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9 Key Findings, Guiding Principles, and Priority Issues for Action This chapter builds on the foundation laid in Chapters 1–8 to draw out the overarching themes of the report and present its primary recommendations. OVERVIEW OF THE COMMITTEE’S WORK The committee’s statement of task charged it to summarize the current state of scientific understanding of the effects of climate change1 on indoor air and public health. The US Environmental Protection Agency (EPA), the report’s sponsor, provided three examples of key questions to address: • W hat are the likely impacts of climate change in the United States on human exposure to chemical and biological contaminants inside buildings, and what are the likely public health consequences? • W hat are the likely impacts of climate change on moisture and dampness conditions in buildings, and what are the likely public health consequences? • W hat are the priority issues for action? While there is substantial scientific literature on the effects of outdoor environmental conditions on the indoors, of indoor environmental condi- 1 This report uses the term climate to refer to prevailing outdoor environmental conditions— temperature, humidity, wind, precipitation, sea level, and other phenomena—and climate change to refer to modifications in those outdoor conditions that occur over an extended period of time. 239

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240 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH tions on health, of climate change on health, of climate change on build- ings, and of buildings on climate change, there is almost no literature on the intersection of climate change, indoor environmental quality (IEQ), and occupant health—and much of what little literature there is summarizes information on one or more of the above categories rather than offering original contributions. The committee was thus required to approach its task by reviewing the available information on components of the climate- change–IEQ–occupant-health nexus and deriving its findings, conclusions, and recommendations and identifying research needs on the basis of a syn- thesis of that information. It considered peer-reviewed papers, government and research organization reports, and authoritative literature reviews, notably publications in the National Academies’ America’s Climate Choices series (NRC, 2010a,b,c,d), the National Research Council reports Green Schools: Attributes for Health and Learning (2006) and Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence (2008), and the Institute of Medicine study Damp Indoor Spaces and Health (IOM, 2004). The committee’s observations and recommendations are based on gen- eral conclusions reached in previous National Academies reports on climate change and literature those reports found to be authoritative. They do not depend on any particular model of future climatic conditions. The literature on IEQ and health is rich and unequivocal: indoor environmental condi- tions have a great influence on human health, and adverse conditions harm occupant well-being. Altered climatic conditions will not necessarily intro- duce new risks for building occupants but may make existing indoor envi- ronmental problems more widespread and more severe and thus increase the urgency with which prevention and interventions must be pursued. The committee structured the results of its work into three catego- ries. The key findings explicate why people and governments should be concerned about the effects of climate change on the indoor environment. Guiding principles are the elements of the public-health mission that in- formed the specific recommendations offered. The priority issues for ac- tion and recommendations are the primary initiatives that the committee believes should be implemented to address the problems that it identified. The details underlying these are contained in the preceding chapters. KEY FINDINGS Three key findings derived from the committee’s literature review un- derlie its conclusion that alterations in indoor environmental quality in- duced by climate change are an important public-health problem that deserves attention and action.

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241 KEY FINDINGS, GUIDING PRINCIPLES, AND PRIORITY ISSUES Poor indoor environmental quality is creating health problems today and impairs the ability of occupants to work and learn. There is an extensive scientific literature on the effects of poor indoor air quality, damp conditions, and excessively high or low temperature on human health. Epidemiologic literature reviewed by the committee indi- cates that pollution intrusion from the outdoors, emissions from building components furnishings, and appliances, and occupant behaviors introduce a number of potentially harmful contaminants into the indoor environ- ment. Dampness problems in buildings are pervasive, and excessive indoor dampness is a determinant of the presence or source strength of several potentially problematic exposures, notably exposures to mold and other microbial agents and to chemical emissions from damaged building ma- terials and furnishings. Damp indoor environments are associated with a number of respiratory and other health problems in homes, schools, and workplaces. Extreme heat has several well-documented adverse health ef- fects. The elderly, those in frail health, the poor, and those who live in cities are more vulnerable to exposure to temperature extremes and to the effects of exposure. Those populations experience excessive temperatures predominantly in indoor environments. Less information is available on the effects of adverse indoor envi- ronmental conditions on the productivity of workers and students. Avail- able studies indicate that inadequate ventilation is responsible for higher absenteeism and lower productivity in offices and schools. Indoor comfort is also important: experiments suggest that work performance and school performance decrease when occupants perceive that a space is too warm or cool or the ventilation rate is too low. There is inadequate evidence to determine whether an association exists between climate-change–induced alterations in the indoor environment and any specific adverse health outcomes. However, available research indicates that climate change may make existing indoor environmental problems worse and introduce new problems by A ltering the frequency or severity of adverse outdoor conditions • that affect the indoor environment. C reating outdoor conditions that are more hospitable to pests, • infectious agents, and disease vectors that can penetrate the indoor environment. L eading to mitigation or adaptation measures and changes in oc- • cupant behavior that cause or exacerbate harmful indoor environ- mental conditions.

