitive performance is reduced under high temperatures in office workers,
college students, and schoolchildren (55, 72, 73, 134). Furthermore, higher overnight temperatures
have been associated with insufficient sleep, especially during summer periods (99), which has
implications for health and performance on the subsequent day.
Heat waves are the largest source of mortality of all meteorological phenomena and cause
thousands of deaths annually. The built environment can exacerbate or mitigate the exposure
to high indoor temperatures during heat waves. Air conditioned spaces can provide thermally
stable environments. Recent research has demonstrated a 3–4% increase in electricity generation
per degree Celsius increase of summer temperatures, which is associated with increases in sulfur
dioxide and nitrogen oxides, as well as the greenhouse gas CO2(1). During heat waves, indoor
temperatures of non–air conditioned spaces can exceed outdoor temperatures owing to the thermal
mass of the building, and these high temperatures extend even after outdoor temperatures drop,
creating indoor heat waves.
CC has increased the frequency, duration, and intensity of heat waves (113). Consequently,
indoor heat waves will present widespread challenges for the built environment, especially in
climates where buildings were designed to harness heat to endure cold winters. As air conditioning
usage increases to tolerate warmer climates, cooling demand during heat waves is expected to
strain the electricity grid, increasing the risk of power outages (113) and threatening the limited
passive habitability of the current built environment (59, 104). Future research can address these
challenges by analyzing the adaptation mechanisms for different climate types, air conditioning
use patterns, and the implications of air conditioning usage under different energy generation mix
scenarios.
Water Quality
The large diversity in water quality and composition globally may result in a mixture of inorganic,
organic, or microbial substances within the water supply. Water infrastructure is critical for more
than 4 billion people who rely on water through a piped connection and 2.4 billion who use
improved sources such as public taps, protected wells, and boreholes (50). Although the United
States has one of the safest public drinking water supplies in the world, problems persist. Water
infrastructure in the United States has significantly deteriorated and is approaching the end of its
useful life as many water pipes and mains are more than 100 years old (19). A 2017 assessment
found water infrastructure in the United States to be in “poor to fair condition and mostly below
standard” with “strong risk of failure,” brought to national attention by the Flint water crisis
in Michigan (11a). Lead and copper water service pipes have been associated with reductions in
cognitive function, hypertension, and reproductive problems in children and adults (26). In 2016,
elevated lead levels were detected in the drinking water of many US public schools across the
country, owing to an aging school building infrastructure that predates the Lead and Copper Rule
(22, 94, 97). Legionella bacteria in building water systems accounted for two-thirds of waterborne
illness outbreaks in the United States, 26% of reported illnesses, and all 14 reported deaths—12
of which were associated with health care facilities (19). Legionella thrive in building plumbing
systems with stagnating water (plumbing system dead legs or areas with infrequent water use),
with warm water, and when residual disinfectant concentrations are low.
There are two key challenges facing water consumption in buildings: water access and wa-
ter quality. The green building movement addresses the first challenge by conserving water
through technology and behavior changes that improve efficiency. Strategies include reducing
flow rate, using alternative water sources, or reducing plant watering. This approach can, however,
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negatively impact water quality; the longer that water sits in service pipes, the greater the uptake
of heavy metals and formation of disinfection by-products (109). Chlorination of drinking wa-
ter has been used in the United States since 1908 and has allowed for widespread disinfection
of water. However, cell culture, animal, and human epidemiological and toxicological studies
show potentially carcinogenic, reproductive complications and endocrine-disrupting properties
of disinfection by-products (8, 50, 74, 96).
CC, rapid urbanization, and population growth will exacerbate deficiencies in the global wa-
ter systems and demand holistic, innovative solutions that consider water composition, process,
delivery, and conservation. Water quality improvements rely on the exploration of novel, cost-
effective filtration methodologies, including solar light catalytic ozonation, electrochemical sepa-
ration, sand filtration, and other types of solid catalysts (49). Owing to uneven spatial distribution
of water stress, assuring global water resources for the building, irrigation, energy generation, and
industrial sectors will require tailored delivery and conservation solutions. Ensuring consistent,
contaminant-free water delivery will be a challenge for the 5 billion people who will be living in
water-stressed areas by 2050 (114).
