Maximizing the Health Benefits of Landscapes

Forest bathing in a Japanese cedar forest / Dr. Qing Li, via Hiking Research

Nature can make our daily lives, which are mostly spent in buildings, much better. With access to ample sunlight; lots of indoor plants; views of trees, green roofs, and gardens outside; and the incorporation of natural building materials, designers can boost our well-being and productivity. But our landscapes really are the places to create the deeply restorative connections so critical to our health. In a talk at the Biophilic Leadership Summit, hosted at Serenbe, an agricultural community outside of Atltanta, Julia Africa, program leader, nature, health, and the built environment at Harvard T.H. Chan School of Public Health‘s Center for Health and the Global environment, and Micah Lipscomb, ASLA, senior landscape architect with Perkins + Will, offered a few ways to maximize the health benefits of our landscapes.

Africa has been doing extensive research on forest bathing programs in South Korea and Japan. According to Africa, “forest therapy centers can provide a range of services, including health assessments and counseling, fresh local foods, hot springs, and guided walks through forests believed to have medicinal properties.” Spending time in forests can provide cognitive, emotional, and physical benefits, but she added there’s “some debate as to whether the benefits spring from physical (phytoncides, exercise), sensory, or social stimuli.” She said while Japan is perhaps more well-known for “Shinrin Yoku” at its centers, South Korea is catching up and may have the more ambitious long-term strategy.

According to Africa, Korea Forest Service plans to open 34 public healing forests and two national forest healing centers by 2017. The goal is to engage Koreans “from cradle to grave” by building a continuous, life-long relationship with healing forests. To perhaps counter the increasingly-widespread digital addiction experienced by Koreans, caused by their smart phones and ubiquitous high-speed broadband, they seek to create “forest welfare services, a system in which forests are used to create health and well-being for the welfare of the nation across various life stages.” Furthermore, “500 forest healing instructors will be trained to staff these centers. And interdisciplinary medical research is planned, with the potential to yield a staggering amount of data on forest bathers.” Africa seemed awed by the effort, wondering “how can we apply this to the United States?”

Japan has 60-plus forest therapy bases, with 100 planned in the future. With the help of her translator Hui Wang, she interviewed five managers of forest bathing centers to better understand how they work. She found that “some forest bathing centers have relationships with companies that have an interest in the region, either through commerce or personal relationships. Employees may be sent to the centers for a few days as a subsidized health amenity. Rudimentary ‘health checks’ for basic indicators like blood pressure, heart rate, reflexes may provide a point of assessment at the beginning and end of a forest visit. If they enter a guided program, a daily schedule may include educational sessions, therapeutic meals, and instruction on taking in the forest through all five senses. Sugi and Hinoki trees are particularly sought after features of the environment, as they are believed to produce phytoncides, a broad class of aerosols that some believe ward off pests and, also, coincidentally, benefit human health.”

Forest bathing in a Cypress forest / Dr. Qi Ling, via Hiking Research

Africa wanted to discover if the forest bathing centers are “linked — functionally or notionally — with any other therapeutic landscapes or facilities?” She found that “no, they are isolated experiences, and the healing experience is conducted in forest bathing parks only.” Learn more about her research.

Africa made another interesting point: our relationship with nature is evolving, because nature itself is in a dynamic state of change, particularly as the effects of climate change ripple through our ecosystems. “Simply examining what appeals to us about nature and why is too simple. We need to keep refreshing our understanding as nature keeps changing.”

Citing Roger Ulrich’s important study of how a view of trees in a hospital room reduced recovery times and pain medication use, Lipscomb focused us on Perkins + Will‘s work to bring nature into healthcare environments. At the Spaudling Rehabitation Center in Charlestown, Masschusetts, patients look out over where the Mystic and Chelsea Rivers meet or a green roof designed by landscape architects at Copley-Wolff Design Group. Other patients doing physical therapy have ample sunlight indoors or can go outside in the garden to do their routines.

Spaudling Rehabilitation Center / Perkins + Will
Spaudling Rehabilitation Center green roof / Perkins + Will
Spaudling Rehabilitation Center / Perkins + Will
Spaulding rehabilitation center garden / Copley Wolff Design Group

At the CARTI Cancer Center in Little Rock, Arkansas, patients in the cancer ward receiving infusions look out on a green roof designed by Perkins + Will.

CARTI Cancer Center / Nick Merrick

On a technical note: Lipscomb cautioned that maintaining biodiverse species of plants in a designed landscape can be challenging for maintenance workers, so either there needs to be a budget for long-term training and maintenance, or landscapes need to feature hardy plants. “Align your plants with the anticipated level of maintenance.”

Lastly, Lipscomb is working on building biophilic connections for his own office of landscape architects and architects at Perkins + Will in Atlanta. Those working hard to integrate nature into our daily lives now get to experience the same benefits themselves. Partnering with University of Notre Dame psychologist Kim Rollings, Lispcomb brought lots of plants into some parts of the office, but not others, and established a control group to test whether there are cognitive benefits from gazing at them. They’ll release their findings in The Dirt early summer.

A Joint Call to Action to Promote Healthy Communities

ASLA 2015 Professional General Design Honor Award. Mill River Park and Greenway. OLIN / Olivier Kpognon

Where we live, work and play can directly impact our physical and mental health. To more aggressively combat negative health factors such as obesity, diabetes, asthma, and anxiety, leaders of the nation’s built environment and public health organizations today pledged their support to promote greater collaboration to advance healthier, more walkable communities.