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242 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH The available research includes • M odels of the potential effects of climate change outdoor condi- tions and experience with extreme weather events, combined with knowledge of how the outdoor environment influences conditions indoors. • M easurements of indoor levels of biologic and chemical agents, combined with information on the determinants of high indoor levels and the relationship between outdoor and indoor levels. • S tudies of the association between exposure to biologic and chemi- cal agents or extreme temperature conditions and adverse health outcomes or productivity effects. • I nformation and experience concerning the design, construction, operation, and maintenance of buildings and how these affect in- door environmental conditions. • S tudies of the potential health consequences of changes made to buildings as a result of climate change or energy conservation concerns. • K nowledge of the health consequences of behavioral responses to problems with buildings and their infrastructure. The lack of directly relevant literature—studies of the intersection of climate change, indoor environmental quality, and occupant health— prevents the committee from drawing more definitive or specific conclusions and underscores the need for the additional data collection and research recommended in this chapter. Data reviewed as part of the National Academies’ America’s Climate Choices series of reports indicate that global mean temperatures have risen over the past 100 years, heat waves have become longer and more extreme, and cold spells have become shorter and milder. Measurements of rainfall show that moist regions are getting wetter, semiarid regions are becoming drier, and extreme weather events are increasing. Heavier rainfall and ear- lier thawing and later freezing of rivers and lakes are leading to increased flooding risks. Climate models suggest that those trends will continue and intensify. Such findings are salient for the committee’s work because condi- tions in the outdoor environment help to determine conditions in the indoor environment. Weather fluctuations and seasonal to annual climate variability influ- ence the incidence of many infectious diseases. Climate change may result in shifting patterns of exposure to pesticides as occupants and building owners respond to infestations of pests like termites whose geographic ranges have changed. Beginning in the 1970s, rising heating fuel costs created economic pres-

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243 KEY FINDINGS, GUIDING PRINCIPLES, AND PRIORITY ISSUES sures to “tighten” buildings to limit heat loss during the winter. Efforts have since expanded to what is now known as the green building movement, which seeks to reduce the energy needed to heat, cool, and light struc- tures and to increase their resiliency in the face of adverse outdoor condi- tions to limit contributions to and adverse effects of climate change. Such weatherization measures can result in decreased building ventilation rates and—in combination with the introduction of new materials and products indoors—lead to increased pollutant levels indoor and associated adverse exposures in some circumstances. Other responses to adverse outdoor conditions may also have conse- quences for indoor exposures and occupant health. Potential increases in the level and frequency of peak electricity demand due to heat waves and in the occurrence of extreme weather events have led to concerns over power outages that could leave building occupants without sources of temperate air and over carbon monoxide poisonings from improper use of generators or other alternative sources of energy and heat. Opportunities exist to improve public health while mitigating or adapt- ing to alterations in indoor environmental quality induced by climate change. Although some climate-change adaptation and mitigation measures for the indoor environment have inadvertent adverse health effects, this need not necessarily be the case. Several building technologies, including mixed-mode or hybrid mechanical systems that support natural ventilation, can produce comfortable indoor environments with lower energy costs and greater health benefits than systems typically in use today. Some of them yield additional benefits, such as lower greenhouse-gas emissions or the ability to maintain safe indoor conditions during extended power outages. Widespread introduction of such measures as cool-color building exteriors and appropriate shading, which reduce the amount of heat absorbed by structures, can lower heat-island effects and benefit entire neighborhoods. Such interventions require up-front investments and will vary in their cost-effectiveness depending on the technology, climate, building type and age, and other factors. Inaction also has costs, though, and the public and governments must consider both when deciding whether and how to act. GUIDING PRINCIPLES The mission of public health is to “[fulfill] society’s interest in assur- ing conditions in which people can be healthy,” and its aim is “to generate organized community effort to address the public interest in health by ap- plying scientific and technical knowledge to prevent disease and promote