Moisture
Water and moisture can enter buildings through many routes: leaks from plumbing, building
envelope openings, condensation on cold surfaces, poorly maintained drain pans, and inadequate
ventilation of kitchens, showers, and combustion appliances. This moisture creates favorable con-
ditions for mold growth, which can destroy the surfaces on which the mold grows, such as wall-
boards, ceiling tiles, insulation, and carpeting. The introduction of moisture into buildings has
been previously identified by the Occupational Safety and Health Administration (OSHA) as the
primary source of building-related illness (100). Studies from Europe, Canada, and the United
States have found mold, mildew, or water damage in 36% of homes (35). This exposure is also
problematic in office buildings, as 85% of office buildings in the United States had water damage
and 45% had active leaks at the time of a US Environmental Protection Agency (EPA) survey
(124).
The most prevalent health effect caused by moisture-induced mold formation is asthma; 21%
of the 21.8 million cases of asthma annually are attributable to residential dampness and mold
(68). Other health impacts that are consistently associated with mold exposure include allergic
symptoms, respiratory effects (e.g., cough, wheeze, chest tightness, hoarseness), and vocal cord
dysfunction (24, 38, 90, 92, 103). Additionally, mold can produce irritating and health-harmful
substances, including VOCs (102). Increased water damage and mold have been found to nega-
tively impact workplace productivity, job performance, quality of life, absenteeism, and classroom
learning for office workers, teachers, and schoolchildren (9, 24, 48). Despite strong evidence that
mold is an asthmagen and an allergen, not all metrics used to measure indoor dampness and mold
exposures are adequate for practical and widespread use in indoor environments because some are
too complex, do not scale for widespread use, or are not health protective (90).
Synthetic materials in newer buildings present a future challenge with higher risk for mold
growth because humidity cannot be dissipated as easily with more hydrophilic materials. CC
will also impact the prevalence of indoor moisture because regions with more frequent heavy
precipitation or severe weather events (i.e., floods, tropical storms), which introduce moisture into
buildings through infrastructure damage (127), will be at an increased risk for mold growth, as
was documented following Hurricanes Katrina and Rita (15). Changes in humidity levels, which
determine indoor humidity, will also have implications for indoor moisture as global climates
change (127).
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Safety and Security
Our search for safety and security originates from the endogenous responses to stimuli perceived
as threats. When our sense of security is threatened, our bodies elicit a cascade of biological
fight-or-flight responses that alter our physical and psychological functioning (115). Perceived
threats to safety flood our bodies with stress-induced hormones, including adrenaline and cortisol,
which elevate heart rate and increase blood pressure (10). Over time, these responses can take
their toll both psychologically and physiologically. Chronically elevated stress hormones suppress
immunity, which can exacerbate autoimmune diseases and other inflammatory conditions, whereas
elevated blood pressure levels can eventually lead to damaged arteries and plaque formation,
putting stressed individuals at greater risk of hypertension and cardiovascular disease (87, 118).
Buildings, by function, are designed to serve as safe havens from environmental and security risks;
in practice, however, they deploy a wide range of features that in some cases exacerbate threats to
safety and security.
Emergency preparedness is considered an essential feature of modern buildings. Fire and life
safety systems are integrated into buildings systems, drawing notice only when inadequate systems
or failures lead to catastrophic consequences. In terms of security features, well-designed measures
such as fences, locks, or secure entry systems have the potential to reduce fear of crime, whereas
evidence is limited for closed-circuit television (CCTV), multicomponent environmental crime
prevention programs, or regeneration programs (80). Perception of safety may be influenced by
the presence of uniformed security guards but only in situations when safety is perceived to be
inadequate without them (43). After enhanced security measures were introduced into Liverpool,
tower block buildings in the United Kingdom, fear of domestic crime was reported as being much
lower among residents relative to the greater population of Britain. These examples highlight the
efficacy of several safety features in buildings; however, research remains limited.
