1

1|me for Co||aborat|on |n nea|th + Urban|sm

A|an M. 8erger, rofessor, kesearch D|rector MI1 Center for Advanced Urban|sm
A|exander D'nooghe, Assoc rofessor, D|rector MI1 Center for Advanced Urban|sm
Ad|e Naud Santos, Dean, MI1 Schoo| of Arch|tecture + |ann|ng

A recenL 13-page crlLlque of Lhe Ml1 CenLer for Advanced urbanlsm's (CAu) prellmlnary flndlngs on Lhe
SLaLe of PealLh + urbanlsm, by Poward lrumkln, Mu, urP, 8lchard !ackson, Mu, MP, AlA (Pon), and
Andrew uannenberg, Mu, MP deserves a response, Lo polnL ouL a few polnLs of clarlflcaLlon and Lo
avold furLher mlslnLerpreLaLlon. llrsL, Lhree of Lhe largesL sysLemaLlc revlews
1
of Lhe research allgn wlLh
Lhe CAu reporL's prlmary flndlng abouL Lhe !"#$"#%&'!() naLure of Lhe relaLlon beLween urban form and
publlc healLh. lrumkln eL al. do noL clLe Lhese revlews ln Lhelr crlLlque, whlch calls lnLo quesLlon Lhe
auLhors' wllllngness Lo conslder counLervalllng evldence from wlLhln Lhelr own flelds. Second, aLLempLs
by myself and my colleagues aL Lhe CenLer for Advanced urbanlsm Lo collaboraLe wlLh Lhls auLhor group
have been rebuffed, whlch renders Lhelr publlc calls for collaboraLlon somewhaL hard Lo comprehend.
2

1hlrd, Lhe auLhors do noL dlsclose Lhelr assoclaLlon wlLh Lhe advocacy group Congress for Lhe new
urbanlsm, an organlzaLlon known for cerLaln urban blases llnked Lo Lhelr deslgn agendas. lourLh, Lhe
crlLlque does noL slLuaLe Lhe purpose of Lhe CAu's reporL. llnally, Lhelr crlLlque sLruck a causLlc and
personal Lone, whlch deLracLs from a proper lnLellecLual debaLe LhaL Lhe lssues demand Lo brlng our
professlonal communlLles LogeLher Lo collaboraLlvely lnnovaLe around healLh and urbanlsm.

1he Context of Cur keport
Cur publlcaLlon was LlLled a "reporL" because lL was a prellmlnary summary of llLeraLure and accounLlng
of work conducLed by graduaLe sLudenLs ln a semesLer-long workshop held aL Ml1, whlch marked Lhe
flrsL 3 monLhs of a 10-year sLudy. As such, lL should noL be mlsconsLrued as elLher a peer-revlewed
sLudy, or as Lhe concludlng documenL of a 10-year sLudy. We dld noL lnLend for Lhe careful deslgn and
presenLaLlon of Lhe reporL Lo fosLer mlslnLerpreLaLlon, however we dld explaln Lhls Lo Mr. lrumkln
several weeks prlor Lo Lhe publlcaLlon of Lhelr crlLlque. arallel Lo LhaL worklng process, Lhe class
lncluded lecLures and lnpuL from publlc healLh professlonals, pollLlcal sclenLlsLs, and geographlc mapplng
speclallsLs. 1hese lecLurers halled from several unlverslLles and lnsLlLuLlons. 1helr conLrlbuLlons plus Lhe
myrlad exchanges and vlslLs sLudenLs had wlLh publlc healLh offlclals from each clLy (we vlslLed every clLy
ln Lhe reporL), whlle regreLLably underrepresenLed ln Lhe summary reporL, noneLheless slgnlflcanLly
shaped Lhe LhoughL and flnal form of Lhe reporL.
3
1hls lnLroducLory look aL Lhe breadLh of healLh lssues
faclng conLemporary urban areas ls only Lhe lnlLlal sLage of a 10-year pro[ecL. 1he ln-depLh clLy
lnvesLlgaLlon and furLher lnLegraLlon of publlc healLh professlonals naLurally follow Lhls sLage. 1he only
concluslon LhaL has been drawn ln Lhls lnlLlal phase ls LhaL lL ls premaLure Lo ouLllne speclflc
prescrlpLlons for urban deslgn acLlon. Along Lhe way, varlous conLrlbuLors Lo Lhe reporL dlscovered
blases ln Lhe publlc healLh fleld. 1rue or noL, Lhese blases were debaLed and LesLed by our sLudenLs
2
wlLhouL ldeology or dogma. Clearlng Lhe alr, and ln Lhe splrlL of movlng forward wlLh our colleagues ln
publlc healLh, lncludlng Lhe auLhors who penned such a personal crlLlque of our work, we explaln our
reporL's lnLenLlons and llmlLaLlons below, and wlll lnclude Lhese noLes ln Lhe on-llne verslon of Lhe
reporL.

