The+built+environment+and+public+health

by Kate Hildahl

=I. Introduction = toc The built environment intrinsically links with human health. Loosely defined as any man-made alteration to the physical world, it has far-reaching impacts on quality of life. In the past, the study of environmental health focused primarily on chemical and biologically active agents, but this definition has since expanded to include the broader influence of the physical environment. These additional factors include urban and housing development, transportation systems, industrial practices, food and water management as well as the degree to which social interaction is promoted by civil infrastructure. 1  This article will examine the history of public health in Italy and efforts to improve health through manipulating the built environment. Rome will then be used as a case study to evaluate the effect of its built environment in present day. Lastly, a future outlook is explored for managing healthy cities.

i. World standards for environmental health
 Monitoring the built environment can have a profound effect on the overall well-being of people within a city. In a 2009 [|report] for the World Health Organization (WHO), urban planning was explored as a method to improve physical, mental, and social health. A well-designed environment can promote health by encouraging physical activity, social interactions and networking, and liveliness. Designing an environment recognizing these factors includes protecting green space and removing deterrents to being outdoors, as well as monitoring sanitation, water quality, and waste management. Furthermore, cities should be equipped to handle increased flooding or other various climate change induced threats. This requires detailed plans for sustainable energy, improved housing, and better air quality. 2 Oftentimes the limiting factor in improving public health conditions lies in challenges to modifying existing infrastructure. In 2010 at the Fifth Ministerial Conference on Environment and Health, the European Region of WHO developed the [|Parma Declaration on Environment and Health] in Parma, Italy. The document focuses on several key points: the environmental health impacts of climate change, health risks to vulnerable populations, inequalities across socioeconomic class and gender, the presence of noncommunicable diseases and persistent chemical toxins, and the interplay between urban development and food and water safety. The document prioritizes action through providing safe water and sanitation, safe environments for physical activity and nutrition, improved air quality, and monitoring the chemical, biological, and physical environment for disease causing factors. 3  More importantly, it provides a model for observing where the built environment fails to meet health standards.

=II. Italian public health history =

The Ancient Romans version of city planning was based on military strategy and defense. The central city and roads were intentionally placed. After the fall of the Roman empire, this connection between structure and function was lost. Focus returned after outbreaks of infectious diseases in the 19th century. Increasingly industrialized cities saw an uptick in overcrowded housing, human waste, and poor sanitation. 4  These issues were reflected across major cities in Europe as well. In response to the cholera outbreak in the 1840’s, England conducted a study on the hygienic standards of its cities culminating in the development of a public health act. This became a model for other European cities experiencing similar urban deterioration. 5  For Italy, this began after its unification in 1861. Measures to improve hygienic conditions helped drop the crude mortality rate from 28/1000 inhabitants per year to 21/1000 between 1888 and 1897. 6  Improving upon this, the first housing specific policies, the Luzzati Law in 1903 and the consolidation bill on public housing in 1908, regulated housing conditions of the poor in the form of financial aid. Furthermore, during this time period the Istiuti Autonomi Case Popolari (Institute for Social Housing) was founded. 6,7  Engineers designing new buildings were required to follow building regulations for baseline lighting and ventilation standards. Another reaction to the outbreak of infectious disease in the 1800’s was the establishment of sewer systems to remove fluid waste from cities. The ancient Romans already utilized this method albeit whether for sanitation, convenience, or other reasons is unknown. Removing waste clearly addressed major health issues, and in addition to fluid waste, people began burning solid waste and generating landfills. Although reduction and treatment of waste would have proved to be better, these methods of diluting waste became the standard. Ultimately this did improve health conditions, and proved that engineering could address health issues caused by housing and sanitation. This time period also saw an increase in literacy, nutrition, and vaccination, further emphasizing the number of factors that influence the well-being of society. 6

