The first wealth is health.
—RALPH WALDO EMERSON
I was born to build. Before I could talk, I had trucks and bulldozers in a cornmeal mini-sandbox in the kitchen. I regaled my infant sister by stacking up cantilevered block structures from floor to ceiling. How much width can we get off a single block base? How few units to reach the ceiling?
This aptitude for building is in my DNA, one could say. In 1904 my great-grandfather left a big national construction firm to establish the George B. H. Macomber Company. He built the first structural steel building in Boston (it’s now called 79 Milk Street) and the Weld Boathouse at Harvard before there was a bridge across the Charles River.
The firm passed from father to son in 1927, and then my own father bought the family business in 1959. One of his early projects, the hexagonal “waffle” slab floors at the Yale Art Museum, showcased his ability to think in three dimensions across time. He had to imagine how the finished concrete would look, where the reinforcing steel would go, and (upside down and backward) how the plywood should end up so that he could effectively strip it from the underside without ripping it apart.
My siblings and I bought the family business in 1990 and picked up where Dad left off. I designed formwork for cast-in-place buildings, where stairs might alternate above and below a continuous sidewall made of the same monolithic concrete pour. No easy feat, but the logic of the puzzle appealed to me, just as it had to my father.
My father and I were both natural physical-world problem solvers, and the projects we worked on included high-rise apartment buildings, data centers, and total mechanical rehabilitation of operating hospitals or museums where the walls themselves were part of the collection. I was the chairman and principal stockholder of the George B. H. Macomber Company for about 15 years, working alongside my siblings. We built landmarks all over New England for clients including MIT, Fidelity, State Street, Mass General Hospital, Children’s Hospital, the Isabella Stewart Gardner Museum, and the Institute of Contemporary Art. We also built dozens of office structures, apartments, and stores for commercial real estate developers.
By 2006, the construction business had become exceptionally competitive, adversarial, and low margin in Boston. I wanted to be a builder, not a full-time litigator and collector of accounts receivable. So my siblings and I sold the business, after four generations and 102 years, and I embarked on a second career as a teacher.
When I first came to Harvard Business School (HBS), I taught two courses. One was Real Property, which is essentially Real Estate 101: how to finance, buy, and flip an office building. It’s taught in the Finance unit at HBS and has an investor-focused orientation. My other course was Real Estate Development, Design, and Construction, jointly listed with Harvard Design School, which got more into the “bricks and sticks” aspect of the industry. I found them both rewarding, of course, but there is not a lot of new academic work going into the purchasing of ceiling tile or the refinancing of an apartment building.
Then two things happened. First, HBS started offering executive education in real estate in India. I was the program chair and I made many trips to India to teach but, more importantly, to do research and write. The subjects of my HBS case studies ranged from water franchising in Gujarat in the Northwest to the redevelopment of informal housing in Mumbai, to low-income housing development in Kolkata in the East, and infrastructure finance nationwide.
It was quite clear that building promoters in India could not rely on the state to provide reliable infrastructure like electricity, consistent clean water, steady sanitation services … or even roads. What’s more, the tools I grew up with—cash flow, concrete, hardhats, and structural visualization—applied just as much to horizontal infrastructure as to my personal experience in vertical buildings. (Most commercial real estate and institutional construction is classified by the US Commerce Department as “light general building”—even skyscrapers and museums—and it is mostly vertical. The other category is heavy construction and civil works like roads, power lines, pipelines, and airports, which are largely horizontal; power plants and refineries also are in this “heavy construction” category.)
Beyond environmental issues, it was clear that the government could not provide housing for everyone; but in certain configurations, the private sector could. My HBS case study “Dharavi: Developing Asia’s Largest Slum” is now used in dozens of schools and was featured in the Wall Street Journal and other outlets. It looks at how public-private partnerships can be used to improve housing for low- and middle-income groups.1
At the same time, I became more and more involved with the Harvard University Center for the Environment and with the HBS Business and Environment Initiative. I’m not qualified to discuss policy issues like how much atmospheric carbon dioxide might lead to how much global warming, and I don’t have the background to discuss COP 222 and the implementation of the Paris accords. So how could I help move the needle?