1he Intent|ons and known L|m|tat|ons of our Study
1. D|sc|a|mers were c|ear. 1he reporL sLaLes Lwlce LhaL Lhe flndlngs from analyLlcally vlsuallzlng Lhe
*$&"+, .)/%+0 1/"2!"3' daLa are merely a prellmlnary sLarLlng polnL for undersLandlng Lhe
geography of healLh. We clarlfy LhaL Lhe analysls calls for addlLlonal research lnLo Lhe
suburban/urban performance dlvergence" and LhaL our analysls was a deparLure polnL for each
lndlvldual clLy lnvesLlgaLlon" (pg. 34). 1hese sLaLemenLs preclsely mlrror Lhe lnLended use of Lhe
counLy daLa as sLaLed by Lhe CuC: 1he maps are presenLed for dlsplaylng posslble geographlc
paLLerns and sLlmulaLlng furLher lnvesLlgaLlon."
4


2. Large sca|e data |s rare and |oca| data does not answer nat|ona| quest|ons. We were prlmarlly
lnLeresLed ln large scale daLa and began wlLh a naLlonal scale assessmenL, worklng down Lo a
reglonal scale. As one of Lhe only naLlonal-level daLaseLs publlcly avallable, Lhe sLrengLh of Lhe
*$&"+, .)/%+0 1/"2!"3' daLa ls LhaL lL can be used for lnlLlaLlng a large scale sLudy examlnlng
prevalence of healLh ouLcomes. 1hls geographlc and parameLer complexlLy ls preclsely why Lhe
reporL sLaLes Lwlce LhaL Lhe flndlngs from analyLlcally vlsuallzlng Lhe *$&"+, .)/%+0 1/"2!"3'
daLa are merely a sLarLlng polnL for undersLandlng Lhe geography of healLh. Agaln, Lhe reporL
approprlaLely used Lhe daLa ln quesLlon, wlLh caveaLs as Lo lLs llmlLaLlons.
3


3. We on|y |ooked at |argest d|fferences. Cur vlsuallzaLlon was based on Lhe acLual prevalence
esLlmaLes and noL Lhelr ranklngs. As we largely analyzed areas wlLh slzable populaLlons, lL ls noL
llkely LhaL Lhe 93 confldence lnLervals around Lhese prevalence esLlmaLes would be so wlde as
Lo negaLe our baslc flndlngs. lor example, ln Cadwell eL al. 8ayeslan model-based esLlmaLe of
dlabeLes prevalence, Lhe average wldLh of Lhe 93 confldence lnLerval was 4.33.
6
ConservaLlve
appllcaLlon of Lhls margln of error ln Lhe same dlrecLlon of effecL Lo all 9 esLlmaLes ylelds a LoLal
dlfference of 40 polnLs, whlch ls less Lhan Lhe dlfference beLween many of Lhe lnner suburbs
and cenLral clLy. ln reallLy, Lhe errors around Lhe esLlmaLes should be random and ln dlfferlng
dlrecLlons, preservlng aL leasL some porLlon of Lhe orlglnal relaLlonshlps reporLed.

4. Lven w|th conservat|ve error account|ng, d|fferences st||| pers|st. 1he goal of our analysls was
noL Lo LesL an / 45!$5! hypoLhesls uslng sLaLlsLlcal lnference meLhods LhaL rely on derlvaLlons of
Lhe varlablllLy of a composlLe healLh measure. 8aLher, we soughL Lo creaLe a descrlpLlve
vlsuallzaLlon LhaL Lakes lnLo accounL Lhe LoLallLy of evldence avallable regardlng 9 dlfferenL
healLh ouLcomes conslsLenLly measured ln a naLlonal daLaseL. 8eporLlng confldence lnLervals for
a composlLe score ls beyond Lhe scope of Lhe vlsuallzaLlon, and would be an overshooL of Lhe
lnLended audlence. Whlle posslbly advlsable Lo lnclude ln a Lechnlcal appendlx, we dld noL flnd lL
approprlaLe for an lnLroducLory LexL Lo an ongolng pro[ecL. 1o more formally compare
composlLe healLh esLlmaLes across counLles, we could noL slmply sum Lhe varlablllLy, as we
would need Lo correcL for covarlance of Lhe meLrlcs wlLhln each counLy. Powever, dolng so
3
would only reduce Lhe LoLal lnflaLed error value, llkely expandlng Lhe magnlLude of Lhe observed
dlfference above. We conslder Lhls level of analysls unnecessary for an lnLroducLory reporL buL
welcome lLs compleLlon should someone be wllllng Lo conducL lL.