<span style="font-family: Verdana,sans-serif; font-size: 10pt;">Italy then faced new issues following the end of the Second World War. Cities were heavily bombed, a housing shortage prevailed from the fascist regime and construction activity declined with the growth of other industries. This led the government to develop the Fanfani Law or INA-Casa, a seven-year plan to build 350,000 housing units. 7 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> This policy plan continued for 50 years despite intentions for it to be a short-term solution. Even with its success, the first housing strike occurred in 1968, with people protesting that the state should play a larger part in regulating housing prices. This ended with the ten year Gescal plan (Gestione Case Lavoratori), which included an emphasis on placing workers in housing with access to green and social spaces. Despite these efforts, health inequality persisted through socioeconomic classes. After this brief period of economic growth, Italy faced a debt crisis in the 1980’s. Housing policies past from the State to regional governments, public funding disappeared, and the industry underwent privatization. The housing market reached its peak in 2006, and although 80% of Italian families own their homes, many begin to face housing issues including shortages and building deterioration. Varying by demographic, much of the demand stems from low-income groups without the resources to compete in the housing market. This led Italy to its current legislation, The Housing Plan – Piano Casa, an expansion of public and social housing. Even with this latest plan, there is no national standard of regulation for urban regeneration. 7 In addition, the majority of efforts in the past<span style="font-family: Verdana,sans-serif; font-size: 10pt;"> to improve the conditions of the built environment focused solely on housing and basic sanitation.

=<span style="font-family: Verdana,Geneva,sans-serif;">III. Case Study: Rome =

<span style="font-family: Verdana,Geneva,sans-serif;">i. History
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">The current conditions of the city of Rome are key to understanding the interplay between the built environment and health. The city must maintain its historical identity and heritage throughout modern development. As the capital of Italy, home of the Catholic Church, a world tourist destination, and a center of historical ruins and architecture, Rome faced issues of industrialization, population growth, and spatial expansion. Rome’s response to this growth required plans to guide city development. The first went into effect in 1883, but proved to be ineffective. Then in 1910, a liberal Roman mayor, Ernest Nathan, generated a second plan that put reforms into place that greatly impacted the city; the plan increased public education, land examination, citizen participation in politics, and city control of important services like transportation, electricity and water. The fascist regime of Mussolini stifled these reform attempts, and a third unsuccessful plan was adopted that displaced many poor residents and migrants to the city’s outskirts. Unlike much of Italy, Rome was not heavily bombed during the Second World War and much of the city remained structurally intact. In the late 1950’s there was little traffic and very few traffic lights but as the population began to increase, the first of three development plans was generated, focused on meeting the growth of Rome by building outward from the historic core. This was achieved through both government and residential action. But, a rapidly growing population resulted in new housing around the core, violating the General Plan of 1931. In response, a fourth general plan was established in 1962 to further combat this growth. Similarly, this plan proposed routes to divert traffic out of the historic core and move both commercial and residential growth outside the city center. It succeeded in generating housing outside the center, but failed to receive sufficient funding to achieve all of its goals. 8 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> In 2014, Rome’s population stood around 3 million and the city provided 1.5 million jobs. 9 <span style="font-family: Verdana,sans-serif; font-size: 10pt;">Rome’s ancient architecture and infrastructure must manage and house this massive population moving through it every day.

<span style="font-family: Verdana,Geneva,sans-serif;">ii. Transportation & physical health
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">Transportation is one of the largest factors of the built environment directly affecting public health and the ease to which people are able to move throughout the city. Typically cities offer several common modes of transportation including walking, biking, private vehicle use, and public transportation. The proximity of where people live and work factors heavily in which route of transportation they will use.

<span style="font-family: Verdana,Geneva,sans-serif;">a. Walking
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">The ability to walk within a city has direct physical benefits. WHO [|studies] and data collection show that physical inactivity is “…a risk factor comparable to smoking…Regular walking and cycling reduces mortality by ca. 10%.” 13 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> Physical inactivity is considered the fourth greatest risk factor in death worldwide. Riding a bike or walking for 30 minutes per day can reduce mortality rates by 30%. 10 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> In other words, the ability to walk within a city can significantly improve physical health. But, in a separate [|WHO European Health and Behavior study] Italy ranked lowest in physical activity. For those aged 15 and below, only 12% of boys and 5% of girls reported themselves as physically active. For the population aged 15 years and over, 51% of men and 61.8% of women failed to meet criteria in order to be considered sufficiently active according to WHO. 12