The “Joint Call to Action to Promote Healthy Communities,” brings together 450,000 professionals who recognize that the built environment — the way a community is designed and built from its buildings and public spaces to how we travel between communities — is a key determinant of health. Working together will create new momentum towards the common objective of creating and sustaining healthy buildings and spaces.

Providing options for how residents want to move around as well as encouraging physical activity can be achieved through a variety of ways. Solutions may include multi-use pathways for walking and biking, Complete Streets policies, equitable and affordable transportation and transit-oriented communities, implementation of green infrastructure, more efficient land, water and resource use, expanded tree canopies, and access to buildings with health-promoting indoor environments.

Improving community health also has a direct economic benefit. The Centers for Disease Control and Prevention (CDC) report 86 percent of health care spending in 2010 was for people with one or more chronic medical conditions.

“Public health is at the very heart of the landscape architecture profession,” said Nancy Somerville, Hon. ASLA, executive vice president and CEO of the American Society of Landscape Architects. “ASLA salutes this collaborative call to action and has committed to working with our partners to inspire positive change in the design of the built environment that can yield greater health benefits.”

The “Joint Call to Action to Promote Healthy Communities” specifically addresses four key points:

  • Creating and fostering partnerships that advance health;
  • Building an understanding of health data and establishing measurable health objectives for plans and projects;
  • Advancing policies, programs, and systems that promote community health, well-being and equity; and
  • Communicating the importance of health.

Read the full Joint Call to Action.

Organizations supporting today’s call to action include:

  • American Institute of Architects
  • American Planning Association
  • American Public Health Association
  • American Society of Civil Engineers
  • American Society of Landscape Architects
  • National Recreation and Park Association
  • U.S. Green Building Council
  • Urban Land Institute

Are Therapeutic Gardens Safe?

Legacy Family Birth Center Garden fountain / Brian Bainnson

Among hospital administrators, there seems to be a growing concern that therapeutic gardens can harbor diseases and spread them to those who have compromised immune systems. There was a case of Legionnaire’s disease spread through a water fountain, and soils can also be a source of some illnesses, but the fears are essentially unfounded, argued a trio of landscape architects at the Environments for Aging conference in Las Vegas. Good design and maintenance can eliminate the risks.

Leah Diehl, director of therapeutic horticulture, the Greenhouse at Wilmot Gardens, college of medicine at the University of Florida, said landscape architects should use “evidence-based knowledge to counter fears.” The evidence points to the incredible health benefits of being in nature. As such, the proven health benefits of “seeing, hearing, touching water” found in a fountain — such as reduced stress, lower heart rates and blood pressures, and an increased sense of tranquility — outweigh the near-zero chance of catching something. In terms of soils, yes, there are toxic bacteria that naturally occur in the mix, but there’s also mycobacterium vaccae, which some scientists think can play a role in reducing the effects of depression and anxiety.

For landscape architect Brian Bainnson, ASLA, “proper design can disrupt the process of infection.” For an infection to occur, there needs to be a pathogen, a susceptible host, and a mode of transmission. He argued that the Legionella bacteria, which causes Legionnaire’s disease, is more often spread through HVAC systems, spas, and jacuzzis than fountains. He said a “lack of maintenance allows the pathogen to grow.” He also said “there is no documented evidence of an infection from a healthcare garden.”

For a healing garden at the Legacy Emanuel Medical Center in Portland, Oregon, he designed a water feature with an integrated design team of physicians, therapists, hospital administrators, and maintenance workers to ensure there was no standing water when the fountain is off, and that patients can’t easily touch the water (see image at top). “Removing standing water is also good for vector control,” meaning it reduces places where mosquitoes can breed.

For another garden in the oncology ward of a hospital, Bainnson recommended administrators install Ultraviolet (UV) or flouridation systems to ensure the water is clean. It’s important in these instances to work with the maintenance staff to make sure those filters are tested and cleaned regularly.

For him, “the benefits of the fountains are too high, and they should outweigh any perceived risks.”

Diehl offered other examples: the Evanston Hospital in Illinois, which has a three-story fountain wall that ends in a pool, use sand filtration and chlorination and tests regularly to ensure the highest levels of water quality. And at the Glenbrook Hospital, also in Illinois, there is an entire water management team charged with infection control that tests the water in their fountains each month.

Glenbrook Hospital fountain / AIA

Jack Carman, FASLA, a landscape architect who focuses on senior care facilities, talked about the potential dangers of flora in therapeutic gardens, arguing that “not all plants are safe.” He said when using a plant in a healthcare setting, it’s important to know if “it’s toxic and highly injurious.”

It can get complicated because some plants may be only mildly toxic, or both medicinal or toxic depending on the interaction. For example, juniper has a medicinal use but its berries are toxic in large amounts. And some other plants are questionable, like daffodils, which are safe, but have toxic bulbs.

But there are some straight-out dangerous plants, like Foxglove, that shouldn’t be in therapeutic gardens. “Also, azaleas and rhododendrons don’t belong in a garden for Alzheimer’s patients.” Plants with extremely sharp edges, like hollies, or thorns, like rose bushes, obviously shouldn’t be found near where anyone is walking.