3. M|n|m|zed data error by comb|n|ng scores and |ook|ng at h|gher popu|ated areas. As sLaLed ln
ALhens eL al., Lhe ranklngs are mosL quesLlonable ln mld-performlng counLles and Lhose wlLh
small populaLlons.
7
1he laLLer ls generally noL an lssue ln urban and lnner suburban areas, where
Lhe vasL ma[orlLy of Lhe u.S. populaLlon ls locaLed, and ls Lhe focus of our reporL. AddlLlonally,
because some healLh facLors were found Lo be more rellable Lhan oLhers (for example, self-
reporLed healLh maLched lLs orlglnal ranklng whlle premaLure morLallLy rarely dld), we chose Lo
analyze a composlLe measure of healLh, whlch reduces some of Lhe nolse ln less preclse
esLlmaLes by borrowlng sLrengLh from oLhers.

6. More caveats. 1he reporL warns Lwlce abouL Lhe dangers of converLlng correlaLlons Lo
causaLlon. We also polnL ouL Lhe posslblllLy for unobserved confoundlng facLors Lo explaln our
flndlngs: "1here may be oLher crlLlcal facLors LhaL conLrol Lhe ouLcomes reporLed LhaL are noL
easlly measured or loglsLlcally obLalnable" (pg.34). Cur reporL never suggesLs LhaL we are aL Lhe
concluslve sLage and any suggesLlon oLherwlse ls a mlsreadlng of Lhe work.

7. eer-rev|ewed reports conf|rm our concerns. 1hree sysLemaLlc revlews of Lhe evldence llnklng
Lhe bullL envlronmenL and healLh ouLcomes have all concluded LhaL llLLle can be learned from
Lhe body of work on Lhe Loplc due Lo heLerogeneous meLhodologles and hlghly varylng resulLs.

1he reporL from Lhe new Lngland !ournal of Medlclne, below, even calls Lhe lmpacL of Lhe bullL
envlronmenL on healLh an unsupporLed presumpLlon.

1he Lv|dence
-A sysLemaLlc revlew on Lhe relaLlonshlp of healLh Lo physlcal acLlvlLy publlshed ln Lhe 67)5!#/"
8$&5"/% $9 :&;%!# .)/%+0 ln 2012 concluded LhaL many of Lhe sLudles on Lhe Loplc are
observaLlonal (raLher Lhan conLrolled sLudles, whose flndlngs are less prone Lo confoundlng
facLors).
8
1he llmlLaLlons of bullL envlronmenL research ln relaLlon Lo physlcal acLlvlLy are
numerous lncludlng llmlLed sLaLlsLlcal power due Lo small populaLlons sLudled, non-
generallzable seLLlngs, relaLlve rarlLy of ob[ecLlve measuremenL meLhods, and overall lnvalld
sLudy deslgn Lo allow for causal concluslons (e.g. a Lemporal relaLlonshlp beLween cause and
effecL cannoL be verlfled from measures Laken aL a slngle Llme polnL). An addlLlonal revlew
relaLed Lo Lhe one above, ln Lhe <)= >"3%/"? 8$&5"/% $9 @)?!#!") ln 2013, concludes LhaL Lhe
assoclaLlon beLween Lhe bullL envlronmenL and obeslLy ls an unsupporLed presumpLlon due Lo
lssues ralsed by lerdlnand eL al.
9
lL sLaLes LhaL no concluslon can be drawn" slnce Lhe sLudles
suffer from lnconslsLenL assoclaLlons (l.e. varylng ln magnlLude and dlrecLlon, pg. 431).
-A Lhlrd revlew ln .)/%+0 /"? :%/#) from 2010 complalns of Lhe greaL heLerogenelLy" of
measures, deslgns, and flndlngs across sLudles LhaL resLrlcLs whaL can be learned from Lhls body
of evldence (pg. 178).
10
lurLhermore, Lhe auLhors warn:
4
Whlle Lhere ls sLrong lnLulLlve appeal Lo Lhe noLlon LhaL Lhe bullL envlronmenL musL be
conLrlbuLlng Lo Lhe obeslLy epldemlc, exlsLlng sclenLlc evldence does noL Lell a clear
sLory." (pg. 186)
-8eyond Lhese Lhree revlews, an overarchlng analysls of 36 revlew papers from 2002-2011,
publlshed ln .)/%+0 /"? :%/#) ln 2012, found conslsLenL research gaps, meLhodologlcal
shorLcomlngs, and sLudy deslgns whlch cannoL provlde sLrong supporL for causallLy."
11
1hese
revlews draw Lhe same concluslons as Lhe CAu reporL - LhaL bullL envlronmenL research ls
lnconcluslve abouL causal relaLlons beLween urban form and publlc healLh, and LhaL lL would be
premaLure Lo advocaLe any parLlcular pollcy aL Lhls [uncLure. 8y any ob[ecLlve measure, Lhe
conslsLenL calls for cauLlon from Lhese ma[or revlews form a resoundlng conflrmaLlon of Lhe
CAu reporL by publlc healLh professlonals Lhemselves. lrumkln eL al. clLe none of Lhese
slgnlflcanL revlews. 1hese revlews were also omlLLed ln our flnal edlLlng and layouL of Lhe reporL,
and we acknowledge Lhls unforLunaLe overslghL.