As CC continues to increase the risk of severe weather events (61), the built environment will
be subject to increasing environmental threats. Buildings with limited capacity to adapt during
extreme weather events impose a great risk of post-traumatic stress disorder and depressive, panic,
and anxiety disorders on their occupants (6).
Lighting and Views
Light exposure has visual and nonvisual effects on human health. The nonvisual effects of light
pertain to its role as the main environmental cue that directs biological circadian rhythms to the
24-hour light–dark cycle. These circadian rhythms synchronize the physiological and behavioral
processes in our body to the cyclic nature of environmental stimuli. With the advent of electrical
light, however, we have significantly altered the timing, intensity, and spectrum of light exposure
relative to available outdoor daylight. The phase-shifting effect of light can lead to circadian
misalignment, as observed in shift workers, and has been associated with an increased risk for
accidents, metabolic disorders, cardiovascular disease, and some cancer types (17, 18, 21, 107).
Conversely, selective light exposure timing, duration, spectrum, and intensity have been studied to
enhance alertness, increase productivity, and treat seasonal affective disorder and sleep disorders
(7, 69, 78, 126). Experimental light interventions have suggested moderate effects in slowing
the progression of neurodegenerative conditions and improving quality of life among the elderly
(110).
Visually induced health impacts include visual strain, eye irritation, and blurred vision from
uncomfortable glare, direct light input, high illuminance, and high-contrast conditions from light-
ing fixtures and computer screens (25). Photosensitive individuals (e.g., migraineurs) report light
intensity and flickering as nociceptive stimuli, even during nonepisodic migraine periods (121).
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Flickering at frequencies lower than 100 Hz has also been associated with impacts on visual search
performance and reading accuracy (65, 71). Furthermore, environmental psychology research has
been focusing on the restorative effects of aesthetic aspects of visual environments with biophilic
elements. Studies of classrooms with views of nature report that students experience faster recov-
ery from stress and mental fatigue, along with improved performance in attentional functioning
tests, when compared with windowless classrooms or classrooms with outer urban views (76).
Novel modeling tools have been developed to predict the visual and nonvisual lighting prop-
erties of a space (66). Thus developers in contemporary architecture seek to design buildings that
minimize the trade-offs between daylight penetration, glare, and excessive solar thermal heat gains
(7). Progress in solid-state LEDs (light-emitting diode light sources) has reduced costs and incor-
porated tunable spectrum features, facilitating the manipulation of light to promote desirable cir-
cadian phase shifting. In addition, light manufacturers, professional societies, and health-oriented
RSs are incorporating melanopic lux or melanopic/photopic lux ratios as new metrics to inform
decisions on lighting systems on the basis of the visual and nonvisual effects of indoor light. Given
the potential conflicting effects of lighting, choosing between enhancing alertness at the expense
of the melatonin-suppression-related health outcomes is a conundrum that will not be solved by
issuing simple recommendations (82).
Noise
In occupational settings, prolonged exposure to high noise intensity [>85 dBA (A-weighted deci-
bels)] is associated with hearing loss (16). Approximately 24% of Americans present with symptoms
of noise-induced hearing loss. Buildings act as structures that mitigate noise propagation from out-
door sources. Still, low-frequency noises can penetrate through structural elements. Even at low
noise levels, the nonauditory effects of noise include cardiovascular disease and sleep disruption.
Physiologic arousal in the autonomic, motor, and cortical systems has been observed from night-
time exposures to sound levels as low as 33 dBA (16).