It turns out that what I am highly qualified to think about is money and construction: notably, how to get trillions of dollars of private capital off the sideline to make high-impact investments in water, sanitation, roads, power, and mass transit that will impact the lives of hundreds of millions of people. Public health is obviously directly connected to society’s success in answering this call.
My research today focuses on cities and buildings. There are several reasons for this: First, cities generate most of the world’s gross domestic product. Second, cities also generate most of the world’s greenhouse gases. Third, cities tend to be the political units that can act. Mayors and city councilors are often closer to their voters, are held more accountable, and can do a lot by thoughtful use of city contracts, zoning, codes, and more. And finally, cities are the right size for private investors: they get how to invest in a road or bridge or power plant or cell tower network at a city scale in a way that’s near impossible to implement at a federal level in a country any larger than Singapore, Israel, or Panama.
Cities are, of course, all about the people who live and work in them. But the hard assets create the framework for these people to thrive. So I look at the design, finance, and delivery of hard assets, including energy and transportation, water and sanitation, and information and communications technology infrastructure. At the center of cities, of course, are buildings.
This led me to two frustrating paradoxes.
The first is the “infrastructure paradox.” One hears a lot about the “infrastructure paradox” in meetings of infrastructure investors, multilaterals like the World Bank, and academics. Here’s what it is. According to Deutsche Bank, there are more than $50 trillion dollars of financial assets invested in the fixed-income portion of the global financial system (from wealthy individuals, pension funds, insurance companies, endowments, and sovereign investment funds)—all seeking yield and currently earning only about 3 percent returns (the current US Treasury bond yields).3 At the same time, there are hundreds if not thousands of seemingly worthy, cash-flow-positive, society-benefiting projects in the infrastructure space. How can we match up the capital and the need to make these projects “bankable”? My HBS course Sustainable Cities and Resilient Infrastructure explores the opportunities, mechanisms, and controls for this. A lot of it has to do with the perception and allocation of risk.
The second paradox is even more vexing. Call it the “healthy real estate investing paradox.” As a society, we are wasting money on bad buildings … and we are wasting lives in bad buildings. To be blunt, the air in our buildings makes us sick and saps our productivity.
This paradox is not about uncertainties at the project level—defaults, accidents, or cash flow problems. It’s about who needs to take what action to make the right long-term engineering investments. Who needs to make what choice to make the right operating decisions? Who benefits in the long run from health—and can investors capture some of that benefit?
Until recently, the benefits of Healthy Buildings have been so abstract that it’s been hard to make an investment case for them. Even now, the incentives for lenders, landlords, tenant companies, and employees have not been aligned. But new quantitative research shows in an objective and reproducible way that our cognitive abilities, health, productivity, and well-being are directly impacted by decisions in the engineering, operations, and running of our buildings.
This is an exciting new way to look at the business models underlying the physical structures where we all spend our time. It’s a way to map tangible health interventions onto our financial models. But before I could make progress, I felt I needed to know more about the science of a Healthy Building.
That’s why I sought out Joe.
Like John, I followed in my parents’ footsteps. Kind of.
My dad was a homicide detective in New York, and a good one—winner of Detective of the Year in the mid-1980s. When he retired after 20 years on the force, he started a private investigation company. He did the fieldwork and my mom kept the books. So my late childhood and early adulthood were spent being a private investigator. Although I never had a Ferrari like Magnum, PI, I spent my days running across the five boroughs of New York doing surveillance, undercover stings, forensic investigations, and skip tracing. (“Skip tracing” is the industry term for the practice of tracking people down to find out where they live, work, and generally spend their time and money. The term comes from the practice of trying to trace the whereabouts of someone who has skipped town.) My PI background is a not-so-secret secret. But be forewarned: if this compels you to Google “Joe Allen private investigator Boston,” you will stumble onto a scandal. That Joe Allen is not me! No relation.
I did this private investigation work through college and after, and when our best client signed my dad up to be their head of security, my brother and I took over the business. I loved it. But I always knew I was a scientist at heart. So while I was a PI, I started applying to graduate schools in environmental science. And, to hedge my bet on the science career, I also applied to the FBI.