American-style Senior Living Comes to China

Cypress Gardens / China Senior Care

In China, traditional Confucian values dictate that children take care of their parents in their old age. It’s taboo to put your parents in a home. But from 1979 to 2015, Chinese parents could only have one child, which means there’s a whole generation of Chinese with four grandparents and two parents to take care of. To get around the taboo, China Senior Care, a company based in Shanghai and Hangzhou, launched a Western-style senior residential care facility. The idea seems to be if a facility doesn’t seem typically Chinese, perhaps the stigma associated with placing an elder in a home will be avoided.

At the Environments for Aging conference in Las Vegas, Jane Rohde, principal with Baltimore-based architecture firm JSR Associates and Jerry Smith, FASLA, design principal at SMITH | GreenHealth Consulting, walked us through the brand-new Cypress Gardens, in Fuyang, a suburb of Hangzhou. The project, which took eight years, is a private, 5-star senior care center, with just 64 beds, some for assisted living and some for memory care for patients with neuro-cognitive disorders. Each room rents for about $5,000 per month. There are community spaces, restaurants, a library, a theater for both relaxation and entertainment. In fact, it replicates a traditional American senior care facility model: the car-dependent, self-contained suburban facility.

China, like the West is rapidly aging. According to the Brookings Institution, there will be nearly 250 million people 65 and older in China by 2030. Today, Chinese seniors are essentially cared for during “extended hospital stays,” said Rohde. “It’s OK if it’s called VIP care. But it’s really out of the 1950s,” with rows of beds packed into one room. It will be interesting to see how the culture and current senior care models evolves as the country ages.

Cypress Gardens sits on a steep suburban site in the side of a mountain, which meant major grading challenges for Smith, and his design-build partner, Yumin Li, ASLA, with POD Design, Shanghai. To deal with the slopes, Smith built in layers of stone retaining walls in the form of step terraces.

Retaining walls and terraces / China Senior Care

A winding drive leads visitors up to the upper level entry. Smith said working with multiple Chinese contractors (two for the building and interior and one for the landscape) was a new learning experience — “just getting the drive and entrance to meet each other was a challenge.”

Many of the rooms have their own terraces. And surrounding the base of the 6-story building are a series of “outdoor rooms,” both public and private, where residents can be alone or socialize, or engage in physical activities like Tai Chi.

Cypress Gardens terraces and outdoor spaces / China Senior Care

Smith said the owners “didn’t want the character of the space to be Chinese. They wanted all new, all Western.” A water fountain on the south wall cascades into a pool, in an effort to achieve the “Bellagio Wow!,” the owners said they wanted.

Still, Smith delivered a tasteful landscape that manages to be packed with a mix of Chinese and Western landscape elements, from pagodas, to a bosque of gingko trees, and a labyrinth.

An outdoor room / China Senior Care

The pagodas mark the transition from the larger public spaces to the quiet memory care spaces, and can be “closed off for privacy and security as needed.”

Chinese children paying to have their parents stay at Cypress Gardens will see a “wonderful place with very high-end amenities,” Smith said. The facility opens in next month and it’s already mostly booked.

The Case for Humane Prisons

Construction of the amphitheater, Iowa Correctional Institution for Women / Iowa State University News Service

Long before anyone defined the field of environmental psychology, prisons were testing grounds for theories about how the design of the built environment could exert a physical and moral influence on people. In 19th-century England, the “Panopticon” prison design proposed a radial organization of brightly-lit and highly-visible cells around a dark central watch tower, to instill in prisoners the moral pressure and paranoia of constant social surveillance. In 21st-century Norway, prison buildings are separated by rolling hills and forests to promote frequent interaction with nature, and guards’ break rooms are cramped and uncomfortable to encourage them to spend their social time with inmates.

The distance between those approaches speaks to the struggle of societies to define the role of prisons as places for punishment or reform, for repentance or rehabilitation. It’s in this arena — fraught with moral undertones and with concerns about safety, accountability, justice, and injustice — that landscape architect Julie Stevens, ASLA, practices.

Stevens, an assistant professor at Iowa State University, has overseen three design-build projects at the Iowa Correctional Institution for Women, a medium-security prison in the small city of Mitchellville. Her approach to prison design is the same as for any community design: build relationships and recognize the humanity of the whole community, while honoring the voices of the most vulnerable — in this case the inmates, or “the women,” as Stevens referred to them most often during a lecture last week at North Carolina State University’s College of Design.

Stevens became involved at the women’s prison in 2011, when administrators were overseeing a $68 million expansion project that included no funding for design of the landscape. “The department of corrections wanted us to help them figure out where to put a few trees and shrubs,” Stevens said. “The prison was a lot of concrete, a lot of lawn, and essentially what happened is that a crew of about 12 women go out and start on one end of the prison with a cheap lawn mower and start mowing. And they push line after line after line, and when they get done, they start all over again.”

“We looked at this, and we thought, ‘We can do a lot better. We can make spaces more productive, more therapeutic.’”

The first design-build project was a limestone amphitheater flanked by two outdoor classrooms, a lawn mound, an aspen grove, and a constructed native prairie (see image above). Iowa State landscape architecture students designed the one-acre space with help from the women, and a team of students and inmates built the whole thing in one summer, using tons of donated gravel and limestone.