<span style="font-family: Verdana,sans-serif; font-size: 10pt;">Walking is a preventative health measure. Walkable urban neighborhoods generally associate with higher physical activity rates and lower incidence rates of obesity, depression, and drug use. D D’Alessandro, a professor of civil building and environmental engineering at Sapienza University in Rome, helped develop a study to evaluate the walkability of urban neighborhoods through direct observation. Termed the Walking Suitability Index of the Territory (T-WSI), the study measures the walkability of every street in a defined urban area. Twelve factors were rated as either excellent, good, poor, or bad and then divided into four categories: practicability, safety, urbanity, and pleasurableness. Algorithms weighted the factors for a final index score. The study first tested Rieti, a small city in Central Italy. In summary, the streets showed good scores for pleasurableness and practicability, but scored poor on safety, especially lacking in protection from vehicles, adequate lighting and safe crossing. 14 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> Although this specific analysis technique has not been applied to Rome, easy comparisons can be drawn. In terms of safety, Rome by far experienced the most pedestrian fatalities by region in Lazio. As seen in Table 1, Rome accounted for 70-85% of casualties in Lazio between 2001 and 2015. 15 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> Promisingly, the number of fatalities has gradually decreased throughout this time period. Road safety continues to be an issue though. Many non-major roads do not have sidewalks and cars and pedestrians share the narrow streets. T <span style="font-family: Verdana,sans-serif; font-size: 13.3333px;">hese unfavorable environments are depicted in Figure 1. <span style="font-family: Verdana,sans-serif; font-size: 10pt;">Furthermore, major streets with crosswalks do not cater to pedestrians who often spend several minutes waiting for a green light to walk. This encourages pedestrians to cross when there appears to be no on-coming traffic. Even when given a green light aggressive turning cars will cut crossing pedestrians off. An example of this is shown in Figure 2. The connectivity of these streets also play a role in promoting walking. Some sidewalks abruptly end, and some streets lack crosswalks in ideal places. These factors diminish the favorability and safety of walking in Rome. Table 1: Pedestrian mortality rates of the cities within Lazio from 2001 to 2015 (Adapted from [|Instituto Nazionale di Statistica] <span style="font-family: Verdana,sans-serif; font-size: 13.3333px;">).





**<span style="font-family: Verdana,Geneva,sans-serif;">Areas for improvement **
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">Rome currently participates in a European Union funded study termed the Physical Activity Through Sustainable Transport Approaches, conveniently giving the acronym PASTA, that focuses on encouraging active mobility in cities by integrating public transport infrastructure with walking and biking. 10 In addition to participation in programs like this that aim to integrate modes of transportation, there are several steps that can be taken to promote walking within the city. Based on the T-WSI test, areas to specifically target include increasing the number of safe street crossings, improving the quality and quantity of pedestrian sidewalks, and working on better street lighting.

<span style="font-family: Verdana,Geneva,sans-serif;">b. Biking
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">Similar to walking, biking offers both mental and physical health advantages over driving in an urban city. Unfortunately, biking opportunities in the city of Rome are rare. Major roads do not offer bike lanes, nor do the narrow cobble-stone roads cater to narrow bike tires. A typical case indicative of the biking environment is shown in Figure 3a. Figure 3b then shows one of the only pathways offered to bikers in the inner city down by the Tiber River. These boulevards were built when the walls went up as a measure of protection for the city from flooding. Although this path is safe from cars, it is isolated and few bother to venture down to the paths as a means of transportation. In the summer, there are bars, restaurants, and tent vendors to make these more inviting spaces, however in the other seasons the paths remain mostly abandoned, desolate, and often flooded with river water as shown in Figure 4. Furthermore, Rome had a bike share program inaugurated in 2010 by ATAC, that failed in a matter of a few years due to a lack of use and absence of safety measures to protect bikers from high vehicular traffic volume 24 <span style="font-family: Verdana,sans-serif; font-size: 10pt;">. Based on the lack of a safe and inviting environment, few residents use biking a means of transportation within the city. This leaves public transportation and personal vehicles as the only other available options. In Rome, around 60% of travel is via private vehicles and 40% public transport and walking. 9



**<span style="font-family: Verdana,Geneva,sans-serif;">Areas for improvement **
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">In 2015, the Mobility Agency of Rome released a new traffic plan for Rome. The plan is described as a way to create a healthier city by promoting sustainability and active mobility. Specifically, it aims to “reconnect the city, reduce the use of private vehicles, recover and redistribute public spaces, improve the environment and the quality of life with limited financial resources.” The plan will focus on incorporating available infrastructure, increasing public transportation efficiency and maintenance efforts, connecting with the railway system, and promoting sustainable mobility and active travel. 11 <span style="font-family: Verdana,sans-serif; font-size: 10pt;">In addition to this traffic control and participation in the PASTA study discussed above, further efforts were put forth to specifically promote city biking. Each borough within the city aimed to identify environmental islands, areas for pedestrians, and to participate in a road safety challenge to be implemented before 2018. In terms of improving the cycling within Rome, the city has been working with Mobility agencies and cyclist associations. Working together, they identified 130 km of potential paths meeting requirements for safe biking. These bicycle routes were ranked by priority and available resources immediately went to designing them starting in 2016, with the goal of finishing by 2018. 15 At the end of summer 2017, there has been little visible progress to achieve these goals, so it will be interesting to see if any routes are truly implemented by the end of 2017.

