Healthy Buildings on the Horizon
Healthy Buildings on the Horizon
Healthy Buildings on the Horizon

Healthy Buildings on the Horizon

Chris Sweeney | Spring 2020

From fighting coronavirus to boosting cognitive performance, Joe Allen thinks clean buildings will be the next public health revolution.

Skyscrapers in Wuhan. Crammed cabins on the Diamond Princess cruise ship. A nursing home in Kirkland, Washington. A conference room at a Boston hotel.

Like many people, Joseph Allen was horrified by the diverse launching pads of coronavirus and the lethal path it cut in the early days of the pandemic. Allen, an assistant professor of exposure assessment science and director of the Harvard Chan School’s Healthy Buildings Program, had been following the epidemiology of the virus closely. He understood the magnitude and enormity of what was unfolding and was looking for clues. While the hotel conference room, the cruise ship, and the nursing home were all distinct focal points spread thousands of miles apart, they offered an important lesson: The buildings we inhabit play a crucial role in the spread of COVID-19, the illness caused by the virus.

“Each instance was different, but they all reminded me of the more dramatic forensic investigations I’ve done where the prevalence of illness is so striking and so high that it indicates the building is playing a key role in disease transmission,” Allen says during a telephone interview in late March from his home in Brookline, Massachusetts, where he, his wife, and three children are cooped up like hundreds of millions of people across the world. “That was the first hint to me that multiple modes of transmission—small droplets, contaminated objects, airborne routes—were happening. And it was clear to me that we needed to be doing everything we could in our buildings—our homes, our hospitals, our schools, even our airplanes—to address all three possible routes.”

Before joining the Harvard Chan School in 2014, Allen worked as a forensic investigator of “sick buildings.” One week he’d be studying whether a series of infant deaths on a military base was linked to poor building construction, the next week he’d don a hard hat and work with engineers to trace a maze of pipes and ducts to pinpoint the source of a deadly Legionnaires’ disease outbreak in a hospital. In each situation, lives were at stake and Allen had to work with limited information to determine whether a building was safe at that moment. “We had to make decisions based on the best available evidence of the situation and the best available science, and we’d have to follow the precautionary principle,” he says. “The last question I always asked myself was, ‘Would I let my wife or kids be in this building?’”

These investigations made Allen acutely aware of everything that could go wrong in buildings. They also showed him that even the sickest building could be revived. “Eventually, I started to see a new path forward,” he says. “I recognized that buildings can promote health.”

Over the last six years, Allen and his team have built up an impressive body of research on the myriad ways in which buildings affect human health, from cognitive performance to the spread of infectious diseases. A 2019 study by José Guillermo Cedeño-Laurent, a research fellow and associate director of the Harvard Chan School’s Healthy Buildings Program, and co-authored by Allen and colleagues, examined electronic medical records of a college health clinic and found that students who lived in dorms with more square footage per occupant and better ventilation systems had significantly lower rates of upper-respiratory infections compared with students who were in older, more-crowded housing facilities.

More recently, Parham Azimi, a postdoctoral fellow on Allen’s team, has been working with him to develop models of measles transmissions in elementary schools. Early findings show that buildings with enhanced ventilation and air-filtration systems have the lowest transmission risk— and that when these systems are combined with typical infection- control strategies, such as vaccines, they can cut the average number of infections among all students in half. He and his team are now working to turn this model about measles and schools into a model for coronavirus and various indoor settings, including hospitals, schools, offices, and homes.

“We’re not helpless,” Allen says. “We know strategies that we can deploy in our buildings and homes to help minimize disease risk and buy more time for front-line health workers so they are not overwhelmed in hospitals around the world and for scientists who are racing to develop treatments and vaccines.”

Since January, Allen and his team have been working tirelessly to get their research into the hands of anyone who can use it—from homeowners to commercial landlords to epidemiologists. He has penned op-eds in the New York Times, Financial Times, Washington Post, as well as two in USA Today with Marc Lipsitch, professor of epidemiology, on how simple steps like improving ventilation and using air purifiers and humidifiers can help reduce the spread of COVID-19. Allen and his colleagues are reexamining data sets from the dormitory study and a study of offices led by doctoral student Emily Jones to better understand the environmental factors that boost the risk of upper-respiratory infections.