1he Urgent Urban Cpportun|ty (and why we need to remove persona| agendas)
1he lnLellecLual debaLe LhaL should be lnlLlaLed by our reporL and rebuLLal ls clear and should noL be
deralled: Pow wlll we proceed ln Lhe fuLure Lo deslgn healLhler places Lo llve, work, and lncrease Lhe
well-belng of humanlLy. We belleve Lhls debaLe ls cruclal Lo Lhe deslgn, plannlng, and publlc healLh flelds
and should noL be sldeLracked by Lhe personal aLLacks and lnaccuracles of lrumkln eL al.'s crlLlque,
whlch volds Lhe debaLe by chooslng lnsLead Lo parse mlnor nuances of our prellmlnary flndlngs as lLs
foundaLlon. lor example, our prellmlnary scan of sclenLlflc llLeraLure on Lhe sub[ecL of alr polluLlon
suggesLs carbon dloxlde may be llnked Lo asLhma-relaLed deaLhs for a varleLy of reasons, lncludlng Lhe
hlgher pollen counLs and LemperaLures.
12
1hey respond by saylng carbon dloxlde lsn'L llnked Lo asLhma
morLallLy, sLrlcLly based on Lhelr cloaked sclenLlflc deflnlLlons (pp. 3-4). When our deslgn and plannlng
sLudenLs read a sclenLlflc paper LhaL sLaLes Among Lhe non-aLoplc facLors (of chlldhood asLhma), Lhe
level of CC2 emlsslons and lLs resplraLory healLh effecLs are among Lhe mosL lmporLanL,"
13
we belleve
Lhere ls more Lo sLudy and follow up on wlLh connecLlons beLween carbon dloxlde and urban healLh.
1hls exclLes and emboldens us Lo flnd ouL more, Lo use our creaLlve energles and complex problem
solvlng skllls Lo address Lhe problem wlLh opLlmlsm and passlon. lrumkln eL al.'s parslng of Lerms Lo
aLLack us wlLh accusaLlons of sloppy scholarshlp, noL only mlsses Lhe polnL of our efforLs, buL obfuscaLes
Lhe essence of Lhe healLh and urbanlsm research, and hlghllghLs gaps ln our muLual undersLandlng of
Lhe sclenLlflc llLeraLure. Across Lhe flrsL Lwo pages of Lhe crlLlque, Lhe auLhors allege we form varlous
unsupporLed concluslons." lrumkln eL al. use Lhe word concluslon" Len Llmes ln Lwo pages ln
reference Lo Lhe essays ln our reporL. ?eL Lhose very essays never use LhaL word-noL once. 1hus, Lhe
reporL uLlllzes phrases llke llLLle consensus" (pg. 23), llmlLaLlons" (pg. 27), and lnvesLlgaLlon" and
flndlng" (pg. 34) ln reference Lo our work raLher Lhan Lhe more flnal Lerm concluslons." Lven ln
sclenLlflc llLeraLure, Lhe resulLs and dlscusslon secLlons are removed from Lhe acLual concluslons, a
dlsLlncLlon whlch ls summarlly lgnored ln Lhe crlLlque.
We dld noL lnLend Lo enrage Lhe docLors worklng ln Lhe fleld of urban healLh, buL raLher engage Lhem
wlLh our curloslLy Lo work slde by slde ln muLual respecL. We have much Lo learn LogeLher. 1haL ls why
we slgned on wlLh Lhe Amerlcan lnsLlLuLe of ArchlLecLs for Lhe uecade of ueslgn pro[ecL. As deslgners,
3
we are ready Lo collaboraLe wlLh Lhe medlcal communlLy and work LogeLher Lo solve presslng urban
lssues, noL quesLlon Lhelr sclence and parse language.
