Green Heart: First Major Clinical Study to Examine the Health Impact of Trees

Tree in parking area under “Spaghetti Junction” near corner of 8th and Main St. Louisville KY/ Randy Olson

Louisville, Kentucky, has some of the worst air in the country. Given the city is a transit hub, tens of thousands of planes, trucks, and trains pass through the city each year, not to mention all the cars. Louisville is also an industrial center where chemicals are manufactured. Heart disease, strokes, asthma and other conditions caused by excessive pollution are found at very high levels. Last year, the city received a failing grade from the American Lung Association in its annual report.

In order to see if trees can help combat the negative health impacts of the city’s deadly air pollution, University of Louisville Medical Center, the Nature Conservancy, Hyphae Design Laboratory and other organizations are coming together in the Green Heart project, the first clinical trial where “nature is the pharmaceutical.”

According to the Nature Conservancy, “this ambitious effort will conduct a first-of-its-kind medical study by planting trees in strategic locations across a cluster of Louisville neighborhoods and observing precisely how they impact residents’ health.” The study is financed by the National Institutes of Health and Louisville-based philanthropies.

Dr. Aruni Bhatnagar at the University of Louisville Medical Center and his colleagues, who essentially created the field of “environmental cardiology,” are doing a controlled experiment to test the impact of nature, as if it was a drug, on a neighborhood scale.

The challenge is “a neighborhood is not a laboratory, where variables are easily controlled. And this project would be far beyond the scale of prior research that identified connections between neighborhood greenness and health.”

Bhatnagar said: “there has never been a rigorous scientific study that quantified the health effects of urban greening. This will be the first attempt to understand, is nature a viable, replicable therapy?”

This past October, the project has its official launch, with a community workshop and the start of baseline data collection. “Temperatures, particulate matter levels, volatile organic compounds in the air will all be tracked by a network of more than 50 passive air monitors as well as more elaborate monitoring arrays mounted on towers and even an electric car.”

Starting next fall, some 8,000 trees, shrubs, and other plants will be planted in South Louisville, according to a map devised by the Nature Conservancy, based in data on where likely impacts will the greatest benefit. As has been noted, trees catch small particulate matter in their leaves, reducing nearby air pollution by a third in some cases; and, if planted near highways, they can act as a buffer, reducing pollution by up to 60 percent.

The Green Heart project is now recruiting 700 neighborhood residents to “participate in several rounds of medical tests, tracking the residual evidence of air pollution in their blood and urine.”

The Nature Conservancy writes that “different chemical signals will be monitored, including the presence of cortisol and adrenaline that are produced when the body is under stress. Participants’ physiological reactions to air pollution will be studied over five years, because some compounds appear within hours of exposure while others take months or years to emerge.” Residents are essentially “human environmental monitors,” said Ray Yeager, PhD, a researcher with the University of Louisville Medical Center lab.

At the end of the five year study, the researchers will have a set of data on residents’ health — looking at both before and after the trees were planted, and, for comparison’s sake, data from people who live nearby but didn’t get new trees. It will be interesting to see if five years is enough to test the benefits of trees — newly-planted, young trees would appear to have less capacity to catch particulate matter and serve as buffers than mature, fully-grown trees with broad canopies.

Unhealthy air is estimated to claim 4 million lives a year. If Dr. Bhatnagar and his colleagues discover medical benefits from the strategic tree placements, the results of this study could result in a new public health model that can help reduce urban pollution-related deaths. Yeager is confident: “what we learn in Louisville is going to affect people all over the world.”

If benefits are proven, the study could also positively affect Louisville, reducing health inequities. The Nature Conservancy refers to data showing that life expectancy in the “leafy suburbs” of the city is 13 years longer than in South and West Louisville neighborhoods with lower incomes and less access to nature, proving once again that “zip code is a reliable indicator of health.”

If the results show positive benefits from trees, the city government should first address inequities and partner with local community groups to build robust tree canopies in the neighborhoods that lack them. With solid data, the city could also further invest in the existing urban forest, which loses about 55,000 trees every year.

Read the full article at The Nature Conservancy.

In Boston’s Leading Hospitals, Nature Is Part of the Therapy

Spaulding Rehabilitation Hospital, roof terrace designed by Hoerr Schaudt Landscape Architects / Steinkamp Photography

In the 1980s, Roger Ulrich discovered hospital patients recover faster and request less pain medication when they have views of nature. Spaulding Rehabilitation Hospital, built on a former brownfield in Charleston’s Navy Yard, and MGH’s Yawkey Outpatient Center, both in Boston, seem to be guided by this essential finding.