Nocturnal noise is associated with shorter proportion of deep sleep and a higher propensity
for wakefulness. Additionally, it has a stronger association with cardiovascular disease than does
daytime noise exposure. The World Health Organization (WHO) estimates that sleep disturbance
constitutes the single most important cause of disability associated with environmental noise
exposure in highly urbanized societies. An annual increase of 1.6% is expected in the number of
people exposed to average noise levels from aircrafts exceeding 55 dBA (20). A 10-dBA increase in
noise levels from aircrafts increased cardiovascular-related hospital admissions in 3.5% (36). These
effects have major societal implications because estimates indicate that 145.5 million people in the
United States may be exposed chronically to levels higher than 55 dBA (51). Open windows and
bedrooms oriented toward the road have shown to increase cardiovascular and hypertension risk
(14). In office buildings, white noise generators are used to mask other noise sources to increase
concentration, under the hypothesis that a moderate arousal decreases one’s attention to cues
peripheral to the task in question (60). In schools, however, masking noise has shown contradictory
effects, affecting high-performance students at the expense of benefiting the lowest-performing
students (56).
Dust and Pests
Dust acts as a reservoir for a variety of harmful agents (27): outdoor particles that penetrate
indoors, viruses, bacteria, chemicals, allergens, building materials, dander, fabric fibers, and flakes
of paint with lead. Indoor exposures to contaminants residing in dust rely on three main pathways:
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(a) inhalation of resuspended dust, (b) direct dermal absorption, and (c) ingestion from hand-to-
mouth behaviors. In fact, occupants are surrounded by a cloud of resuspended dust as they go
about daily activities. This mass of dust that enters the body each day is relevant to human health.
Studies have documented that the amount of chemical that is present in indoor dust can be directly
correlated with the amount of chemical found in the blood of people who live and work in these
environments (135). Some of these agents (such as viruses) may exist in dust for only a few hours,
whereas others may remain in the dust for decades. Indoor dust is the primary route of exposure
for lead (129), which can accumulate in dust from flaked paint or lead-contaminated dirt tracked
in from outdoors. Unlike chemicals in the air, chemicals in dust, known as persistent organic
pollutants (POPs), can continue to expose occupants long after the sources have been removed;
examples include flame retardants, stain repellent, and plasticizers. For example, flame-retardant
chemicals can be found in many common furnishings and building materials used in schools.
Flame-retardant chemicals that are used in consumer products migrate out of those products into
air and dust (5). Many flame-retardant chemicals are endocrine-disrupting chemicals that interfere
with the reproductive system and are associated with thyroid disease (42).
Indoor allergens are typically harmless substances that we encounter every day. Common
household allergen sources include pet dander, pollen, mold, and pest and rodent excrement.
Particles containing these allergens commonly settle into carpets, drapes, soft furnishings, and
other locations where settled dust collects (40). A survey of 851 homes across the United States
found that more than half of the homes had at least 6 detectable allergens (112). When allergens
are inhaled or come into contact with eyes, they can trigger an immune response that leads to an
allergic reaction. Allergens can assist in the development and the exacerbation of asthma and nasal
allergies. In the United States, asthma causes 439,000 hospitalizations, 1.8 million emergency
room visits, and 3,600 deaths annually (29). Young children, the elderly, those who are genetically
predisposed, and low-income individuals are most vulnerable (2, 88). Poor IAQ can also aggregate
domestic allergen load (40, 105).
Pesticides are chemical or biological agents that kill or control common household pests (e.g.,
cockroaches, mice), microbial contamination (e.g., viruses, bacteria, protozoans), disease-carrying
outdoor pests (e.g., mosquitos, ticks, rodents), and other bacteria. Widespread pesticide use in
modern society makes it difficult to avoid exposure. The EPA reported that 75% of households use
pesticides in their homes, usually in the form of insecticides or disinfectants. They also found that
80% of most people’s exposures to pesticides were indoors and that significant levels of more than
one dozen pesticides had been measured in the air inside homes (125). Pest control chemicals such
as pyrethroids and organophosphates are toxic substances that have the potential to cause long-
lasting effects, even in low doses (32, 67). Pesticides have been linked to a wide range of human
health and environmental impacts but most often affect the nervous system. Symptoms may range
from mild (e.g., headache, dizziness, nausea, sweating) to moderate (e.g., excessive salivation,
blurred vision, muscular incoordination), to severe (i.e., inability to breathe, loss of reflexes,
unconsciousness, death) (123). In particular, long-term pesticide exposures have been associated
with a number of cancers (57, 133). Adequate ventilation, nonchemical methods of pest control,
and integrated pest management are suggested pathways to reduce indoor pesticide exposure.