MosL lmporLanLly, we belleve LhaL Lhe crlLlcal soluLlons LhaL wlll lead Lo beLLer urban healLh do noL sLop
aL Lhe klnds of deslgn elemenLs and developmenL LemplaLes embraced by formulalc and uncrlLlcal new
urbanlsL lmagery of sldewalks and mlxed-use sLreeLscapes.
14
1lme and Llme agaln, our sLudenLs
reporLed conLradlcLory evldence, professlonal blases, and nalveLy ln Lhe physlcal ouLcomes descrlbed by
medla ouLleLs ln dellverlng vlslons of healLhy clLy form, largely comlng from dlsLorLed second hand
reporLlng of lrumkln's and !ackson's assoclaLlons wlLh 1he Congress for Lhe new urbanlsm.
13
Cne
glarlng example comes from an archlLecL who wrlLes abouL suburban lnflll: ur. lrumkln's work and LhaL
of hls CuC colleagues have helped recognlze Lhe llnks beLween auLomoblle-dependenL developmenL
paLLerns and obeslLy, chronlc dlseases, ln[urles, and alr and waLer quallLy degradaLlon.1he confluence
Loday of Lhe economlc crlsls, healLh-care crlsls, and envlronmenLal crlsls mean we can'L afford Lo reLurn
Lo gas-guzzllng developmenL paLLerns."
16
1hese asserLlons are caLegorlcally unLrue, and as Lhese auLhors
descrlbe ln Lhelr own crlLlque, and we agree, all of us should be more careful ln crafLlng our messages so
LhaL Lhe medla does noL mlsconsLrue or sensaLlonallze our research.
17
As Lhese auLhors say ln Lhelr own
book and our research allgns wlLh, 1here ls no slmple formula for deploylng deslgn feaLures LhaL are
shown Lo promoLe physlcal acLlvlLy. 1here ls no guaranLee LhaL, say, lncreaslng denslLy of a
nelghborhood wlll resulL ln more physlcal acLlvlLy of lLs resldenLs."
18
As alleged by Lhelr crlLlque of our
reporL, we agree LhaL medla ouLleLs can ofLen sensaLlonallze and LwlsL research ouLcomes, such as when
Lhese sclenLlsL's good work ends up ln headllnes LhaL read: urlvlng makes you faL, urban sprawl
bankrupLs you, oLher llfe-savlng new urbanlsL eplphanles."
19
8aLher Lhan feed LhaL flre by aLLacklng each
oLher, we should be worklng LogeLher Lo crafL a more educaLed, well-rounded message abouL healLh
and urbanlsm.
As deslgners and planners, a sLep forward wlll requlre muLual respecL from Lhe medlcal communlLy
regardlng urban deslgn and clLy plannlng, and our research meLhods. 1hls deserves an open mlndedness
regardlng many Lypes of urban form ln myrlad conLexLs, and musL lnclude lnnovaLlons ln cross-cuLLlng
plaLform Lechnologles, moblllLy sysLems, energy sLorage, and envlronmenLal englneerlng, Lo name a few
of Lhe Lhlngs we excel ln aL Ml1. lL needs Lo be sLaLed LhaL we do have conslderable overlap and
agreemenL LhaL a slmpllsLlc reverslon Lo LradlLlonal mlxed-use nelghborhoods and Lree-llned
sLreeLscapes wlll noL solve our urban healLh problems. SubsequenLly, as we enLer only Lhe second year
of our decadal pro[ecL wlLh AlA, we have already reached ouL Lo form new relaLlonshlps wlLh publlc
healLh and plannlng agencles ln our selecLed clLles for furLher lnvesLlgaLlon.
20