I was darn close to heading to Quantico to become a Special Agent, too. They liked my application and invited me to take a multihour written exam, which I passed. I then submitted a 50-page dossier about everyone I ever knew and interacted with (they contacted many of them, if not all). After that I was selected to advance to the next round and was flown to Philadelphia for an all-day grilling by a roundtable of FBI Special Agents. This was followed by another exam, this one involving combing through lengthy documents and piecing together a cogent argument on financial fraud. I passed that, too.
My last two tests before heading off to become a Special Agent were going to be easy—a polygraph test and then a fitness test. I’d been training for months for the fitness test and was ready, so the polygraph was the last real hurdle.
I failed it. Before you go thinking I was the first incarnation of Paul Manafort hiding some secret life of crime, I was really the victim of an unskilled examiner. In a polygraph exam, you’re hooked up to the machine, and after the formal set of questions, the examiner comes around the table and engages in small talk. You’re still hooked up to the machine, obviously, but the ploy is to get you to think the test is over. Then, the examiner continues the conversation. Well, my examiner started in on a series of laughably preposterous scenarios designed to make me feel at ease about opening up about some nefarious secrets I might be hiding.
“Hey Joe, I have a friend who’s got a friend who’s a dentist, and that guy gets him prescription drugs on the side. It’s really not a big deal, so you can just tell me and I’ll keep it confidential. Is that what you’re doing?”
Me: “Um, no,” trying to keep from laughing out loud.
“Hey Joe, I have a friend who is on an antigovernment internet forum under a pseudonym. It’s no big deal, we’re all entitled to our opinions, right, so why don’t you tell me and we’ll get back to the exam. Is that what you’re doing?”
And on and on. We covered sex, drugs, rock and roll, communism, and everything in between. Each topic followed the same pattern: “Hey Joe, my friend is doing _____. It’s no big deal. Is that what you’re doing?”
Naturally, I formally appealed after I learned I had failed. My FBI handler agreed with the appeal. As a result, the FBI literally flew in their top interrogator from Iraq to retest me. (Didn’t he have better things to do?) The guy they brought in was right out of central casting—a six-foot-six-inch-tall hulking mass of a man with a mean scowl. He came in wearing his ass-kicker boots, ready to beat the hell out of me mentally (while trying to physically intimidate me).
We did the same tests, but this guy was skilled. None of the silly scenario stuff. His approach was to be as intimidating as possible. But I stayed calm, even when he got up and stood two inches from my nose and yelled at me. He kept saying, “I know what you’re doing, so cut the bullshit!” And all I could think was, “I don’t know what you’re talking about, but weirdly I’m finding this fun!”
I stayed cool. I figured this was part of the test—seeing how I would respond to intense intimidation. After it was all over, I was certain I had passed, even as he continued his tirade while leading me out of the examination room, screaming at me in front of hundreds of other Special Agents and nearly hitting me in the back as he slammed the main door on me. I thought this slamming of the door was the big finale of the test, so I remained very calm and collected, thinking, “Nice try, but you can’t rattle me.” I half-expected the door to reopen with him standing there smiling, telling me I’d won, kind of like Willy Wonka at the end of the Charlie and the Chocolate Factory movie.
Well, the door didn’t reopen. They failed me again. This time they failed me for performing “countermeasures.” Which, of course, is ludicrous. I have no idea what a polygraph countermeasure would be. I didn’t know then and don’t know today. I did learn one thing that day though—I came away with a healthy dose of skepticism about the misapplication of “science.”
The crazy thing was, the same day I took and failed the polygraph for the second time was the first day of classes for my graduate program in public health. I guarantee I’m the only public health student ever to fail an FBI polygraph in the morning and start graduate school a few hours later. I sometimes wonder if I would’ve gone to that first class if the FBI had passed me earlier that day …
I think I would have been a pretty good FBI Special Agent, but I’m really glad that guy screwed up in failing me on that polygraph test. It led me to my true calling and passion. Oddly enough, it was still in the field of forensic investigations.
It was during one of my first forensic investigations of a “sick building” that I first saw the power and potential of this burgeoning Healthy Buildings movement. This was no ordinary case of sick building syndrome; it wasn’t a stuffy cubicle farm where people sometimes report symptoms like headaches, eye irritation, dizziness, or allergic reactions. I don’t mean to diminish those types of sick buildings in any way, but this was a hospital and the lives of four people were in jeopardy.