ASLA 2015 Student Community Service Award of Excellence, Landscapes of Justice. Students and inmates plant a tree, Iowa Correctional Institution for Women / Julie Stevens

During that first summer of construction, Stevens and her students noticed that prison staff tended to congregate at their cars after work, decompressing in the hot parking lot before driving home to their families. The next design-build project became a decompression deck for prison staff. When that was done, Stevens and her team created a healing garden to serve prisoners in the mental health unit. Now she’s building support for a design to serve the women and their children.

The projects are driven by the relationships Stevens has cultivated with prison administration, staff, and inmates. The designs accommodate administrators’ requests by promoting calm, creating functional spaces, and addressing security concerns — through open sight lines, for example, and the use of epoxy to keep limestone pieces fixed in place and unusable as weapons. The designs serve the women as daily spaces to gather and, during design and construction, as opportunities to build employable skills. But the effects are also more subtle.

“Some of these women have come from some pretty unthinkable situations, years of abuse. But when we’re in the garden and we’re working together, we have a single vision, we’re working toward a common goal, and we all get to be equal,” Stevens said. “Gardens are inclusive.”

The designs at the prison are informed by research on environmental preference and attention restoration theories, and Stevens has assembled a team of researchers to help capture the impact of the projects. They’re tracking protective factors, which are thought to reduce recidivism and which include demonstrations of teamwork and problem-solving. They’re also using surveys to keep track of the gardens’ effects on prisoners. Results so far suggest that being in the landscape makes the women feel calmer, more optimistic, and in greater control of their lives.

ASLA 2015 Student Community Service Award of Excellence, Landscapes of Justice. Prisoners experience the landscape, Iowa Correctional Institution for Women / Julie Stevens

For Stevens, who is a co-founder of the ASLA’s Environmental Justice professional practice network (PPN), those metrics are important. They start to illustrate the impact of the landscape in people’s lives, and they help make the case for corrections departments everywhere to invest in humane design.

But the root of her work at the prison, and in environmental justice generally, is deeper. It’s a belief — common to the history of thought on prison design — that the measure of a society lies in the treatment of its most vulnerable populations, that good design is important and should not be reserved for those with a voice. Stevens identified the solution at the end of her lecture: design and action driven by love.

“We have a lot of work to do. It’s really good work, and it’s really important work,” Stevens said. “We have to love and care for other people.”

This guest post is by Lindsey Naylor, Student ASLA, master’s of landscape architecture candidate, North Carolina State University.

New Senior Living Model Needed to Satisfy Aging Boomers

Crotona Senior Residences, Bronx, New York / Rendering by architectural firm of record: Magnusson Architecture and Planning PC, via Welcome to the Bronx

Senior living communities can either be car-dependent and isolated, or an urban or suburban “destination for experiences,” with proximity to transportation, services, arts and culture, restaurants, shopping, and personal development opportunities. Which community would you want to live in? The answer was clear in a session at Environments for Aging in Las Vegas.

According to Michael Hass, managing partner, Drive Development Partners, who is also a member of the Urban Land Institute’s senior housing council, from 1990-2009, senior living communities, mostly geared towards the World War I-era “silent” generation, were all about providing “a sense of security, peace of mind, ‘safety in numbers,’ and belonging.”

But in 2009, occupancy across the senior living industry dropped. This was a key year, the first year baby boomers (those born between 1946 and 1964) became consumers of these places themselves, not just shoppers of these facilities for their parents. Their views on the traditional places could be summed up with: “I’ll never live in a place like that.”

Starting in 2009, senior living developers saw new demand among some of the oldest baby boomers for communities with “flexibility, choice, a unique variety of experiences, and spending opportunities.” They don’t want the self-contained campus, “35 acres in a cornfield.” Hass said: “They want an individualized experience, not the same formal dining room every day.”

Sean Thomson, senior living director, CR Architects, said a new model is needed to reach the 75-million-strong boomers, and walkable urban communities could be it. Walkable urbanism is in demand among all age groups, but is particularly appropriate for seniors.

A report from the George Washington University school of business found that “walkable urbanism is gaining market share.” Furthermore, there is a 90 percent premium for walkable office space, 71 percent premium for retail, and 66 percent premium for multi-family housing.

A 2013 report from Fannie Mae found senior communities with a WalkScore above 80, which means they are walkable, had a “relative risk of default that is 60 percent lower.” Those communities with a WalkScore below 8, which deemed them totally car-dependent, had a “risk 121 percent higher.” As Thomson explained, “walkable communities have a real human impact, but they also have real financial results.” Places with WalkScores in the 60 and 70s have some services in walking distance, but those with scores of 90-plus are ideal.

The ideal walkable senior community is basically found in dense European and Asian cities, or New York City. Imagine an apartment complex in a highly walkable environment, open to the surrounding neighborhood, with ground floor shops, cafes, and restaurants, and close to multi-modal transit opportunities, parks, plazas, self-storage facilities, and co-working spaces. Instead of all these services provided within an isolated campus, they are distributed through the surrounding neighborhood.

Thomson said an urban environment can provide better quality and a higher range of restaurants than any isolated senior community can. Embedding a senior community in a neighborhood also enables that inter-generational contact, social integration, and intellectual engagement so critical to “successful aging.”

Thomson summed up the benefits of walkable urbanism for seniors: “you don’t have to build the amenities; they are already there.”

To make these kinds of communities happen will take some creative housing development strategies. Senior housing developers can partner with medical groups, physicians networks, hospital districts, religious institutions, fitness or wellness companies, or become parts of existing mixed-use developments. “Senior living developers are almost never the top bidders so they need to be part of mixed-use projects, attach themselves to bigger projects.”