At Spaulding, patients recovering from traumatic injury are rejuvenated by good medical care, but also sunlight, garden terraces, and views of the surrounding Charles, Mystic, and Chelsea Rivers. The hospital landscape is a multi-functional therapeutic space where therapists aid patients in the air and sun. In a tour of the 132-bed facility at the 2017 Greenbuild, Jeffrey Keilman, an architect with Perkins + Will and Sean Sanger, ASLA, principal at landscape architecture firm Copley Wolff Design Group explained how the facility heals, but is also one of the most sustainable and resilient hospitals in the country.

Spaulding picked this brownfield site in part because rehabilitating it would help tell the story of resilience to its patients. If a toxic place can become a place of healing, then a broken person can return to health stronger as well.

The LEED Gold-certified hospital — designed by Perkins + Will, with Copley Wolff Design Group and Hoerr Schaudt Landscape Architects — has all the usual green building features, but its the extra, humane elements that make it something special — the custom-made sinks so that a patient in a wheel chair can more easily wash their hands; the tall wall of windows in the main rehabilitation room that offer views of the river; the light and views every patient enjoys from their rooms; the garden terraces with horticultural therapy spaces, as well as the gardens just for staff; and the multi-functional therapeutic landscape.

Spaulding Rehabilitation Center, designed by Perkins + Will / Anton Grassl/Esto
Spaulding Rehabilitation Center, designed by Perkins + Will / Anton Grassl/Esto
Spaulding Rehabilitation Center employee terrace, designed by Hoerr Schaudt Landscape Architects / Anton Grassl/Esto

The landscape — which was ingeniously designed by Copley Wolff Design Group to significantly reduce the impact of flooding in a 500-year storm event — is both for patients and the public. Like the building, the landscape has small but thoughtful features that exemplify patient-centered design.

For example, there are small brass sculptures of animals spread throughout. While these can be enjoyed by visitors and the public, they are really there for patients recovering from traumatic brain injuries who search for them in scavenger hunts in order to rebuild cognitive abilities and memory.

Starfish at Spaulding Rehabilitation Hospital, designed by Copley Wolff Design Group / Copley Wolff Design Group

A multi-functional space for physical therapy was designed for “active use.” Patients and caregivers didn’t just want “a space for respite and solitude. They wanted a space for activity, so they can get mentally and physically ready to re-enter society,” explained Sanger.

The space offers a “beginner’s walk,” with a slight grade and handrails. Throughout, there are benches, so patients can take a break.

Therapeutic landscape at Spaulding Rehabilitation Hospital, designed by Copley Wolff Design Group / Luke O’Neill

Sculptural rock forms on poles are actually therapeutic tools for building upper body strength.

Therapeutic landscape at Spaulding Rehabilitation Hospital, designed by Copley Wolff Design Group/ Luke O’Neill

Amid the gardens, there is also a ramp for teaching patients how to use a wheelchair.

Therapeutic landscape at Spaulding Rehabilitation Hospital, designed by Copley Wolff Design Group/ Luke O’Neill

In warmer months, the hospital puts recumbent bikes on the waterfront harbor walk. Rails along the walk were specially designed so people in wheelchairs can use them to pull themselves up.

Our tour then moved over to MGH’s Yawkey Outpatient Center, where cancer and other patients are treated in downtown Boston in a maze of co-joined buildings. Here was a therapeutic landscape that feels like the opposite of the one at Spaulding: a small but impactful place of respite and restoration.

As you enter the roof garden, which was added later after the building had been built, the broad trees and gorgeous views of the Charles River momentarily awe. The space is a welcome surprise in the midst of the vast hospital complex.

Yawkey Outpatient Center garden / Boston’s Hidden Sacred Spaces

Designed by Robert Adams, ASLA, principal at Halvorson Design Group, the garden is well-loved by adults and children undergoing cancer treatment.

The enclosed entry pavilion, with expansive glass windows, is open year round. Cancer patients often have a terrible, metallic taste in their mouth, so any metal fittings were painted over so as to not remind them. A journal is available for patients to write in. A giant urn is filled with rocks. Patients take the rocks to keep as touchstones; and survivors often bring back stones from their journeys, replenishing the urn, which has a “most sacred” duty, Adams said.

Yawkey Outpatient Center garden / Anton Grassl/Esto

And the garden itself, with its simple shade-covered walking loop, benches facing the river, and sculptures, is open in warm months. “You’ll often see patients with their IV in tow walking the loop.”