He’s asked journals to waive fees and make pertinent research open-access. He connected with CEOs to get the business community engaged on the topic, established a collaboration with a renowned architectural firm to start thinking about how schools can be enhanced once students return, and is co-chairing a new task force on buildings and coronavirus with former Surgeon General Richard Carmona and former Robert Wood Johnson Foundation CEO Risa Lavizzo-Mourey.

“It’s an all-in moment for public health,” Allen says. “It’s the most urgent challenge all of us have faced. We’re trying to address the immediate needs while also thinking about the long-term challenges, because understanding how our buildings can be used to improve health is going to be critically important as we begin to repopulate our buildings and restart our economy.”

Protecting an indoor species

It’s not surprising that Allen’s public health work has tapped into forensics, a field of science most often associated with law enforcement. His father was a prominent homicide detective in Nassau County, New York, and Allen followed in his footsteps. He spent a few years as a young man working for his dad’s private investigation firm, tailing a cast of shady characters through New York City’s five boroughs, before stepping up to run the company when his dad retired. He then sailed through the FBI’s recruitment process and was days away from beginning training at the FBI Academy in Quantico, Virginia, to become a special agent, until he failed two polygraph tests despite the fact that he had answered every question thrown at him truthfully. Shocked, and with nothing to hide, he came away with a heavy dose of skepticism of the misapplication of science. It was this serendipitous glitch that sent him into the field of environmental science and ultimately into a public health doctoral program at Boston University.

As a forensic building investigator who was often called in during moments of crisis, Allen spent a lot of time thinking about the ways in which our infrastructure was making people sick. But his line of interrogation flipped when he arrived at Harvard. Instead of focusing on unhealthy buildings, he began wondering how indoor environments could be optimized to promote healthier living, exercise, and more nutritious diets.

Allen—tall and bald, with a firm, pre-pandemic handshake and hearty laugh—likes to say that humans are an “indoor species.” The average person, he explains, spends 90 percent of his or her life indoors. By the time someone turns 40, it adds up to 36 years inside; those lucky enough to survive until 80 will have spent a staggering 72 years within the walls of the built environment.

And yet, very little is known about the ways in which indoor environments affect human health and performance. From bedrooms to offices, hotels to hospitals, the spaces we inhabit are rife with potential health hazards: volatile organic compounds (VOCs) that off-gas from a new mattress; hormone-disrupting flame retardants and cancer-causing stain-repellent chemicals in an office chair; disease-causing bacteria that multiply in the bowels of industrial air-conditioning and water systems.

“Much of what we know about healthy living comes from these great, huge, epidemiological cohort studies—the Nurses’ Health Study, the Framingham Heart Study, the Harvard Chan School’s Six Cities air pollution study. One thing they all have in common is that they followed many people over long periods of time and fundamentally changed our understanding of health,” Allen says, sitting behind a cluttered desk in a small glass-walled office overlooking part of Boston’s Emerald Necklace, weeks before widespread social distancing took effect. “But they also have something else in common: None of them examined how the indoor environment affects health. This is a glaring hole in our understanding of what it means to live a healthy life.”

To help fill in that hole, Allen and his team have for several years been working on a trio of studies examining how office spaces impact workers. He colloquially calls this research the “CogFx” studies. For the first study, he brought two dozen white-collar employees of a Fortune 500 company into a simulated office environment for a week. “They’d do their normal 9-to-5 work routine, and at the end of each day we’d administer a cognitive- function test,” Allen explains. “What they didn’t know is we were changing the air they breathed each day—levels of carbon dioxide, levels of VOCs, and ventilation rates. It was double-blinded, and when we analyzed the data, we saw dramatic effects on how these workers performed.”

Published in 2015 in Environmental Health Perspectives, the study showed that employees’ scores on cognitive performance exams were, on average, 101 percent higher in building environments with enhanced ventilation than those in conventional building environments. Among the more surprising findings, Allen says, was the profound effect that levels of CO2—a byproduct of breathing and not typically considered an indoor pollutant—had on participants’ reaction times and decision-making skills.