GREEN BUILDINGS AND THE HUMAN RIGHT TO HEALTHY
INDOOR ENVIRONMENTS
Concurrent with the origin of the green building movement, the WHO issued a document rec-
ognizing that access to a healthy indoor environment is a human right (130; see the sidebar titled
Principles of Healthy Indoor Air). The document is intended to inform decision makers, public
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PRINCIPLES OF HEALTHY INDOOR AIR
P1. Everyone has the right to breathe healthy indoor air.
P2. Everyone has the right to adequate information about potentially harmful exposures and to be provided with
effective means for controlling their indoor exposures.
P3. No agent at a concentration that exposes any occupant to an unnecessary health risk should be introduced into
indoor air.
P4. Everyone associated with a building bears responsibility to advocate or work for acceptable air quality.
P5. Socioeconomic status should have no bearing on people’s access to healthy indoor air, but health status may
determine special needs for some groups.
P6. All relevant organizations should establish explicit criteria for evaluating and assessing building air quality and
its impact on health.
P7. Where there is a risk of harmful indoor air exposure, the presence of uncertainty shall not be used as a reason
for postponing cost-effective measures to prevent such exposure.
P8. The polluter is accountable for any harm to health and/or welfare resulting from unhealthy indoor air exposures.
P9. Health and environmental concerns cannot be separated, and the provision of healthy indoor air should not
compromise global or local ecological integrity or the rights of future generations.
Source: Adapted from Reference 130
health officials, landlords, property managers, architects, lawyers, individuals, and organizations
to ensure that healthy indoor environments are a human right for all. However, this report, along
with the literature documented in the summary of the nine foundational elements, has not been
enough to completely transform the building sector to design and manage buildings that promote
healthy indoor environments.
Transforming the building sector requires action for all classes of real estate. In this review, we
have focused predominantly on high-end real estate in developed countries. We should be mindful
that exposure to indoor pollution is still one of the most significant contributors to the global
burden of disease, primarily in the developing world (30). Massive attention is now being given
to the respiratory effects associated with the use of biomass for heating and cooking (e.g., China’s
100 Million Clean Cook Stove Program), and international aid organizations have been working to
improve combustion, incorporate exhaust ductwork, and introduce cleaner fuels. However, more
than 1.5 billion people are still being exposed to dangerously high levels of particulate matter and
carbon monoxide on a daily basis (106).
We face challenges in providing healthy IEQ while also confronting rapid urbanization (new
structures) and the renovation of the existing building stocks. Is it even reasonable to expect
that certification of green buildings, which has a limited niche of high-end buildings, and new
construction will make much of an impact? In 16 years, Leadership in Energy and Environmental
Design (LEED), the most prevalent green building RS in the United States, has certified 29,000
commercial buildings out of ∼5.5 million buildings (63). For green buildings to spearhead the
attainment of health in the built environment, their foundational elements must be within the
reach of all buildings.
Unfortunately, most of the examples in which many individuals have benefited from improved
indoor environments have come through banning a substance, setting product standards, or engag-
ing in wide-scale public education on such hazards as asbestos, radon, polychlorinated biphenyls
300 Cede˜
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(PCBs), lead paint, urea formaldehyde, and chlorinated pesticides. Smoking has been the one in-
door air hazard that has seen broad and substantial societal change: After 30 years of accumulating
evidence and two US Surgeon General reports, secondhand smoke was unequivocally recognized
as a public health risk. Public health evidence finally shifted the civic debate to guarantee the right
to smoke-free indoor environments.