<span style="font-family: Verdana,Geneva,sans-serif;">c. Public Transportation
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">In addition to physical health benefits, walking and biking also reduce road congestion. Lowering the number of vehicles on roads in turn improves the safety of roads. The ease of mobility within a city also affects the mental health of a population. In other words, a fluid and user friendly public transportation system can reduce mental stress and frustration. A study by Giulia Melis et al of the Higher Institute on Territorial Systems for Innovation in Torino Italy, showed a link between accessibility of transport services, urban density, and use of antidepressants. 16 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> Several public transportation options exist within Rome: metro lines, city buses, and trams. Every year, Rome moves around 900 million bus riders, 50 million tram users, and 265 million metro users. 15 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> All of these public transportation choices use the same ticket, at € 1.50 for a 100-minute period, various prices for day long periods, or €24 for a week. For city transportation, this system successfully manages a large population and demand. Decently priced, tickets are easy to acquire at frequent newsstands and tabacchi. The metro is fairly simple to use, with three lines that run from 5:30 AM to 11:30 PM, making it user friendly and an ideal commuter option if the route is applicable. Figure 5 shows people waiting for the metro to arrive. However the metro does not cover a large portion of the city, requiring the use of buses. Similar to other city bus systems, routes have numbers and the stops of each route are listed at each bus stop. Unfortunately, the bus system fails to be as reliable as the metro. Most major bus routes can be relied upon to show up during rush hours, but during off hours or at less popular stops, buses can run more than a half hour late or not show up at all. Buses have monitors that give real-time information on bus status. This information can be very inaccurate or entirely wrong resulting in many people waiting around for public transportation to come as seen in Figure 6. This provides another source of frustration for use. Transportation apps on phones can be useful, as they directly track buses. Buses that are not tracked, generally do not show up. Although slightly more reliable, the trams also do not always run on schedule. In summary, although fairly extensive with the integration of multiple modes of travel, the inefficiency in the public transportation system and high usage rates cause frustration and anxiety.



**<span style="font-family: Verdana,Geneva,sans-serif;">Areas for improvement **
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">The connection between public transportation and public health can easily be strengthened by addressing demand and recognizing areas for improvement. Currently, there is s <span style="font-family: Verdana,sans-serif; font-size: 13.3333px;">ignificant work being done on the metro including the opening of a new C line and extension of the B line. The C line is meant to provide a means for more rapid transportation of large masses. Furthermore, t <span style="font-family: Verdana,sans-serif; font-size: 10pt;">he Roma ATAC website describes the use of an integrated payment method as a way to facilitate mobility in Rome and Lazio. In 2010, ATAC merged with the metro and trambus systems to become a leading urban mobility operator. In 2014 it served 1.3 square kilometers, covered 154 kilometers of public service, and transported over 1.3 million passengers. The joint management covers buses, trams, electric vehicles, metro lines, railways, park and rides, metered street parking, and attempts to integrate public and private transport. Furthermore the mission statement given includes increasing safety, accessibility, and comfort for both users and pedestrians. Specifically mentioned is recognition of the impact on the quality of life of everyone living in the city. By raising quality standards, introducing measures to reduce traffic flow, and providing as much information as possible to the public, this integrated system can <span style="font-family: Verdana,sans-serif; font-size: 13.3333px;">strengthen the transport system <span style="font-family: Verdana,sans-serif; font-size: 10pt;">. 17 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> With the merger of ATAC and Servizi per la Mobilita del Comune di Roma, the mobility agency of Rome, public transport and traffic management came under the control of one model. The city of Rome even requires companies with 30 or more employees to have mobility managers, who help with plan development. 9 Clear measures are being taken to improve public transportation, although continued action will be required to meet growing demand.