It was Grady Hospital in Atlanta in 2009. Four patients on the same two floors had developed Legionnaires’ disease within the same month: a classic disease outbreak scenario.
Before we go any further with how the Grady Hospital outbreak unfolded, let me give you some quick background on Legionnaires’ disease, a disease that to this day continues to impact many thousands of Americans every year, in and around buildings. Legionnaires’ disease is pretty common—7,500 cases are reported each year, but this is a gross underestimate of the actual number of cases. Legionnaires’ disease is underdiagnosed and underreported. It’s also a deadly disease—1 in 10 people who get it die.4
Legionnaires’ disease was first “discovered” after the infamous outbreak at the convention of the American Legion at the Bellevue-Stratford Hotel in 1976. Over the course of a few days, 2,000 people became sick with a severe, life-threating type of pneumonia. Twenty-nine of those people died.
The scariest part? No one knew the cause. The other 10,000 people who attended the convention were, rightfully, in a panic about their own health. This was front-page-of-Newsweek-type stuff. (In the age before the rise of internet news, making the cover of Newsweek was a big deal.)
The disease was dubbed “Legionnaires’ disease” because of the location of this outbreak—at the American Legion meeting, where members call themselves Legionnaires. After several months of investigation, the US Centers for Disease Control and Prevention identified the cause of the outbreak: a bacterium in the building air-conditioning system that they named—you guessed it—Legionella.
Legionella are naturally occurring waterborne bacteria that can cause a pneumonia-like illness. Out in the natural world, where they are everywhere, their numbers stay small. But given an environment where water stagnates and where temperatures stay lukewarm, they proliferate. That makes a few places in a building a nice home for Legionella. They like to live, and grow, inside the biofilm in water pipes, inside cooling towers on the roof of a building, or, in the case of that infamous American Legion outbreak, in the condensate drains of air conditioners.
Within a building (a hospital, for example), Legionella are also commonly found in “dead legs” of a building’s plumbing system. Dead legs are sections of the plumbing system areas where an old line was cut off, say, during a renovation in which a water fountain was removed. Sometimes, for reasons of efficiency, cost, laziness, or shortsightedness, rather than cutting the water line all the way back to its joint in the plumbing system, the building owner just caps the pipe where the fountain used to be and patches up the wall. Thus, a dead leg is created.
The dead leg of the system is that extension of pipe that is no longer part of the normal circulating water flow, so the water stagnates and stays lukewarm. These are the perfect conditions for Legionella to grow. And importantly, they grow in an area where they can’t be easily “attacked” by residual disinfectant in the building’s water supply (traditionally chlorine), and therefore they act as a source that continually feeds bacteria into the main line of the water system.
But simply having Legionella in water doesn’t mean you’ll get sick from it. The way we can get Legionnaires’ disease is by breathing in the bacteria. So the mere presence of Legionella in a building doesn’t mean there’s a problem; the bacteria must also be aerosolized, or released into the air in tiny droplets. In the case of the American Legion outbreak, the bacteria were aerosolized and distributed around the convention through the air-conditioning system.
Since that time, we have done a much better job of controlling Legionella in our cooling systems. (For the most part, anyway. Outbreaks still frequently occur, like the outbreak in Disneyland in 2017 that impacted 22 people, or the outbreak in Portugal in 2014 that sickened 336 and killed 10.) And in most commercial buildings, there really aren’t many opportunities indoors to aerosolize the water in any meaningful way, other than through spray from the sink or postflush spray from the toilet. (Yes, you read that right.) Hospitals, on the other hand, have a lot of opportunities for aerosolizing water that other types of buildings don’t always have—showers. (Hotels fall into this category, too, and there have been many high-profile outbreaks in hotels.)
Now that you’re armed with the basics of Legionella, let’s go back to Grady Hospital in Atlanta. When we sampled the water in the plumbing lines, sure enough, we found Legionella in the water on the two floors experiencing the outbreak.
