by Valerie Gregg

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

He believes "smart growth" is the answer.

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

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