<span style="font-family: Verdana,Geneva,sans-serif;">d. Private Transportation
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">Use of personal cars and motor vehicles is high in Rome. Similar to public transportation, frustration and mental stress from private transportation plays into its effect on public health. Figure 7 shows a map of Rome's road usage, revealing a large number of heavily used roads. During 2014, around 2 million cars and 500,000 motorcycles were registered to citizens. 9 This high traffic volume has a negative effect on both mental health and air quality, which will be discussed in more detail below. There are few measures to discourage citizens from driving, as parking is allowed in most places at only one euro per hour. An easy way to monitor vehicle flow is by increasing road use and parking prices but this is not generally tracked. Although as discussed above in walking, many side roads narrow, making it difficult to maneuver around pedestrians which can deter people from driving in certain parts of the city. In addition, some roads closer to the historic center of Rome close to private vehicles to promote the use of public transport.



**<span style="font-family: Verdana,Geneva,sans-serif;">Areas for Improvement **
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">The best way to improve private transportation is to decrease its usage which is implicit in participating in the PASTA study mentioned above and work to improve efficiency and convenience of public transportation. In addition to these improvements, efforts to reduce vehicle use have also been implemented. This is being done through use of restriction zones which are shown below in Figure 8. The closer one is to the city center, the stricter the restrictions get. Deterrents include monitoring car emission levels, vehicle type, permits, and parking fees. In some places only walking and electric based transportation is allowed. The six zones all have specific objectives and work to balance the need for all modes of transportation. For example, Zone 1, the central zone, ideally severely minimizes private vehicle traffic, and heavily promotes public transportation, walking, and biking. In order to do this, the entire area is divided into smaller segments, termed environmental islands, where routes for pedestrians and cyclists can be identified and established for safety. Other possible methods suggested to reduce traffic flow are the promotion of vehicle sharing systems, reducing cross-traffic, reorganizing parking, adding additional crosswalks and sidewalks, and improving road signs. 11 In order to enforce some of the goals defined in this plan, Rome implemented limited traffic zones with the use of electronic gates. This so called access control system began in 1989 and initially used paper permits. In 1994, the system expanded to include fines for violating the permit zones. In 1998, the system became completely automated and was fully functional in 2001. 9 A key to this plan’s success was financial measures instituted to obtain permits. Within three years of operation, data showed a decrease of 15-20% of traffic flow, a 4% increase in traffic speed, and a 5% increase in public transportation use. Unfortunately, the additional fees places on vehicles, led to higher use of polluting two-wheeled motorcycles and motor scooters. 9



<span style="font-family: Verdana,Geneva,sans-serif;">iii. Air Quality
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">Regardless of which type of vehicle used, clear trends exist between proximity to high traffic roads and public health consequences of air pollution. Particulate matter, less than 2.5 micrometers in diameter (PM2.5), levels in the air induce increase mortality and hospitalization. These fine particles are produced during combustion and in some agricultural and industrial processes. In urban cities, vehicle emission dominates as the source of air pollution. A [|WHO study] in 2015 estimated a cost of 1.6 trillion US dollars for diseases and deaths related to air pollution in Europe. A global mean ambient particulate matter level is 2.5 μg/m3. As show in Figure 9, in Rome it levels at 17 μg/m3. 18 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> Studies often use distance from major roads and traffic density to correlate with health effects. Giulia Cesaroni et al reported a high portion of the population exposed to traffic in Rome in the Rome Longitudinal Study. Interestingly, the authors reported a higher number of the elderly and those of medium socioeconomic position living in these areas based on historical stratification of the city. 19 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> The effect of the Mobility Masterplan from Roma Capitale has positively impacted air pollution. Between 2013 and 2015 a change of mobility towards active transport (i.e. biking, walking) by about 10%, decreased CO <span style="font-family: Verdana,sans-serif; font-size: 5pt;">2 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> and CO emissions by about 15%. 11 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> This shows the effect that manipulating the built environment can have just by moving towards active transport and improving public transport.