In revitalizing second-tier cities, senior housing developers have a real chance, particularly if they piggy-back on mixed-use developments where it’s advantageous to have a set of new fixed-income resident buyers all in one place. “Senior living communities can become an asset to a community.”

Senior housing developers can remake under-performing hotels or extended-stay hotels, or B and C class multi-family housing. “They can partner instead of acquire.”

Also, Thomson can even see universities and colleges building nearby housing for retired alumni who want to return to the area.

They created a vision of a 2.5-acre urban senior development with medical facilities, spa, club, street-facing “fast, fresh” restaurants, shops, a playground, grocery store, and housing for 100-200 residents. “It wouldn’t be adult daycare, but a place where people enjoy themselves.” Perhaps this model could be deemed senior or grey urbanism?

When asked where this comprehensive vision is actually happening in the U.S., both Thomson and Haas said “some elements are happening incrementally, but not all together.”

Empathize and Then Design

Virtual dementia tour / The Davis Enterprise

“Dementia used to be viewed as a psychological problem, a mental illness. There was a stigma associated. Now, we know it’s an organic problem related to cell death in the brain. It’s a medical condition,” said P.K. Beville, founder of Second Wind Dreams, at the Environments for Aging conference in Las Vegas. Dementia, which includes diseases like Alzheimer’s, some forms of Parkinson’s, Lewy body disorders, and others, is now called a neuro-cognitive disorder. It affects more than 5 million Americans and their families.

Throughout the conference, perhaps the major focus was how to orchestrate a shift to more empathetic or patient-centric care for those with neuro-cognitive disorders. Just like with autism, it’s now understood there is a spectrum of neuro-cognitive disorders. One person with the disorder is really one person with the disorder. Designers, physicians, and researchers are partnering to better understand what it’s like to have a neuro-cognitive disorder and then create more sensitive processes and empathetic spaces that can help alleviate the pain these patients experience while institutionalized in memory-care facilities.

With these disorders, there is a loss of cognitive abilities. Our ability to hear, speak, read, and understand come from different parts of our brain. If there is cell death in these areas, then forging understanding connections with others becomes much more challenging. For many of these patients, long-term memory may be intact, but not short-term episodic memory. Also, semantic memory, which deals with abstract concepts, and procedural memory, which helps people remember how to get from point A to B, may be damaged. With the loss of abstract memory, “the goals or intentions of life is lost,” explained Terry Zborowsky, a researcher with HGA architects and engineers in one session, which is why they need “so many cues from the environment.” The loss of procedural memory means those care environments become incredibly confusing, so designers must be really thoughtful to make them more legible.

In her keynote, P.K. Beville said she wants caregivers to better understand why patients with neuro-cognitive disorders behave the way they do. When this is achieved, we can create spaces to better meet their needs. For example, Alzheimers patients in advanced stages “don’t get warning signals when they have to go to the bathroom.” All of the sudden it just comes on and they have to go. If the bathroom is far away, they may miss it and then be labeled incontinent and placed in briefs. “That’s a horrible threat to their dignity. How can we get them to their bathroom faster?” Some ideas: make the bathrooms more easily accessible via hallways, instead of hiding them, and put them in direct line of sight from beds.

Patients with neuro-cognitive disorders often have macular degeneration, which will put a large black spot in the middle of their vision. Their peripheral vision will also be significantly degraded. Their field of view is then limited to just a few feet, which is why they often look down to see where they are going. Beville said, knowing this, “it’s really silly that caregivers are still sitting to the sides of patients when they feed them. Imagine this fork flying out of space into your mouth.” When a patient balks or refuse to eat, they are then labeled difficult and that behavior gets “charted.” It makes much more sense to sit directly in front of the patient and create dining spaces that enable this.

In neuro-cognitive patients, degeneration of the reticular activating system is “what’s causing all the mess. It removes what’s important, causing a loss of focus. When this area of the brain is damaged, the brain picks up all sensory input, relevant or irrelevant.” These patients will hear everything — a door being slammed, a vacuum cleaner, a TV, and even the HVAC system. A dog barking or baby crying will be incredibly painful. When these patients are overwhelmed, they will begin to rock or become agitated. It’s important that memory care facilities then eliminate all sounds that can cause an annoyance. “The dining room can become a cacophony of sound. No wonder the residents don’t want to eat.”

Beville has created an amazing virtual reality tour that demonstrates what it’s like to have a neuro-cognitive disorder like Alzheimer’s. Working with leading medical professionals, researchers at Georgia Tech, and patients, she modeled the effects using goggles, which layers the effects of macular degeneration on whatever you are looking at; gloves that reduce fine motor skills; and headphones that mimic the aural sensory overload these patients can experience. Some two million caregivers in senior facilities have taken the tour.

At the conference, she modeled the newest iteration of the tour using Samsung Gear virtual reality (VR) headsets, instead of goggles, which augment a user’s field of view. The woman who tested it said it was a “terrifying experience.” She said she had “no perception of depth or peripheral vision; it was very hard to hear. I was very, very anxious.”

Studying the responses of the caregivers who have taken the tour, Beville found they exhibit the same behavior as those with Alzheimer’s and other neuro-cognitive disorders. They mumbled or hummed in an attempt to focus and block out the extraneous noises. They were agitated, wandered, rummaged, made negative statements that indicated they felt overwhelmed or depressed. Just 8-10 minutes in the headset caused some to have “strange or bizarre behavior.” Now imagine someone struggling with this condition for years.