Allen wondered whether the results would hold up in a real-world setting. He and his team designed a follow-up study to compare workers based in green-certified, high- performing buildings with those in buildings that weren’t green certified. It was a national endeavor that spanned five states, 10 buildings, and more than 100 participants. “Lots of boots on the ground,” Allen says. “Our team needed to be in each of the buildings. It was labor intensive.”

In the end, as Allen suspected, workers in high-performing green- certified buildings, with better thermal conditions and better lighting, not only scored higher on cognitive tests but also slept better at home and reported far fewer health symptoms, such as sore throat, headaches, and skin irritation, compared with those not in green-certified buildings.

Putting knowledge into practice

When Allen first began preaching the gospel of healthy buildings in classrooms and conferences, he was surprised by how little business leaders, real estate developers, and other influential decision makers knew about the issue. He recalls once delivering a presentation at a conference about healthy buildings and sustainable urbanization. Afterward, an executive from a company that sold air filters for commercial buildings approached Allen and asked earnestly whether there was any data on if exposure to fine particulate matter affected human health. Allen’s jaw nearly hit the floor. “That’s like asking an astronomer if there’s evidence that the moon goes around the Earth,” he jokes.

The encounter, and many others like it, convinced Allen that he could do all the studies in the world, but their impact would be limited if they remained in the academic bubble of public health. Allen didn’t want to simply place a brick in the edifice of scientific knowledge; he wanted to spark a movement to improve indoor environments around the world by bringing architects and real estate developers, engineers and executives to the table so that they knew the stakes.

To amplify his call to action, Allen applied for an Activation Award through the Dean’s Fund for Scientific Advancement. His proposal focused on strategically bridging the divide between the world of MPHs and the world of MBAs. “Dean Williams took a chance on me with this because we weren’t proposing a field study or proposing a lab analysis—the type of work my team typically does,” Allen says. “We were proposing using the award to build and extend partnerships across disciplines to focus on why healthy buildings make sense from a business perspective and from a public health perspective.”

The award enabled Allen to research and co-author the recently published book Healthy Buildings: How Indoor Spaces Drive Performance and Productivity (Harvard University Press) with John Macomber, a senior lecturer in finance at Harvard Business School (HBS) who has years of experience working in real estate construction. They also used the award to co-author an upcoming HBS case study on healthy buildings and develop a series of cross-school lectures.

“When Joe discusses the CogFx studies with my classes, you can see the students just sit straight up in their seats,” Macomber says. “They instantly recognize how important the findings are.”

With scientific and cultural momentum in his favor, Allen was eager to build on the success of the first two CogFx studies. He and his team sketched out plans for the third—the largest, most ambitious research effort to date on how indoor environments affect human performance. The study would span three continents, six countries, nearly 50 buildings, and more than 400 workers. It would measure air quality, cognitive function, physical activity, and a host of other factors for a full year.

There was just one problem: “How would we actually do this type of distributed large-scale cohort study? We couldn’t have boots on the ground all over the world. We couldn’t be at each site, each day monitoring the conditions and collecting data,” he says. “We needed new tools and new technologies. We needed to innovate.”

Transformative sensors and apps

Sitting among the papers on Allen’s desk is a white hexagonal device that looks like a beefed-up smoke detector. It’s one of five commercial environmental sensors with an app through which Allen’s team can continuously monitor VOCs, CO2 ventilation rates, and a host of other environmental conditions in an office. “It’s plug- and-play, and as soon as it’s plugged in, we’re collecting environmental data,” Allen says.

Last fall, he and his team shipped hundreds of these sensors around the world to study participants, along with a Fitbit to measure physical activity and sleep. “Previously, we would have to go to each office with a piece of equipment and take a measurement, maybe for an hour or eight hours or two days, or even a week,” Allen says. “Now, we just drop these in the mail.”