To be fair, what happened at Grady Hospital wasn’t, and isn’t, all that unusual. Legionella in buildings, including hospitals, is common. In fact, it has been found in up to 90 percent of US hospitals, according to some surveys.5 And having cases of Legionnaires’ disease isn’t all that unusual either; remember, there are thousands of cases per year in the United States. What was unusual about Grady Hospital was that four cases occurred on the same two floors, in the same month. This was an outbreak.
The leadership team at Grady Hospital immediately recognized the severity of the problem. After trying a few techniques that failed to fully eradicate Legionella from the pipes on those two floors—like shocking the water system with high levels of disinfectant—they hired the environmental consulting firm Environmental Health & Engineering to take the lead. This was the company I worked for right after getting my graduate degrees in public health.
Our charge was to stop the outbreak. Pretty straightforward goal, but pretty complicated in practice. (Of course, that’s why they hired us. As I said to my team anytime we came across a tough project and there were complaints about how hard or complex a particular project was, if it were easy, they wouldn’t have called.) So there I was, newly minted “Dr.” Joe Allen, with my fancy new degree, on a plane with the owner of the consulting company, heading to Atlanta, Georgia, to help stop this outbreak.
The biggest problem, put to me by my astute wife as I packed my bags for the trip, was this: “What the hell do you know about Legionnaires’ disease?” Solid question. She was right, of course. I had graduated from a school of public health, but my dissertation was focused on toxic flame-retardant chemicals found in products in your home and office. I had all of 30 minutes of formal lectures on Legionnaires’ disease in my graduate coursework as part of an Introduction to Environmental Health seminar. Now I was headed to work on an outbreak in a hospital where lives were at stake. Was this gross negligence?
No, it wasn’t. I may not have had formal training on Legionella, true, but I did have real expertise in my field, exposure and risk assessment science. You may ask, “What does that even mean?” It means I was trained to evaluate sources of exposures to chemicals and biological hazards; understand how these toxics migrate through our air, water, and dust in buildings; and figure out how they get into our body, what happens once they are in our body, and how to mitigate the source of exposure. This, it turns out, is precisely the skill set that comes in handy for investigating Legionnaires’ disease—or any other sick building problem.
So I told my wife, “I got this. I’m just applying these exposure and risk science tools to a new problem—bacteria in water.” I was saying this to myself as much as to my wife. “I got this,” I said in my head, to build my own confidence. And I had to be right, because the stakes were high.
But that was actually true then, and it’s still true today. I’ve added new tools along the way, but what I did essentially describes my approach over the course of my career: apply the fundamentals of exposure and risk assessment science to any sick building problem. This has allowed me to work with forensic teams to investigate and resolve hundreds of such problems, from a breast cancer cluster in a commercial office building to a concern about radon emitting from granite countertops. I’ve evaluated the environmental causes of 11 infant deaths on a US military base and led an investigation into the “Chinese Drywall” issue that plagued the Southwest United States for several years around 2010.
But let’s get back to Grady Hospital. So there I was, sitting on that plane to Atlanta next to my new boss, having read every single important published research paper on Legionella since the 1970s over the past 24 hours. He had decades of experience doing this type of sick building work, and together we were, and remain, quite a formidable team. By the time the wheels touched down in Atlanta, we had a plan. Not just to stop the outbreak, but to be sure it never happened again.
I can’t go into the details of what we did at Grady Hospital because of confidentiality concerns—so far I’ve only given you publicly available information—but I will tell you this: we stopped the outbreak. It was a multipronged strategy that used a combination of point-of-use water filters; additional shock treatments of the water system; a permanent chlorine dioxide water treatment system; a rigorous monitoring campaign for indicators of water quality like pH, temperature, and bacterial growth; and, ultimately, upgrades to the hot water heaters and water circulation system. The financial cost for all of this? Greater than $1 million but less than $5 million (I can’t disclose specifics). But that’s nothing compared with the human toll and the cost in lost revenue from closing two floors of the hospital for several months.
There were no new cases from the moment we were involved until the moment the contract ended a few years later (and as far as I know, no new outbreaks after we left). Of course, we didn’t do this alone. We had a team supporting us, and we had a multistakeholder and multidisciplinary team from Grady Hospital of administrators, nurses, infection control experts, water disinfection experts, and doctors. And, most important of all, the building engineers.