Yawkey Outpatient Center garden / Anton Grassl/Esto
Yawkey Outpatient Center garden / Anton Grassl/Esto

For Adams, the only wrinkle is the garden has become so popular staff can no longer easily access. Before, staff were eating lunch there and visiting often. This is a sign that “staff need open spaces, too.” As author Clare Cooper Marcus described in a recent interview, over-worked and stressed doctors and nurses means more deadly medical errors. Just a 15-minute break for these critical workers outdoors can help boost their cognition and lower stress.

Why aren’t more hospitals creating restorative spaces not only for patients but also for their staff? Spaulding and Yawkey, two of the best hospitals in the country, offer models for how to bring nature into healthcare environments that other facilities can learn from.

SITES Aims to Transform the Marketplace

ASLA 2017 Professional Communications Honor Award. Ecology as the Inspiration for a Presidential Library Park. Black Locust bridge. Michael Van Valkenburgh Associates / MVVA Inc

With the General Service Administration (GSA) and now the state of Rhode Island adopting the use of the Sustainable SITES Initiative™ (SITES®) certification system for landscape projects, SITES is gaining momentum. The system now has the potential to transform the marketplace for landscape products as well, explained Hunter Beckham, FASLA, a landscape architect; Meg Calkins, ASLA, a professor of landscape architecture at Ball State University; and April Phillips, FASLA, principal of April Phillips Design Works, in a session organized by ASLA professional practice manager Linette Straus, ASLA, at the 2017 Greenbuild in Boston.

Given SITES v2, which covers landscapes, and LEED v4, which covers all types of buildings, now have a number of synergies designers and developers can take advantage of, the potential market impact of SITES is even greater, Beckham said.

Calkins argued that it’s critically important landscape architects and designers leverage SITES to reduce the harvesting of Amazonian hardwoods for seating, decks, and boardwalks. “Some 18 percent of the Amazon has been cut down in the past 20 years.” With SITES, “we can transform the market away from tropical hardwoods.” SITES incentivizes this transformation with its prerequisites that “eliminate the use of wood from threatened tree species.”

For example, Ipe, a rare hardwood that appears once every 7-30 acres and is a signature species in the Amazonian rainforest, has often been used in landscapes because of its durability. But SITES — which refers to plants on the Convention on International Trade in Endangered Species (CITES)’s list of those threatened with extinction and the International Union for Conservation of Nature (IUCN) “red list of threatened species” — prevents the use of this endangered tree species in SITES-certified landscapes.

One big problem with the current approach, Calkins explained, is the “IUCN list is dreadfully behind.” Many tree species were last assessed more than a decade ago, so it allows many woods that are no longer plentiful, like Cumaru.

Another issue: In the Pará state of Brazil, some 28 percent of hardwoods are harvested illegally. Even some Forest Stewardship Council (FSC)-certified woods’ documentation is forged, with “shady chains of custody.” And while the Lacey Act is designed to prevent American companies from purchasing illegally-harvested rare Amazonian hardwoods, “fraud still happens.”

Instead of trying to find the few sustainably-harvested rainforest hardwoods, Calkins called for using alternatives like fused bamboo lumber, which is rapidly renewable and outperforms Ipe in durability; American Black Locust lumber, a hardwood native to the Ozarks and Appalachian regions and can be harvested in one-third the time of Ipe; thermally-modified woods, which are heated so they are twice as hard as the original wood and are disease resistant; polymerized woods, which has been developed in the European Union; and acetylated woods.

Furthermore, “landscape architects need to see environmental product declarations and quantifiable data” for all the products they are considering specifying. The architecture field is “way ahead” of the landscape architecture field in this regard of measuring and verifying the life cycle of products, as there are already a number of independent 3rd party product verification systems.

For Calkins, who researches the sustainability of landscape products, just finding basic information on wood products for landscapes is a challenge. “Corporate sustainability reports are a source of information, as are marketing brochures.” But, again, she is looking for independent 3rd party verification of any sustainability claims, and those don’t seem to exist for landscape products.

To shift the marketplace, landscape architects need to “ask more questions of product manufacturers, demand they disclose information and be transparent, and use environmental product declarations when specifying.”

According to landscape architect April Phillips, who has designed and built SITES-certified projects, the key is to track the sourcing of all materials from the get-go. In a “living roof native landscape” she created for 38 Dolores in San Francisco, she used 44 percent recycled materials and 60 percent regional ones.

38 Dolores / April Phillips Design Works
38 Dolores / April Phillips Design Works

And for a new, 1,500-acre landscape on the site of a former airport in Alameda, California, Phillips is reusing found logs as benches.

Phillips also made the case for environmental product declarations, claiming that too often the only ones she can find are from products made in the Netherlands or New Zealand. And importing these products to the U.S. only adds to projects’ carbon emissions and is discouraged in SITES.