Through the tours, Beville found older patients with this condition need “three times the light to see than younger people.” So facilities and their landscapes need to be well lit. The reaction time of the pupil is also delayed, so any changes in lighting causes major issues and should be avoided. Noise needs to be reduced to eliminate distractions. And patients want clear guidance — “something to do” — to help them focus.

After taking the tour, more caregivers agreed with the statement that neuro-cognitive disorder patients “don’t get the care they need.” The tours then help facilities begin to institute performance-based systems to improve quality of care. After taking the VR tour, caregivers say they will be “more patient and understanding with patients, will take more time and provide more attention, and communicate better.” Beville and her group are measuring the changes before and after sensitivity training to demonstrate improvements, which can be measured in adaptive behaviors among patients (engagement, communication, wayfinding, and social integration) and maladaptive behaviors (aggression, confusion, disorientation).

In another session, we heard how to take empathetic design to the next level. Architect Alana Carter, with HGA architects and engineers, explained how she checked herself into a healthcare facility she was redesigning, pretending to be a stroke victim with degraded capabilities on her entire left side. She was fed, washed, and helped in the bathroom. She called the experience “extremely humbling,” but it gave her insights into what needed to be done better from a patient point of view.

Carter and her colleague Zborowsky called for “walking in the footsteps” of patients first, using a comprehensive design methodology to uncover design solutions that will improve environments for aging. Their teams put GPS tracking devices on staff and patients and apply sensors that generate heat maps to understand the flow and popularity of areas in a facility. This kind of analysis can reduce inefficiencies in layout and help discover what features patients feel most comfortable around. Using VR headsets, HGA then prototypes Revit designs of new spaces in real-time, working with caregivers to optimize layouts and features. Finally, they test implemented designs through comprehensive pre- and post-occupancy reviews.

Carter concluded: “We need to move design for seniors out of the care facilities and into museums, galleries, movie theaters, and the home. We need to bring empathetic design to all places. We need to design for the outliers.”

We Must Better Communicate the Health Risks of Climate Change

Climate change march / Safety Messenger
Climate change march / Safety Messenger

“Climate change is a complicated topic, which makes it anathema to clear communication,” explained Dr. Ed Maibach, who runs the center for climate change communication at George Mason University. At the climate and health summit at the Carter Center, Maibach said most Americans associate climate change with “plants, penguins, and polar bears,” and view it as a “22nd century problem.” Climate change is seen as a “scientific, environmental, and political problem, but not a public health one.” Given only about one-third of Americans are environmentalists, framing climate change as a health problem first and foremost could help spur more action. Everyone is concerned with the health of their communities and children.

Maibach is seen as a leading expert on climate change communications. His advice for how we can better reach the public is practical: “the less you say, the more you’re heard; say the things that have the most value; and use audience research to determine which messages have the most value.”

When crafting communications messages, it’s important to “repeat things over and over again,” adapt key messages, reinforce them, but also find a variety of trusted voices, like doctors and nurses, to convey them. “Aim simple, clear messages at target audiences. They will then share with their family members and friends.”

Maibach has been studying what messages will work with various segments of the public. He found there are a number of different Americas. “About 18 percent are alarmed by climate change, 34 percent are concerned, 23 percent are cautious, 5 percent are disengaged, 11 percent are doubtful, and 7 percent are dismissive.”

The messages that will resound with more of these groups include: “(1) 97 percent of climate scientists are convinced human-caused climate change is happening; (2) climate change is already harming our health now. All of us can he harmed, but some are more likely to be harmed, like children, the elderly, pregnant women, student athletes, the sick and poor; and (3) reduce energy waste and embrace clean energy, so we can clean up our air and water.” Maibach said even “the dismissive segment gets that last point, as many of them are enthusiastic about renewable energy.”

Dr. Susan Pachecho, University of Texas Health Science Center, said instead of focusing on tailored messages, communicators must create narratives with personal stories that really connect. “Stories of patients work. Less is better.” She also called for using the humanities — fiction, poetry, art, and music — to better reach students on the health risks of climate change.

And one of the most intriguing speeches came from Jerry Taylor, head of the Niskanen Center, and a Republican who was a climate denier at the Cato Institute for decades before he saw the light and started to believe the science. Taylor explained how to reach Republicans, who really are the ones who need to shift their views if we are going to have more support for climate action. “Democratic opinion on the left and center has been there [supportive of efforts on climate change] for 25 years. Republican opinion: What will move them?”

Taylor said “for the most part, tribal political leaders guide public policy. What drives Republican opinions on climate change are Republican political leaders.” In 2008, Senator John McCain promoted a cap and trade program to reduce carbon emissions. Positions have shifted farther to the right in just under a decade, as neither presidential candidate Mitt Romney or Donald Trump put forth any climate plan. (But, still, 49 percent of Trump supporters agree climate change is happening, and 62 percent want to see emissions regulated).

What’s needed are a few more McCains, Republican tribal leaders who will show some leadership on the issue, just like former Secretaries of State James Baker III and George Schultz, along with former Secretary of the Treasury Henry Paulson did with their call for a revenue-neutral carbon tax.