Building engineers and facilities managers are the true heroes of our health. (As you’ll see, they are the reason why I often say, “The people who manage your building have a greater impact on your health than you doctor.”) At Grady Hospital, we spent countless hours in the belly of the beast, poring over the plumbing plans and mapping the pipes in the basement with these unsung heroes of Healthy Buildings.
I’m proud of our work at Grady Hospital. It was also a great period of growth for me. I was trained in exposure and risk assessment science, but what I didn’t get in my graduate studies at a school of public health was formal training in a whole lot of building science. And yet, I was beginning to see firsthand that solving the problems of sick buildings required a merging of the skills of building science and health science. In the years following this Legionnaires’ disease investigation, I learned building science on the job by being part of, and leading, teams of building engineers, mechanical engineers, toxicologists, epidemiologists, statisticians, and exposure and risk experts, solving complex sick building issues.
Consulting comes with an immediacy that is missing in academia, where we end every peer-reviewed paper with the sentence, “More research is needed.” In the real world, the question is, “Is it safe for people to be in that hospital right now?” We are forced to make decisions with the best information we have at that moment. For me, the final test on each project was asking myself, “Would I give the same recommendation if my daughter or wife worked in this building?” If the answer was ever no, I never gave the all-clear.
Now, as a professor at Harvard, I’m trying to rectify what I saw as a shortcoming in my own formal public health training. I teach a class that merges building science and health science, to give our public health students an understanding of the importance of the building that I never got. And I operate with the same great sense of urgency that I learned in consulting. I expect the same from everyone on my team. Written on the wall in my lab is, “How will your research impact the world?” We publish plenty of papers, teach many classes, and give frequent seminars. But how we judge ourselves is all about impact.
Along the way I picked up new tools and skills. The most important of these is the focus of this book: business science. And much like the Grady Hospital Legionella outbreak, which opened my eyes to the power of my training in exposure and risk, it was a different Legionnaires’ disease project at a different hospital that opened my eyes to the importance of paying attention to the economics of Healthy Buildings.
For this example, I can’t give you names, places, or dates, because I was hired as an expert witness and the details remain confidential. But I’ll give you big-picture details, with some names and places changed to protect the client.
The setting was the same—a hospital experiencing an issue with Legionnaires’ disease. But this time, someone died. (This is not that uncommon with Legionnaires’ disease outbreaks. It turns out that, in hospitals, about 40 percent of those exposed to Legionella develop Legionnaires’ disease. This is what epidemiologists call the attack rate. Then, once someone is sick [“attacked”], he or she has about a 10 percent chance of dying from the disease. This is what epidemiologists call the mortality rate.6)
As with Grady, I was hired as an expert to evaluate and advise the hospital on the case. By this point, though, I was further along in my career and a seasoned forensic investigator across many sick building issues, having led several Legionella outbreak investigations and many dozens of other projects. I reviewed the hospital’s approach and data and confirmed that the hospital had taken appropriate corrective actions.
This hospital decided to settle the lawsuit with the patient’s family for several million dollars. But what happened next shocked me. To this day, it is stuck in the forefront of my brain, and it is one of the primary motivations for my wanting to write this book.
Someone had died. The hospital had just spent millions of dollars settling this case, and a couple hundred thousand more on the many experts who were involved in the investigation, me included. Being a good public health scientist (and businessperson), I pitched the hospital on a proactive Legionella risk management plan. Because of my experience with previous hospital outbreaks, and the success of the plan we put in place at Grady Hospital that led to no new outbreaks over four years, I was essentially guaranteeing this hospital that they would not have another case of Legionnaires’ disease while we were working for them.
The plan I pitched cost $20,000. That’s it. Against the backdrop of a multimillion-dollar outlay (not to mention the damage to the brand from bad press), I told the owner of the company I worked for that the proposal I submitted was a done deal. In fact, we both thought we were underpricing our service at $20,000. “This is too cheap for what we’re offering,” we thought. We rationalized that this would simply be one of many Legionella risk management plans the company could pitch to hospitals around the country.