Perhaps there is an opportunity to frame health-promoting indoor environments and expand
the green building movement in the context of sustainability, instead of the outdated version
of the three-legged stool of economy, environment, and society. A more relevant sustainability
framework posits that sustainability, inclusive of social well-being, is determined by the accessi-
bility to the planet’s capital assets (89). The authors suggest that society’s pursuit of sustainable
development since the first Rio World Conference in 1992 has been misguided by the myopic
examination of material and energy flows. Companies, cities, countries, and individuals wishing
to be responsible have established inventories, set goals, and managed the flows of water, waste,
energy, and resources. This effort has proven to be insufficient, considering that populations are
increasing, economies are expanding, and resources are diminishing. We will be resilient against
future disruptions only if we grow our human, natural, material, social, and knowledge capitals.
We reframe the purpose for green buildings as a transformational process to develop a health-
ier built environment. Within this framework, green buildings have demonstrated their ability
to contribute to the natural and manufactured capital assets (Figure 1). However, the greatest
Cycle of production
How green buildings contribute to each
Natural capital
Environmental
resources
provided by
Earth systems to
support life
Manufactured
capital
Infrastructure
contributing to
well-being by
facilitating access to
natural capital
Knowledge
capital
Conceptual and
practical knowl-
edge such as
general princi-
ples, information,
facts, designs,
and procedures
Social capital
Norms of
reciprocity and
trust in human
interactions such
as laws, rules,
and nancial
arrangements
Human capital
Demographic,
geographic,
economic, and
educational
status of the
population
Reduction of
natural resources
depletion;
preferred use for
local resources;
reuse and recycle
of materials
Low environmental
impact during the
life cycle of the
building; design,
construction, opera-
tion, and mainte-
nance practices
defending the basic
elements of a
healthy building
Research
platform for
evidence genera-
tion of health
benets of green
infrastructure;
establishment of
green building
cohort for longi-
tudinal studies
Development
and improve-
ment of building
codes, standards,
and certication
systems that rely
on continuous
measurement of
building
performance
Reduction in body
burden of chemi-
cals and chronic
disease; productiv-
ity benets;
improvements in
cognitive function;
promotion of well-
being and sense of
community
Developed capital
Needs improvement
Figure 1
Role of green buildings in the social-environmental sustainability framework. Adapted from Matson et al. (89).
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pending contribution of green buildings is expected to occur in the knowledge capital domain,
positively influencing the human and social capital assets.
With respect to knowledge capital, we consider that green buildings could become an evidence-
generating platform on which to conduct longitudinal cohort studies that support the epidemiology
of building-related health outcomes. In green buildings, the adoption of pollution source control
beyond the enforceable requirements directly appeals to two principles of The Right to Healthy
Indoor Air, the principle of nonmaleficence (avoiding chemical compounds that pose unnecessary
health risks) and the precautionary principle (delaying the introduction of chemicals with uncertain
health risks, until proven safe) (130). This approach constitutes a natural intervention adequate to
study the long-term effects of indoor environmental exposures on outcomes with a long latency
period, from which we know little at this time. Moreover, the shift from design- to performance-
oriented rating criteria would enable environmental exposure data collection at an unprecedented
level. Given the amount of time that individuals in modern societies spend indoors, these data could
inform a significant portion of the lifetime personal environmental exposures (i.e., exposome).
Strengthening the knowledge capital should inform decisions about how we interact with the
natural and manufactured capitals in the face of civilizational challenges, such as CC. As experi-
enced with the public health successes of the past (e.g., control of radon, lead, and secondhand
smoke), knowledge capital could catalyze changes in legislation (social capital) that foster the
well-being of the population (human capital).
CONCLUSION
Green buildings are a necessary, but not sufficient, component of the future of sustainable ur-
banization. Building for health is the paradigm of the future that includes a focus on ecosystem
health (green buildings) and indoor health (healthy buildings). The evidence presented here is but
a small fraction of the overwhelming evidence generated over the past 40 years that demonstrates
how buildings influence human health.
DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.