To reach more Republican and grow more of these leaders, Taylor advised against using phrases like “massive socio-economic transformation.” He said “that’s not going to happen, and Republicans like capitalism and the 21st century as it is.” Also, “unleashing the government,” like the environmentalist Bill McKibben has proposed, with a sort of New Deal for a new green economy, also isn’t going to fly, as that would be viewed as a “war on the economy.” He said for Republicans, “it’s not about the debate on the climate science,” but fear of government control of the economy.

Taylor also urged Democrats “not to overplay certainties. There is less knowledge of future scenarios” than many would like. “Will we reach a new climate stability in 60 years or 3-4 centuries? Will temperatures level out at a 1.5-3 Celsius or 8-10 Celsius increase? There is a lot we don’t know about how bad it will be.”

Instead, “risk management works well on Capitol Hill. There is a big distribution of possible outcomes, with one option being ‘no impact,’ and another being ‘big impact.'” Advocates can present the “most likely outcomes,” which will encourage Republicans to hedge their bets. Also, discussing the co-benefits of fighting climate change, like improved health, works. For example, we can have a cleaner and healthier planet.

But “de-industrialization, raising energy costs, massively increasing government spending — we don’t need to do this. Harnessing the market is a near-universal remedy that Republicans can put into play.”

The Climate + Health Challenge: “We Have the Solutions” (Part 1)

Wind and solar installation / Stanford University News
Wind and solar installation / Stanford University News

If we don’t reduce the billions of tons of carbon dioxide pouring into the atmosphere each year, there will be significant health impacts, argued former Vice President Al Gore and some of the world’s leading scientists, at a summit organized at the Carter Center in Atlanta. The first half of the conference explained the challenges facing the world if we surpass an increase of 2 degree Celsius (3.6 degree Fahrenheit), which is seen as a key thresh hold: the accelerated spread of infectious diseases, less nutritious food, more challenging mental health problems, and more dangerous air pollution. In the second half of the day, Gore and others offered some solutions — to mitigate climate change, and thereby reduce expected health impacts, and better anticipate and manage the coming public health challenges.

After hearing so much doom and gloom, Gore said “we have the solutions at hand. Hope is justified.” Just a few decades ago, environmentalists hoped we would achieve 30 gigawatts of wind power by 2010. In 2017, we have achieved 17 times that amount. The estimates were for 18 gigawatts of solar power by 2010. In 2017, we achieved 77 times that number.

Gore explained that three-fourths of new energy plants being created around the world are either wind or solar. And coal has fallen out of favor in many countries. India has issued a new policy that will stop all coal plants moving forward. China is retiring old coal plants and put a moratorium on new ones.

In addition to the climate benefits, there are real health benefits to shutting down coal plants. As has been described, coal energy generates more air pollution than other sources of energy, shortening lives. In his talk, Sir Dr. Andy Haines, London school of hygiene and tropical medicine, explained how a “7 percent increase in clean energy investments can save 3 million lives by 2040.” He said President Obama’s clean energy plan would avoid 175,000 deaths, while the tougher vehicle emissions standards finalized in the final days of the Obama administration would save another 125,000 lives. “The health benefits of this offset 25-1050 percent of the costs,” depending on how you calculate them.

Haines called for fixing CO2 prices worldwide, around $20-100 per ton, in order to create a consistent and transparent tax on pollution. “A tax wouldn’t have to be an overall increase. It could be non-regressive.” In Sweden, a ton of carbon now costs $160, but the country has still seen growth and is now shifting to a low-carbon economy. Unfortunately, only 12 percent of the world’s emissions are now covered by a pricing scheme. Furthermore, most of the world currently rewards fossil fuel production, as governments give oil, coal, and gas companies some $5 trillion in subsidies per year.

The world’s cities account for 85 percent of the world’s economy, and some 71-16 percent of global carbon dioxide emissions. If cities can reduce their emissions, as many are working on doing so, we can make a great deal of progress, regardless of the politics of any country. Comparing Atlanta and Barcelona, which each have about 2.5 million people, Haines demonstrated the potential emission reductions that could happen with better urban planning and design. In Atlanta, which is some 7,000 square miles, each car-owning resident spews out 7 tons of carbon each year. In comparison, Barcelona, which is just 648 square miles, each person release less than 1 ton of emissions a year. Barcelona is far more walkable and bikeable with more public transit, and cities like Atlanta need to become like Barcelona much faster. Not only is walking and biking better for the environment, but there are also major health benefits. And for those who don’t have the strength to bike, Haines made the case for e-bikes. (In another talk, Laura Turner Sydell, board member of the Turner Foundation, said “Atlanta has come light years in the past 20 years,” but still has much further to go).

Trends of urbanization in Atlanta and Barcelona / Morphocode
Trends of urbanization in Atlanta and Barcelona / Morphocode

Carbon dioxide stays up in the atmosphere for 1,000 years. But we can target short-lived pollutants now to reduce some of the worst climate and health impacts. Haines called for targeting black carbon, methane, tropospheric ozone, and HFCs. “Regulating these gases can keep us well below a 2 degree Celsius increase.” Black carbon can be reduced with the distribution of clean cook stoves, which also cut back dangerous indoor air pollution. Cows are a major source of methane. In 1961, there were 2.4 billion of these ruminants; today, there are more than 3.8 billion of them. Encouraging a more vegetarian or vegan diet can reduce methane emissions without changing overall dietary profiles much. And methane from natural gas production and landfills can be easily captured and reused as fuel.