We were dead wrong. To my shock, the hospital balked at our proposal. Why? They told me that the price was too high. What?! I was flabbergasted. The public health scientist in me could not understand this in any rational way. How could a hospital that had just had a patient die, a hospital that had just spent millions, not go for a $20,000 plan that would guarantee it would not happen again?
The answer, it turns out, is that I was naïve about the economic drivers of decision-making in buildings and business. What I failed to recognize, but learned after some digging, is that the millions of dollars in settlements were paid by the insurance company, but our $20,000 risk management plan would come out of the facilities budget.
An aha moment for me, for sure. The hospital wasn’t paying the settlement to the family of the patient who had died. (Maybe in some way through higher insurance premiums, but the reality is that this one case is a small drop in the bucket in relation to the many factors that set their insurance premiums.) But the $20,000? Well, it turned out that was a big line item in the facilities team’s budget, and it wasn’t something they could afford. After all, “patient health” wasn’t their charge—that was the purview of the doctors and nurses, right?
Thus came my introduction to the issue of split incentives. For this hospital, the issue reveals itself in misalignment between the goals of the facilities team and those of the business, and a split incentive between the business and the insurer.
Of course, the issue of split incentives is not the exclusive domain of hospitals. Split incentives pop up all over the place in this Healthy Buildings conversation. Real estate investors, owners, developers, and tenants all have different goals, which creates disincentives for investing in Healthy Building strategies. It’s a topic that we will repeatedly come back to in this book, along with ideas for how to present win-win solutions designed to overcome split incentives.
Seeing these split incentives as a barrier to the adoption of Healthy Building strategies over and over is the primary reason why I have made it a goal to spend more time connecting my research on health to a business argument.
This is why I sought out John.
We partnered up and have been talking with business leaders together for several years now. It seems that with every new conversation, many of these leaders are surprised to learn about all of the information and tools that are at their disposal from the health and business worlds, information that could greatly help them but that has not permeated beyond the halls of academia—even some of what we consider the basics.
Here’s an example. Joe was at a conference giving a speech titled “The Nexus of Green Buildings, Global Health and the U.N. Sustainable Development Goals.” The presentation wound its way through scientific data showing how buildings are at the center of our sustainable urbanization efforts, covering everything from indoor health to environmental health. On the latter point, Joe mentioned that buildings were major contributors to air pollution, as most of the energy they use comes from fossil fuel sources. The story necessarily brings in the basics of outdoor air pollution and the health effects of one of the most studied air pollutants: PM2.5.
At the end of the presentation, Joe was engaged by a C-suite executive from a company that is involved in selling air filters for buildings. This executive asked, with a straight face, “Is there any data on the health effects of PM2.5?”
For those of us in the world of public health, this would be akin to someone asking an astronomer, “Is there evidence that the moon goes around Earth?” The scientific literature on PM2.5 could quite literally fill a hundred-story building. PubMed lists nearly 7,000 scientific papers on PM2.5 and health, with over 1,000 papers published in each of the past few years. (That’s about 3 papers per day.) Here are some examples of what we know about PM2.5:
For reference, the current ambient exposure limit in the United States is 12 μg / m3, and the annual average in Los Angeles for the past few years ranged from 13 μg / m3 to 19 μg / m3. In Beijing and New Delhi, PM2.5 concentrations have exceeded 1,200 μg / m3. (This notation is common for talking about the amount, or concentration, of air pollution in the air. This is read as, “10 micrograms of PM2.5 for every cubic meter of air.”)
Joe’s mouth was agape for a full 20 seconds. But that’s not the only time this has happened. Here’s another equally shocking example, from someone who controls the health of millions of people each day. Or rather, millions of kids each day.
US Secretary of Education Betsy DeVos did an interview with 60 Minutes in 2018 in which she said something that should make anyone reading this book fall off his or her chair: “We should be funding and investing in students, not in school buildings.”10
What?! As if the two aren’t directly related! There are over 200 scientific studies documenting how the school building influences student health, student thinking, and student performance.11 The facts are astounding:
To be fair, DeVos is not alone in her lack of knowledge of the scientific literature. Most people don’t have this type of scientific data at their fingertips. But most people can be forgiven for not knowing; DeVos is in a leadership position in an organization that depends on knowing this type of stuff. And you, as a reader of this book, are likely finding yourself in that same position—making key decisions about the health of people, and your business, without yet having a full understanding of how health science, building science, and business science can be leveraged to your advantage.