In addition to the sensors, Anna Young, a doctoral candidate on the Healthy Buildings team, nested a smaller study within the global cohort that used silicone wristbands to identify chemicals that people are exposed to within their offices. “Joe knows that choices are being made about building design and building materials every day,” she says, “and he wants our research to help inform those decisions.”

What really excites Allen is the digital platform that powers just about every facet of the study. “We built an app-based research platform called AppLab in order to administer the entire study remotely,” Allen says. “It allows us to do everything from collecting signatures for informed consent to pushing out cognitive function exams to capturing real-time environmental data.”

The inspiration for the tool traces back to a study led by Allen’s colleague Cedeño-Laurent, who was interested in measuring how students who lived in dormitories without air conditioning fared during a heatwave compared with students whose dorms had air conditioning. He needed a way to administer cognitive exams in the morning, when the students woke up. An engineer with a knack for coding, Cedeño-Laurent bootstrapped a smartphone app to administer the cognitive tests and collect crucial data.

It was a novel approach that worked well. The study showed that during a heatwave, students in buildings without air conditioning experienced 13.4 percent longer reaction times on color-word tests and 13.3 percent lower scores on basic arithmetic questions compared with students with air-conditioned rooms. Allen asked Cedeño-Laurent to join his Healthy Buildings Program and spearhead the development of a digital tool that could be a one-stop-shop for the third phase of the CogFx study.

Cedeño-Laurent had a better idea: Build it as a platform that could be modified for studies of all types. Allen loved the suggestion. “Joe’s support and enthusiasm speaks volumes to his leadership,” Cedeño- Laurent says. “He pushed us to build something big and impactful.”

It took nearly a year and close to half a million dollars from Carrier Global Corporation and JLL Inc. to develop, but AppLab appears to be quickly paying dividends. It has worked seamlessly for the global CogFx study, Allen says, and has allowed his team to gather data that would have been impossible to collect otherwise. For instance, he says, they were able to set it up so that when the environmental sensor detected a specific level of CO2 in an individual’s office, AppLab could automatically push out a little quiz to the person’s smartphone to measure reaction time and cognitive function. They also used the platform to “game-ify” the study to incentivize participation—study participants received badges and points for completing tasks that could be redeemed for gift cards.

While it’s early days for AppLab, there are signs that it could make it easier and less expensive for public health researchers to gather real-world data. David Christiani, Elkan Blout Professor of Environmental Genetics, is integrating it into a study analyzing the behaviors of e-cigarette users. Cedeño-Laurent and Jack Spengler, Akira Yamaguchi Professor of Environmental Health and Human Habitation, are using it in a collaborative study with outdoor retailer REI aimed at understanding how spending time in nature might improve health. Physicians have reached out about using AppLab to study heart health, and researchers in Europe want to use it to study indoor environments in ways totally unrelated to Allen’s work.

“Not every study has the budget or timeline to build out these types of tools,” Allen says. “AppLab simplifies the process and lowers the cost of this novel technology for everyone.”

No one can predict what the global cohort of the current CogFx study will reveal. Allen and his team began analyzing the data at the start of the year.

Then coronavirus erupted and everything—including the team’s ability to analyze the voluminous data—changed.

There is no telling what the long-term biological, social, and economic ramifications of the current pandemic will be. One thing’s clear, though: “We’re all becoming more aware of our indoor environments as a result of this novel coronavirus,” Allen says. “And I suspect that when we start sending our kids back to school and we start returning to our offices, we’re going to look at those buildings differently. Our expectations around how our buildings support our health will be heightened, and they should be. This is going to force dramatic change in how we design, operate, and maintain our buildings going forward.”

One persistent hurdle that Allen has encountered over the years is the widespread misconception that only gleaming new skyscrapers can be a healthy building. “Any building can be a healthy building,” Allen says.

It’s a mantra we may need to embrace immediately if we’re going to protect the health of future generations from acute threats such as coronavirus and long-term dangers such as climate change. “The decisions we make today regarding our buildings,” Allen says, “will determine our collective health going forward.”

Chris Sweeney is an environmental journalist and senior science writer in the Harvard Chan School Office of Communications.