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244 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH health” (IOM, 1988). The committee took a public-health approach in formulating its recommendations for reducing the health effects of altera- tions in IEQ induced by climate change, which can be summarized in three guiding principles: Prioritize consideration of health effects into research, policy, programs, and regulatory agendas that address climate change and buildings. Energy-conservation considerations have been the driving force in weatherization-related research. Ventilation guidelines and standards for buildings are based largely on occupant comfort and odor perception. As the country moves toward a future in which climate change will spur the need for increased action to lower buildings’ energy demands and increase their resistance to adverse outdoor conditions, it is vital that public health be put in the forefront of the criteria taken into account in making decisions on issues that affect indoor environments. Make the prevention of adverse exposures a primary goal when de- signing and implementing climate change adaptation and mitigation strategies. As Damp Indoor Spaces and Health noted, prevention is a founda- tion principle in public health (IOM, 2004). Indoor environments already present myriad opportunities for exposure to chemical agents in products, outgassing from building materials, emissions from dampness-related mi- croorganisms, airborne pollen and infectious agents, and the like. Common sense suggests that eliminating or lessening those exposures and limiting the introduction of new agents should be the first consideration when responding to potential problems. However, although some steps in that direction have been taken with the introduction of testing regimes to evalu- ate emissions from building materials and products and the emergence of low-emitting alternatives, more can be done. Collect data to make better-informed decisions in the future. A central aim of public-health professionals is “to maximize the influ- ence of accurate data and professional judgment on decision-making—to make decisions as comprehensive and objective as possible” (IOM, 1988). As this chapter has already observed, there is almost no literature at the intersection among climate change, IEQ, and occupant health. It is possible to offer informed views on strategies to minimize the adverse effects of climate change on the basis of existing research, but uncertainties abound, including uncertainties in

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245 KEY FINDINGS, GUIDING PRINCIPLES, AND PRIORITY ISSUES • T he details of the changes that will take place, the rate at which they are manifested, and their magnitude. • T he influence of technologic advances and other influences on in- door conditions. • T he effects of weatherization and of other adaptation and mitiga- tion measures on public health. Collecting data that support assessments of the effects of climate change on the indoor environment and health and data on the effects of mitiga- tion and adaptation measures on health will allow future policy to be set in a more informed manner and help to identify misguided or inefficient approaches so that they can be corrected. PRIORITY ISSUES FOR ACTION AND RECOMMENDATIONS Chapters 4–8 offer several observations regarding how climate change may affect indoor air quality; dampness, moisture, and flooding; infectious agents and pests; exposure to thermal stress; and building ventilation, weatherization, and energy use. The items below constitute a distillation of the committee’s thoughts on how their findings and conclusions should be operationalized. The committee recommends that the Environmental Protection Agency undertake the following actions. The Environmental Protection Agency should work with such agencies as the Centers for Disease Control and Prevention to assist state, terri- torial, and local health and emergency-management agencies in efforts to initiate or expand programs to identify populations at risk for health problems resulting from alterations in indoor environmental quality induced by climate change and to implement measures to prevent or lessen the problems. EPA is a source of expertise on a number of issues related to the indoor environment and health. The Centers for Disease Control and Preven- tion (CDC)—which has the lead federal role in monitoring health, detect- ing and investigating health problems, and developing and implementing responses—already works with EPA on topics of common interest such as the health effects of dampness and mold. Such cooperation will become more important in an era in which extreme weather events are more fre- quent and severe. EPA’s knowledge in such fields as weatherization—where changes in the building envelope may affect ventilation and the presence of moisture indoors and thus IEQ and health—will be of great use in