<span style="font-family: Verdana,Geneva,sans-serif;">iv. Green Spaces
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">The presence of more green spaces within a city also promotes physical exercise and walking. In addition, mental health is equally important to physical health, and has a high influence in cities. While pollution, housing, and transportation are widely explored in public health analyses, mental health aspects are often left out. Previous studies show links between mental health and spatial distribution of the built environment, traffic, noise pollution, safety, and access to green space. 16 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> Increasing green space reduces environmental pollution and has water drainage benefits. These spaces offer a place for social gatherings free of bustling urban sprawl. As can be seen in Figure 10 20 <span style="font-family: Verdana,sans-serif; font-size: 10pt;">, Rome scores only average as a major city in Europe on green space availability. This study collected data about urban morphological zones from the European Environment Agency and mapped green urban areas across city areas. Results showed Rome with between 2-16% green space coverage within the city as well as between 10-38 m 2 green space per capita. 20 Figures 11a and 11b 21 give a general sense of the extent of green space within Rome. Despite these statistics, Rome does tend to do better than other Italian cities in this area, although this may just be due to the large size of Rome itself. 2009 data shows a density of public green area in municipal spaces as 27.5% in Rome versus the Italian average of 9.3%. A similar trend exists in the availability of public green areas per capita. 15





v. Water and Food Safety
<span style="font-family: Verdana,sans-serif; font-size: 10pt;">Adequate and nutritious food intake is a cornerstone of health. Factors affecting the food system within a city include source proximity, quantity, and type of food available. The Roman economy primarily comprises of tourism, banking, technology, and general services, lacking in heavy industrial practices and agriculture. Much of the food comes into the city from surrounding areas in Lazio, with high yields of fish, vegetables, and grapes. In 2008 [|WHO] estimated 54% of the adult population in Italy to be overweight, with a prevalence of obesity at 19.8%. In terms of nutrition, Italy intakes 11.3% of calories from saturated fats, slightly higher than the max of 10% set by WHO. In 2009 Italy had a fruit and vegetable supply of 885 grams per capita per day, higher than the WHO recommendation of at least 600 grams per day. Additionally, Italy reports a high salt intake of 11 grams per day for men and 8 grams per day for women compared to WHO's recommended 5 grams or less per day. Lastly, 50.2% of the population fails to meet an ideal intake of 100 μg/L of iodine per day. 22 <span style="font-family: Arial,sans-serif; font-size: 10pt;">‍ <span style="font-family: Verdana,sans-serif; font-size: 10pt;">Several <span style="font-family: Arial,sans-serif; font-size: 10pt;">‍ <span style="font-family: Verdana,sans-serif; font-size: 10pt;">measures can be undertaken to improve the food quality and intake in Italy. First, incentives can be provided for the food industry to make changes to the process of growing, supplying and labeling foods. Second, consumers can be educated through printed sources, electronic sources, schools, and conferences.

<span style="font-family: Verdana,sans-serif; font-size: 10pt;">Historically, Rome laid the groundwork for water practices and management. In terms of basic sanitation, the first sewer system was established in Ancient Rome. Also, basic preventative health measures were taken to provide safe potable water to the city. Rome recognized the importance of a steady supply of water for both domestic and health purposes. 11 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> Aqueducts brought water to Rome from varying sources, some of which were cleaner than others with the best water coming from springs and the worst from rivers. The Romans would not have known about bacterial, viral, or potential carcinogenic toxins present in water, but did have an understanding that some drinking sources were safer to consume than others. Although unlikely aware of ground pollution, the Romans also took water from high sources which was necessary for the design of aqueducts. Furthermore, there were drainage measures and a sewage system consisting of the Cloaca Maxima. 23 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> Whether unknowingly or not, these measure greatly reduced the outbreak of diseases that would later hit Europe including typhoid, cholera, and the plague. Waste was sent straight into the Tiber River, making it unsanitary. This practice has continued to current day, making the Tiber one of the most polluted rivers in Europe. With this groundwork laid by the Ancient Romans, infrastructure already reflects public health measures that would later be adopted worldwide. In terms of current drinking water, Rome enjoys a sustainable supply of water into the city, and the Center for Disease Control describes both the food and water in Rome to be safe to consume with normal precautions. Although the water tends to be slightly hard, there are no health disadvantages to consuming it normally. Water services in Italy changed after reforms in 1994 under the Galli Law. This law connected all of the different water service: aqueducts, purification systems, and the sewage system. These reforms are not complete but aim to better manage and track the status of water availability and quality within Italy. More can be read at: <span style="color: #0000ff; font-family: Verdana,sans-serif; font-size: 10pt;">UW Foreign and International Law Database