8|as and Methods Cha||enges Ahead
urban deslgn has a sLrong normaLlve componenL LhaL embraces complexlLy. 1he core buslness ls Lo sLaLe
whaL '0$&%? happen, qulLe ofLen wlLh a falr amounL of lnLended blas and searchlng for exLended
neLworks LhaL celebraLes complexlLy. As a fleld, lL conLalns a serles of poslLlons, each of whlch arrlve aL
dlfferenL, conLradlcLlng sLaLemenLs LhaL may noL yleld concluslve evldence. 1hese poslLlons reflecL
ldeologlcal [udgmenLs abouL our socleLy and lLs pollLlcal cholces. Sclence, on Lhe oLher hand, operaLes
skepLlcally, lnLerrogaLlng, ldenLlfylng, and lf posslble ellmlnaLlng blas Lo undersLand complexlLy ln
lsolaLed, measurable momenLs. ln Lhls case, Lhe roles have been reversed. 1he CAu research Leam
6
operaLed under Lhe assumpLlon LhaL no blas should be Laken Lowards a glven soluLlon before Lhe
research would allow us Lo draw clear recommendaLlons. lLs sLaLemenLs only alm Lo demonsLraLe blas
where lL exlsLs, and Lo quesLlon and lnLerrogaLe lL. SLrangely, ln Lhelr rebuLLal, Lhe auLhors from Lhe
sclenLlflc communlLy are Lhe ones havlng exhlblLed a sLrong blas Lowards a speclflc poslLlon.
lrumkln eL al. asserL LhaL revlew arLlcles" were already summarlzlng new work abouL clLy plannlng and
healLh, clLlng hls own oplnlon plece from 2002 as evldence.
21
Self-clLaLlon ls a Lrend LhaL follows Lhls
Lhree-auLhor group. ln 2003, Lhls same seL of auLhors publlshed a research agenda Lo assess Lhe lmpacLs
of land use and deslgn on publlc healLh.
22
1he openlng senLence clalms LhaL Lhe deslgn cholces we
make.can have ma[or effecLs on healLh" (pg. 1300). 1he clLaLlon ls Lhe exacL same oplnlon plece used ln
Lhe crlLlque, somehow Lransformed lnLo evldence LhaL deslgn and healLh have been verlflably llnked.
Come on, man!
Moreover, Lhe crlLlque's dlscusslon of experLlse suggesLs a mlsundersLandlng of Lhe role of
blosLaLlsLlclans. unllke fleld speclallsLs, blosLaLlsLlclans focus an lmparLlal, analyLlc eye on Lhe resulLs of
any daLa-based research Lo assess Lhelr valldlLy and poLenLlal blases. 1hey are experLs ln ldenLlfylng blas
and flawed sLudy deslgn, whlch are clearly aL play ln bullL envlronmenL research as evldenced by Lhe
revlews above. As Lld eL al. observed, Lhe debaLe over urban sprawl and obeslLy ls ldeologlcally
charged" (pg. 399).
23
Charged research areas especlally beneflL from lmparLlal, ouLslde observers llke
blosLaLlsLlclans and Lhe meLa-level analysls of whaL can be known and whaL ls con[ecLure.
Cn Lhe Loplc of food deserLs, Lhe crlLlque auLhors use a subLle shlfL of language Lo falsely allege we have
no supporL for our sLaLemenLs. Cn pg. 7 of Lhe crlLlque, Lhey have shlfLed whaL we called a lack of
consensus lnLo whaL Lhey Lerm concluslons." 1he clLed sLudles are never represenLed as Lhe enLlreLy of
Lhe fleld. 8aLher, Lhey comprlse a slgnlflcanL dlssenLlng volce --all Lhree clLaLlons supporL our conLenLlon
LhaL consensus cannoL be clalmed on Lhe food deserL lssue. 1hls Loplc ls rarely represenLed as Lhe
ongolng debaLe LhaL lL acLually ls. 1he reporL clLes boLh an essay and a peer-revlewed arLlcle by Pelen
Lee.
24
As a hlsLorlcal prlmer on Lhe sub[ecL, her work aL Lhe 8reakLhrough lnsLlLuLe flrsL aLLempLs Lo
descrlbe Lhe developmenL of Lhe ldea of food deserLs." Whlle perhaps noL recognlzed ln Lhe publlc
healLh realm as equlvalenL Lo peer-revlewed publlcaLlon, Lhe Lraclng of ldeologlcal developmenLs ls a
meLhod uLlllzed by humanlLles scholarshlp Lo assess Lhe rooLs, soclologlcal underplnnlngs, and valldlLy of
ldeas LhaL enLer Lhe culLural sphere. 1he llmlLed space and rlgld sLrucLure of sclenLlflc [ournal arLlcles do
noL allow for Lhese more fluld argumenL consLrucLlons whlch llnk larger culLural movemenLs and
paLLerns LogeLher. 1hese paLLerns are noL easlly reduclble Lo quanLlzed varlables ln lsolaLlon and
cerLalnly noL as a collecLlve seL. More recenL [ournal arLlcles, noL avallable aL Lhe Llme of our reporL's
producLlon, reafflrms LhaL a small buL growlng" group of sLudles suggesL LhaL poor access Lo food
reLall envlronmenLs may noL always be assoclaLed wlLh poor dleL and obeslLy ln chlldren or adulLs."
23