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Annual Review of
Public Health
Volume 39, 2018
Contents
Symposium
Commentary: Increasing the Connectivity Between Implementation
Science and Public Health: Advancing Methodology, Evidence
Integration, and Sustainability
David A. Chambers pppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp1
Selecting and Improving Quasi-Experimental Designs in Effectiveness
and Implementation Research
Margaret A. Handley, Courtney R. Lyles, Charles McCulloch,
and Adithya Cattamanchi ppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp5
Building Capacity for Evidence-Based Public Health: Reconciling the
Pulls of Practice and the Push of Research
Ross C. Brownson, Jonathan E. Fielding, and Lawrence W. Green pppppppppppppppppppppppp27
The Sustainability of Evidence-Based Interventions and Practices in
Public Health and Health Care
Rachel C. Shelton, Brittany Rhoades Cooper, and Shannon Wiltsey Stirman ppppppppppppp55
Epidemiology and Biostatistics
Selecting and Improving Quasi-Experimental Designs in Effectiveness
and Implementation Research
Margaret A. Handley, Courtney R. Lyles, Charles McCulloch,
and Adithya Cattamanchi ppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp5
Agent-Based Modeling in Public Health: Current Applications and
Future Directions
Melissa Tracy, Magdalena Cerd´a, and Katherine M. Keyes pppppppppppppppppppppppppppppppp77
Big Data in Public Health: Terminology, Machine Learning,
and Privacy
Stephen J. Mooney and Vikas Pejaver pppppppppppppppppppppppppppppppppppppppppppppppppppppppp95
Environmental Determinants of Breast Cancer
Robert A. Hiatt and Julia Green Brody pppppppppppppppppppppppppppppppppppppppppppppppppppp113
v
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Meta-Analysis of Complex Interventions
Emily E. Tanner-Smith and Sean Grant pppppppppppppppppppppppppppppppppppppppppppppppppp135
Precision Medicine from a Public Health Perspective
Ramya Ramaswami, Ronald Bayer, and Sandro Galea ppppppppppppppppppppppppppppppppppp153
Relative Roles of Race Versus Socioeconomic Position in Studies of
Health Inequalities: A Matter of Interpretation
Amani M. Nuru-Jeter, Elizabeth K. Michaels, Marilyn D. Thomas,
Alexis N. Reeves, Roland J. Thorpe Jr., and Thomas A. LaVeist ppppppppppppppppppppp169
Social Environment and Behavior
The Debate About Electronic Cigarettes: Harm Minimization or the
Precautionary Principle
Lawrence W. Green, Jonathan E. Fielding, and Ross C. Brownson pppppppppppppppppppppp189
Harm Minimization and Tobacco Control: Reframing Societal Views
of Nicotine Use to Rapidly Save Lives
David B. Abrams, Allison M. Glasser, Jennifer L. Pearson,
Andrea C. Villanti, Lauren K. Collins, and Raymond S. Niaura ppppppppppppppppppppp193
E-Cigarettes: Use, Effects on Smoking, Risks, and Policy Implications
Stanton A. Glantz and David W. Bareham ppppppppppppppppppppppppppppppppppppppppppppppp215
Increasing Disparities in Mortality by Socioeconomic Status
Barry Bosworth pppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp237
Neighborhood Interventions to Reduce Violence
Michelle C. Kondo, Elena Andreyeva, Eugenia C. South, John M. MacDonald,
and Charles C. Branas ppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp253
The Relationship Between Education and Health: Reducing
Disparities Through a Contextual Approach
Anna Zajacova and Elizabeth M. Lawrence ppppppppppppppppppppppppppppppppppppppppppppppp273
Environmental and Occupational Health
Building Evidence for Health: Green Buildings, Current Science, and
Future Challenges
J.G. Cede˜no-Laurent, A. Williams, P. MacNaughton, X. Cao,
E. Eitland, J. Spengler, and J. Allen pppppppppppppppppppppppppppppppppppppppppppppppppppp291
Environmental Influences on the Epigenome: Exposure-Associated
DNA Methylation in Human Populations
Elizabeth M. Martin and Rebecca C. Fry pppppppppppppppppppppppppppppppppppppppppppppppppp309
vi Contents
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From Crowdsourcing to Extreme Citizen Science: Participatory