While these stories give us the opportunity to point to the folly of others, really the only thing these two examples show is our own failing. That’s right. We are the ones who should be laughed at. Here we are, sitting on mounds of scientific data, laughing at others for not putting that data to use when, in reality, nearly all of that data is locked up in dusty scientific journals full of inaccessible jargon, caveats, uncertainty, and titles like this: “Cytotoxicity and Induction of Proinflammatory Cytokines from Human Monocytes Exposed to Fine (PM2.5) and Coarse Particles (PM10–2.5) in Outdoor and Indoor Air.” This style of writing is great and informative for scientists, and in fact necessary—it’s what we expect and want to see—so we don’t mean to minimize the value of the scientific process. But it’s no wonder that so much of this information can’t be put to use by practitioners. Collectively we, the scientific community, need to work harder to translate the hard science into accessible language and actionable recommendations.
With this book, we aim to correct this failing. We have read the scientific papers and business case studies so you don’t have to. Our goal is to now bring the rich science of our fields into the hands of practitioners and to make sure any future Secretary of Education, or anyone else in control of the health and productivity of millions of people in buildings, never again utters a phrase like, “We need to invest in our people, not our buildings.”
To be clear, we won’t just talk about the academic literature. We’ll also draw on our knowledge gained from years of practice working with leaders in the building space. We will show you how to use all of this data and information to your advantage, so you will see that when you focus on optimizing buildings for health, your business wins, too.
We structured the book in two parts. In Part I, we make the case for Healthy Buildings. In Chapter 1 we began by sharing some motivations for our work together on this book and the value in having crosstalk between our two disciplines—health and business. In Chapter 2 we describe the challenges and opportunities in front of us all. To have a discussion about the role of health and buildings without discussing the gigantic forces that are shaping and reshaping this industry would be a fool’s errand. We show how 10 global mega-changes are shaping our world, our businesses, our buildings, and our health:
They all converge on one point: Healthy Buildings.
Grounded in the global forces at work, we will quickly move to the primary goal of this book: to make the business case for Healthy Buildings in a straightforward manner. We present the irrefutable evidence that the indoor environment is a key determinant of our health and productivity, and show that a business strategy that focuses on the people in your building drives bottom-line performance (Chapter 3). Then we show you how to put the building to work for you (Chapter 4). We give you the economic evidence demonstrating how even just one building factor—ventilation—can lead to significant enterprise-wide gains, and show you how to create and capture this value (Chapter 5).
Once you are well versed in these 10 global mega-changes and the straightforward business case for Healthy Buildings, you will be right to ask, “So what else matters, and what do I do now?” We know you’ll ask that because everyone does.
In Part II, we expand our discussion of what it means to have a Healthy Building and give you tools to operationalize A Healthy Building Strategy. In Chapter 6 we bring to life the science behind the 9 Foundations of a Healthy Building, putting the tools and knowledge of health science and business science at your fingertips, complete with recommendations you can implement today for each foundation. In Chapter 7 we explore the products we place in our buildings and how they influence health, and then we explore Healthy Building certification systems, the economics behind them, and what we think are the key elements that should define any Healthy Building certification (Chapter 8). Last, recognizing that we can’t improve what we don’t measure, we move to a discussion about how to use Health Performance Indicators, or HPIs, in tandem with Key Performance Indicators (KPIs) and new sensor technologies, to track the impact of your Healthy Building strategy (Chapter 9).
We close our book with two chapters that are really about expanding the winner’s circle around the Healthy Building movement. In Chapter 10 we expand the Healthy Buildings conversation to include health impacts beyond the four walls of the building. We will dive into the building-energy-health-climate-resilience nexus and explore the business opportunities, and challenges, around quantifying the social performance of real estate and making decisions about resiliency in the face of a changing climate. In Chapter 11 we explore how to scale the Healthy Buildings movement from flagship projects to business as usual by asking, “What’s now?” and “What’s next?” Finally, we conclude with a synthesis of the key arguments and a clear demonstration of how everyone wins in this Healthy Buildings movement.