1hls group of sLudles have exLra robusLness due Lo Lhelr larger sample slzes and longlLudlnal deslgns,
boLh of whlch help avold selecLlon blas and Lhe spurlous assoclaLlons ofLen found ln cross-secLlonal
observaLlonal sLudles. 8oLh Lhe food envlronmenL and Lhe bullL envlronmenL body of work have serlous
sLrucLural concerns LhaL arlse ln revlews. 1he crlLlque auLhors obscure Lhe unresolved naLure of Lhese
lssues by slmply llsLlng groups of sLudles LhaL flnd Lhelr correlaLlons yeL provlde no assessmenL of Lhe
quallLy of sLudy deslgn.

7
Cur Iuture
CAu supporLs no slngular panacea, no prescrlbed rules of scale for whaL Lroubles urban areas (from
nelghborhoods Lo reglons) and Lhelr populaLlons. uynamlc urban fuLures wlll requlre dlllgenL,
mulLlscalar, lnvenLlve appllcaLlon of boLh publlc healLh knowledge, deslgn experLlse, and a whole hosL of
oLher neLworked flelds. Much work ls yeL Lo be done Lo devlse fuLure dlrecLlons for urban hablLaLs, and
CAu plans Lo conLrlbuLe Lo LhaL crlLlcal pro[ecL, ln expanded collaboraLlon wlLh unblased professlonals ln
Lhe publlc healLh fleld. 1hls has always been our goal.

keferences and Notes

1
See noLes 8-11.

2
hone call beLween lrumkln and 8erger on 1hursday leb. 20, 2014. Cn Lhls call 8erger lnvlLed lrumkln Lo come
Lo Ml1 Lo collaboraLe on Lhe pro[ecL wlLh Lhe CAu Leam, all expenses Lo be pald by CAu. lrumkln dld noL respond.

3
1he conLrlbuLors Lo our course are llsLed on Lhe lnslde cover of Lhe reporL publlcaLlon. ln addlLlon, our sLudenLs
lnLervlewed, by phone and ln person, publlc healLh and plannlng dlrecLors ln all elghL of Lhe clLles we sLudled.

4
hLLp://www.cdc.gov/dlabeLes/aLlas/counLydaLa/CounLy_MeLhods.hLml

3
lbld.

6
Cadwell 8L, 1hompson 1!, 8oyle !, 8arker LL. 8ayeslan small area esLlmaLes of dlabeLes prevalence by u.S.
counLy, 2003. 8$&5"/% $9 A/+/ B#!)"#) (2010) 8(1): 173-188.

7
ALhens !k, CaLlln 88, 8emlngLon L, Cangnon 8L. uslng Lmplrlcal 8ayes MeLhods Lo 8ank CounLles on opulaLlon
PealLh Measures. :5)( *05$"!# A!' 2013,10:130028.

8
lerdlnand A, Sen 8, 8ahurkar S, Lngler S, Menacheml n. 1he relaLlonshlp beLween bullL envlronmenLs and
physlcal acLlvlLy: a sysLemaLlc revlew. 67 8 :&;%!# .)/%+0 (2012),102:e7-e13.
9
Casazza k, lonLalne k8, AsLrup A, 8lrch LL, 8rown AW, 8ohan 8rown MM, uuranL n, uuLLon C, losLer LM,
Peymsfleld S8, Mclver k, MehLa 1, Menacheml n, newby k, aLe 8, 8olls 8!, Sen 8, SmlLh, !r. uL, 1homas uM, and
Alllson u8. MyLhs, presumpLlons, and facLs abouL obeslLy. < >"3% 8 @)? (2013), 368:446-434.
10
leng, !., Class, 1.A., Currlero, l.C., SLewarL, W.l., SchwarLz, 8.S. 1he bullL envlronmenL and obeslLy: A sysLemaLlc
revlew of Lhe epldemlologlc evldence. .)/%+0 /"? :%/#) 16 (2010):173-190.
11
ulng, u, Cebel k. 8ullL envlronmenL, physlcal acLlvlLy, and obeslLy: WhaL have we learned from revlewlng Lhe
llLeraLure? .)/%+0 /"? :%/#) 19 (2012),100-103.

12
llLLer AP, llLLer 8S. 8apld changes ln flowerlng Llme ln 8rlLlsh planLs. B#!)"#) (2002) May 31, 296(3373):1689-91.

13
uosan[h A. Chlldhood asLhma and anLhropogenlc CC
2
emlsslons. 8$&5"/% $9 6'+07/ /"? 6%%)53, (2011:4):103-
103.