Research for Environmental Health
P.B. English, M.J. Richardson, and C. Garz´on-Galvis ppppppppppppppppppppppppppppppppppp335
Migrant Workers and Their Occupational Health and Safety
Sally C. Moyce and Marc Schenker ppppppppppppppppppppppppppppppppppppppppppppppppppppppppp351
Mobile Sensing in Environmental Health and Neighborhood Research
Basile Chaix pppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp367
Public Health Practice and Policy
Commentary: Increasing the Connectivity Between Implementation
Science and Public Health: Advancing Methodology, Evidence
Integration, and Sustainability
David A. Chambers pppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp1
Building Capacity for Evidence-Based Public Health: Reconciling the
Pulls of Practice and the Push of Research
Ross C. Brownson, Jonathan E. Fielding, and Lawrence W. Green pppppppppppppppppppppppp27
The Sustainability of Evidence-Based Interventions and Practices in
Public Health and Health Care
Rachel C. Shelton, Brittany Rhoades Cooper, and Shannon Wiltsey Stirman ppppppppppppp55
The Debate About Electronic Cigarettes: Harm Minimization or the
Precautionary Principle
Lawrence W. Green, Jonathan E. Fielding, and Ross C. Brownson pppppppppppppppppppppp189
Harm Minimization and Tobacco Control: Reframing Societal Views
of Nicotine Use to Rapidly Save Lives
David B. Abrams, Allison M. Glasser, Jennifer L. Pearson,
Andrea C. Villanti, Lauren K. Collins, and Raymond S. Niaura ppppppppppppppppppppp193
E-Cigarettes: Use, Effects on Smoking, Risks, and Policy Implications
Stanton A. Glantz and David W. Bareham ppppppppppppppppppppppppppppppppppppppppppppppp215
Neighborhood Interventions to Reduce Violence
Michelle C. Kondo, Elena Andreyeva, Eugenia C. South, John M. MacDonald,
and Charles C. Branas ppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp253
Mobile Sensing in Environmental Health and Neighborhood Research
Basile Chaix pppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp367
Policy Approaches for Regulating Alcohol Marketing in a Global
Context: A Public Health Perspective
Marissa B. Esser and David H. Jernigan pppppppppppppppppppppppppppppppppppppppppppppppppp385
Contents vii
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Problems and Prospects: Public Health Regulation of Dietary
Supplements
Colin W. Binns, Mi Kyung Lee, and Andy H. Lee pppppppppppppppppppppppppppppppppppppppp403
Health Services
Achieving Mental Health and Substance Use Disorder Treatment
Parity: A Quarter Century of Policy Making and Research
Emma Peterson and Susan Busch ppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp421
Data Resources for Conducting Health Services and Policy Research
Lynn A. Blewett, Kathleen Thiede Call, Joanna Turner, and Robert Hest pppppppppppppp437
Designing Difference in Difference Studies: Best Practices for Public
Health Policy Research
Coady Wing, Kosali Simon, and Ricardo A. Bello-Gomez pppppppppppppppppppppppppppppppp453
How Much Do We Spend? Creating Historical Estimates of Public
Health Expenditures in the United States at the Federal, State, and
Local Levels
Jonathon P. Leider, Beth Resnick, David Bishai, and F. Douglas Scutchfield ppppppppppp471
Modeling Health Care Expenditures and Use
Partha Deb and Edward C. Norton pppppppppppppppppppppppppppppppppppppppppppppppppppppppp489
Promoting Prevention Under the Affordable Care Act
Nadia Chait and Sherry Glied pppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp507
Treatment and Prevention of Opioid Use Disorder: Challenges and
Opportunities
Dennis McCarty, Kelsey C. Priest, and P. Todd Korthuis ppppppppppppppppppppppppppppppppp525
Indexes
Cumulative Index of Contributing Authors, Volumes 30–39 ppppppppppppppppppppppppppp543
Cumulative Index of Article Titles, Volumes 30–39 ppppppppppppppppppppppppppppppppppppp549
Errata
An online log of corrections to Annual Review of Public Health articles may be found at
http://www.annualreviews.org/errata/publhealth
viii Contents
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