=<span style="font-family: Verdana,Geneva,sans-serif;">IV. Future Outlook = = = <span style="font-family: Verdana,sans-serif; font-size: 10pt;">In order to maintain health in cities, several areas must be addressed. First, a plan should be put in place for maintaining air, water, and land quality while reducing waste. This would include planning for more open space and sustainable urban transportation. In addition, new building projects should utilize climate appropriate material, which also protect from noise pollution and allow for natural lighting and ventilation. In Rome and other historic cities, this type of planning can prove to be more difficult due to restraints placed on buildings or surroundings as historic places of significance. Venice in particular faces this issue. As a city with ancient framework, it faces many modern environmental challenges to maintain it. Building new structures is nearly impossible, and renovations to existing buildings is strictly prohibited. Therefore attempting to modify the built environment while being conscientious about health faces many additional challenges. Comparisons can be drawn from Venice to any city that consists of ancient infrastructure protected as historical. In Rome, many buildings over the years have been readapted for new purposes. This is promising because the most sustainable and economical way to build a city is by renovating what is already there. But, moving forward these reuse projects should take note of the impact the changes have on human health, whether directly or indirectly.

<span style="font-family: Verdana,sans-serif; font-size: 10pt;">In one study, PASTA generated a theoretical framework predicting the transport decisions people will make. Social context, physical context, and individual level determinants all factor in. Social context includes urban transport and related policies, social norms, and the characteristics of a certain community. Physical context is determined by infrastructure for walking, biking, public transport, and motorized traffic. For these variables, amount, quality, connectivity, safety, and navigability play a large role. On an individual level, perception and habits are most influential in making personal decisions. 10 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> Frequent unpleasant experiences with the buses in Rome, for example, are a deterrent to continuing to use the bus as a means of transportation. Combining these behavioral characteristics with physical and social determinants provides valuable guidance for engineering solutions to promote active travel.

=<span style="font-family: Verdana,Geneva,sans-serif;">V. Conclusion =

<span style="font-family: Verdana,sans-serif; font-size: 10pt;">As any urban city with building deterioration, industrial sprawls, and crowded populations, Rome experiences challenges to maintaining a healthy environment for citizens. Efforts to create healthy and sustainable cities involve incorporating natural water and energy resources and acknowledging specific threats to areas by climate change. Past uncontrolled urban and building growth has made some areas vulnerable to natural disasters and disease outbreaks, but monitoring and planning city expansion to facilitate a healthy community greatly reduces the likelihood of these risks. New policies can help protect cities from environmental change and prepare for emergencies. Often more difficult is planning for future dangers and threats that are not obvious and do no threaten the current needs of a population. The Italian Ministry of Environment, Land and Sea does have a national health adaptation plan. 23 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> Furthermore, monitoring the housing market is critical, as low-income populations are often forced into unhealthy living conditions, geographically distant from social services. 6 <span style="font-family: Verdana,sans-serif; font-size: 10pt;"> With the current migrant crisis occurring in Italy and around the world, the built environment and its connection to public health must be carefully monitored. An influx of immigrants results in a rapidly increasing population. The built environment can be designed to adapt to this and provide a healthy environment for all.

Overall, I think Rome has successfully maintained its identity throughout the years despite industrialization and a massive increase in population. Sometimes this has come at the expense of opportunities to improve living conditions or the health of the population overall. There is certainly an interchange between modernizing cities for a more sustainable future and protecting historical identity and culture. In particular, Rome manages to move a large population through its city center without putting its ancient architectural structures at risk. While this puts a strain on housing demand close to the city as well as transportation options, it preserves key characteristics of the city itself. In addition, despite the statistics discussed above about green space, there seems to be little escape from urban sprawl in the inner city except for small pockets in parks. In that sense, the city has not been successful in limiting the removal of its natural spaces. Rome should continue to search for ways to improve access to green spaces as there is such a strong link between the environment and mental health. Based on all the factors that contribute to public health within a city, key challenges for Rome are integrating transportation, housing, and environmental concerns into further city development. As a major world city that has previously faced transition, Rome will likely be one of many on the forefront of world-wide challenges that we are likely to see in the upcoming years. As the world's population continues to increase, it will worsen many of these preexisting issues. Beyond that, areas that have not been significant issues for Rome before, like access to clean food and water, will become more important. Changes in the past have come slowly, but in the coming decades it will be critically important that effective and compassionate changes can be made quickly to combat overpopulation, global warming, and inequality.

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