14
lor example, see PealLhy Puman PablLaLs: Poward lrumkln aL 1Lux8alnler, scan Lo 6:20 mark.
hLLp://youLu.be/ufm80Lf8x8

8

13
As an Ponorary Chalr" of Lhe Congress for Lhe new urbanlsm's 2009 meeLlng, lrumkln, Lhe prlmary auLhor of
Lhe crlLlque, has allgned hlmself wlLh an advocacy organlzaLlon, as has 8lchard !ackson as Cnu's plenary speaker ln
2012. 1hls blas was noLed by Lhe auLhor of a crlLlque of lrumkln and hls auLhor group ln a 2012 book revlew from
Lhe C)52)%), :%/""!"3 8$&5"/%. 1he revlewer sLaLes LhaL a lack of clarlLy" pervades Lhe book and makes Lhe reader
wonder lf Lhey are geLLlng Lhe whole sLory" (pg. 249). 1he revlew goes on Lo call some of Lhe conLenL overly
deLermlnlsLlc" by [umplng pasL Lhe complex web" of causaLlon (pg. 249). See 8lggs, W. 8evlew of Maklng PealLhy
laces: ueslgnlng and 8ulldlng for PealLh, Well-8elng, and SusLalnablllLy" C)52)%), :%/""!"3 8$&5"/% 23 (2012):248-
231.
16
"new urbanlsm: 8x for PealLhy laces" May 19-22 wlll explore llnks beLween developmenL paLLerns and healLh
(12/1/2009). Avallable onllne: hLLp://www.cnu.org/cnu-news/2009/12/cdcL28099s-dr-howard-frumkln-
named-honorary-chalr-cnus-18Lh-congress

17
lL should be noLed LhaL an arLlcle LhaL appeared ln ALlanLlc ClLles afLer publlcaLlon of CAu's reporL dld noL lnclude
any lnLervlews or dlrecL conversaLlons wlLh any auLhors of Lhe reporL from CAu. Avallable onllne:
hLLp://www.LheaLlanLlcclLles.com/nelghborhoods/2013/12/much-whaL-we-know-abouL-publlc-healLh-and-urban-
plannlng-wrong/7886/

18
lrumkln P, lrank L, !ackson 8 (2004). D5;/" B45/=% /"? :&;%!# .)/%+0E A)'!3"!"3F :%/""!"3F /"? C&!%?!"3 9$5
.)/%+0, *$77&"!+!)'. lsland ress, Wash uC, p. 106.

19
Llnsday, C, A5!(!"3 7/2)' ,$& 9/+F &5;/" '45/=% ;/"25&4+' ,$&F $+0)5 %!9)G'/(!"3 ")= &5;/"!'+ )4!40/"!)'. lasL
Company, May 21, 2010. Avallable onllne: hLLp://www.fasLcompany.com/1630173/drlvlng-makes-you-faL-urban-
sprawl-bankrupLs-you-oLher-llfe-savlng-new-urbanlsL-eplphanles.

20
lor example, our mosL recenL call wlLh Lhe ClLy of PousLon lncluded plannlng offlclals from Lhe clLy and reglon,
as well as publlc healLh agencles LhaL represenL Lhe counLy and clLy levels.
21
lrumkln P. urban sprawl and publlc healLh. :&;%!# .)/%+0 1)4. 2002,117(3): 201-17.
22
uannenberg AL, !ackson 8L, lrumkln P, Schleber 8A, raLL M, kochLlLzky C, 1llson PP. 1he lmpacL of communlLy
deslgn and land-use cholces on publlc healLh: A sclenLlflc research agenda. 67)5!#/" 8$&5"/% $9 :&;%!#
.)/%+0. 2003,93(9):1300-1308.

23
Lld !, Cverman PC, uga u, 1urner MA. laL clLy: CuesLlonlng Lhe relaLlonshlp beLween urban sprawl and
obeslLy. 8 D5;/" >#$" 2008,63(2):383-404.
24
Lee, P. (2013). 1he Maklng of Lhe CbeslLy Lpldemlc: Pow lood AcLlvlsm Lead ubllc PealLh AsLray. 1he
8reakLhrough !ournal, Sprlng. hLLp://LhebreakLhrough.org/lndex.php/[ournal/lssue-3/ Lhe-maklng-of-Lhe-obeslLy-
epldemlc/. Also see Lee, P. (2012). 1he role of local food avallablllLy ln explalnlng obeslLy rlsk among young school-
aged chlldren. Soclal Sclence & Medlclne, 74(8), 1193-1203.

23
Cummlns, S., lllnL, L., MaLLhews, S.A. new nelghborhood grocery sLore lncreased awareness of food access buL
dld noL alLer dleLary hablLs or obeslLy. PealLh Affalrs lebruary 2014 vol. 33 no. 2 283-291.