Forests are another important part of the solution. “Forests reduces air pollution, clean water, decrease malaria transmission and other disease risks,” while serving as important carbon sinks and sources of biodiversity. “We need to have stable forests to stay below a 2 degree increase.”

For the first time, carbon dioxide emissions have been flat the past two years, despite the fact that world economy grew, Gore said. “Carbon dioxide emissions are going to start to go down. But we aren’t solving the crisis fast enough.”

For that to happen, Gore is pushing for more solar and wind capacity. He thinks renewable energy sources are good for the U.S. economy. “Solar jobs have grown 12 times, more than any other energy sector.” He also called for retrofitting buildings to make them more energy efficient. “Those jobs can’t be outsourced.” And as Haines explained, “cutting building-related CO2 emissions could prevent some 5,000 deaths” by reducing air pollution.

The UN Paris agreement to limit carbon emissions requires states to provide an update on their progress every five years. The idea is to use these five-year marks to ratchet up expectations and actions. Countries are already preparing for the first five-year mark in 2021, Gore said. Unfortunately, it’s unclear whether the Trump administration will continue to meet the obligations of the agreement.

Read part 2.

The Climate + Health Challenge: “We Have the Solutions” (Part 2)

pollution
US Embassy in Beijing air pollution monitor app / Digital Journal

If we don’t reduce the billions of tons of carbon dioxide pouring into the atmosphere each year, there will be significant health impacts, argued former Vice President Al Gore and some of the world’s leading scientists, at a summit organized at the Carter Center in Atlanta. The first half of the conference explained the challenges facing the world if we surpass an increase of 2 degree Celsius (3.6 degree Fahrenheit), which is seen as a key thresh hold: the accelerated spread of infectious diseases, less nutritious food, more challenging mental health problems, and more dangerous air pollution. In the second half of the day, Gore and others offered some solutions — to mitigate climate change, and thereby reduce expected health impacts, and better anticipate and manage the coming public health challenges.

A number of scientists called for boosting the amount of climate change adaptation funds that go to health. Of the $1.2 billion collected for adaptation by the United Nations, only 2 percent of that goes to health measures, said Dr. Kristie Ebi, University of Washington. And, unfortunately, there is almost no serious research being conducted on the health impacts of climate change.

Dr. Rainer Sauerborn, Heidelberg Institute of Public Health, made the important point that there is no one-sized-fits-all solution for climate adaptation. Every community’s challenges will be unique, which means support for local research and action is vital. He wondered why there were no researchers from the Middle East or Africa at the conference.

Public health officials made the case for increased spending on public health surveillance and early warning systems. In Beijing, for a period of time, the U.S. embassy provided the one reliable indicator of air pollution levels in the city. Its feed has spurred activism and Chinese government action to better monitor and reduce air pollution. If more developing world cities had more reliable air pollution monitoring and alert systems, those particularly vulnerable to poor air could be instructed to stay inside on really bad days. These systems also generate demand for air quality improvements.

With more funding, public health organizations can better monitor disease threats as well. For example, the European Center for Disease Control and Prevention (ECDC) is monitoring the precursors of vibrio, an aquatic pathogen, explained Dr. Jan Semenza, and sending alerts to communities before a vibrio outbreak strikes. Testing the system against Swedish data, they’ve found “there is an epidemic signal we can predict.”

Dr. Howard Frumkin, University of Washington, a leading environmental health specialist, and co-editor of Making Healthy Places, called for doctors and scientists in the public health field to seek partners “outside their comfort zones” and reach out to those working on the built environment, like planners, landscape architects, and architects.

The Centers for Disease Control and Prevention (CDC) was represented by Dr. George Luber, who explained the tools the CDC has available for communities planning for health impacts, such as the Building Resilience Against Climate Effects (BRACE) framework, which also includes technical assistance. Luber said the role of the CDC is to provide accessible scientific guidance and decision-making support tools.

But it’s important that all communities get support for dealing with their climate and health challenges in the future. Catherine Flowers, with the Alabama Center for Rural Enterprise, said parts of Alabama were like a “third world country,” with sewage bubbling up and contaminating front lawns. “This is where environmental justice and climate intersect.”

And Gary Cohen, Health Care Without Harm, thinks the healthcare sector can come together as a single force for good. Given the sector accounts for 17 percent of the U.S. economy, it’s poised to play a lead role. Gundersen Health in Wisconsin, which was almost entirely fueled by coal a few years ago, now runs on power generated from wind and bio-waste. Cohen said in more than 200 cities, the healthcare sector is the biggest employer. Associations of these firms are moving to renewable energy and divesting from any fossil fuel stocks.

These companies can help shift the U.S. to a more sustainable, less polluting form of energy production, and speak out about the health risks with climate change. “If we mobilize the health community, we have a massive army at hand. Doctors and nurses are among the most trusted people in America. We will be unstoppable,” argued Cohen.

However, despite all the positive talk about how we can manage the coming challenges, many scientists at the conference agreed that there are many “unknown unknowns” looming out there. For example, there are new worries about the micro-organisms now dormant under the vast permafrost. Just ten years ago, no one knew the nutritional value of many important crops would be reduced in a higher carbon atmosphere. What other impacts are lurking out there? There is much that still can’t be predicted. 

The most important investment now may be to dramatically boost funding on scientific research, and monitoring and early warning systems.