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246 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH anticipating which future populations may be at risk and in developing solutions. The committee thus recommends that interagency collaboration between EPA and CDC expand into emerging issues of climate change and IEQ. Populations whose health, economic situation, or social circumstances make them more vulnerable to adverse consequences will require special attention in this regard. The Environmental Protection Agency and other federal agencies should join to develop or refine protocols and testing standards for evaluating emissions from materials, furnishings, and appliances used in buildings and to promote their use by standards-setting organiza- tions and in the marketplace. Standards should include consideration of emissions over the operational life of products and the effects of changes in indoor temperature, dampness, and pests. Prevention of adverse exposures to materials in the indoor environment and those introduced as a part of weatherization and other climate-change mitigation activities should have high priority, but relatively little informa- tion is available. Organizations and government entities in the United States and other countries are pursuing and promoting testing protocols, but the report notes that these efforts are fragmentary. Facilitating the development of uniform test standards not only will let builders and occupants make more informed decisions about which materials, furnishings, and appliances to use in buildings but will simplify compliance for manufacturers. EPA’s Environmental Technology Verification Program and Environ- mental and Sustainable Technology Evaluations projects, which include a microorganism-resistant building material testing initiative (EPA, 2011a), constitute an example of the agency’s current work in this field. Expanded and coordinated action with other federal agencies—including the National Institute of Standards and Technology, which sets testing standards for products and systems and is heavily involved in building research, and the Federal Trade Commission, which is concerned with the accuracy of envi- ronmental-product marketing claims—will help to ensure that the resulting protocols are comprehensive and to promote their acceptance. The Environmental Protection Agency should expand and accelerate its efforts to ensure that indoor environmental quality is protected and enhanced in building-weatherization efforts by facilitating research to identify circumstances in which mitigation and adaptation measures may cause or exacerbate adverse exposures; by reviewing and, where appropriate, changing weatherization guidance to prevent these expo- sures; and by establishing criteria for the certification of weatherization contractors in health-protective procedures.

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247 KEY FINDINGS, GUIDING PRINCIPLES, AND PRIORITY ISSUES One of the primary points made in this report is that buildings are complex systems whose siting, design, and operation interact in ways that are not necessarily easy to predict. Weatherization measures have the po- tential to inadvertently increase adverse exposures. For example, changes that would reduce ventilation rates would tend to increase indoor radon levels and might also alter the effective radiation dose received.2 The use of untested building materials could introduce toxic agents to the indoor environment. EPA and the Department of Energy (DOE) are already cooperating on protocols for home energy-conservation upgrades that were in draft form when the committee completed its report (DOE, 2011b; EPA, 2010). Such recognition of health effects on both occupants and persons performing weatherization work is welcome. It will need to be followed, however, by surveillance activities that evaluate whether guidance is achieving its health- protective objectives and by a mechanism to revise guidance on the basis of evaluation. Certification of weatherization contractors in health-protective procedures would allow consumers to make better-informed decisions on whom they choose to perform work and give governments and utilities guidance on potential service providers. The research suggested here will take time to yield usable results and, in the interim, EPA will need to use the best available information to inform its judgment on health-protective weatherization policies. The Environmental Protection Agency in coordination with the Depart- ment of Energy, the American Society of Heating, Refrigerating and Air-Conditioning Engineers, and building-code organizations should facilitate the revision and adoption of building codes that are region- ally appropriate with respect to climate-change projections and that promote the health and productivity of occupants. Building codes are predicated in part on local environmental condi- tions. Codes in northern parts of the country account for the possibility of extended cold and snowy conditions; those in areas prone to hurricanes may require that structures be resistant to extreme weather. If climatic con- ditions in a particular area change—for example, if there are more severe or more frequent episodes of intense precipitation—buildings constructed under existing codes and designed to operate under previously existing 2 An investigation conducted by EPA in the 1990s found no consistent relationship between air tightness and indoor radon levels (Dyess, 1994). A large-scale, field study that was under way when this report was completed is revisiting the question, measuring pre- and post- weatherization levels of radon in a nationally representative sample of approximately 550 homes (Tonn et al., 2011).

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248 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH conditions may fail under the new conditions. That suggests that careful consideration must be given to revising building codes and practices to anticipate future climatic conditions and to taking a coordinated approach to addressing risks. EPA works in cooperation with the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), a professional organization, in developing guidelines for indoor air quality and ventila- tion, notably the Indoor Air Quality Guide: Best Practices for Design, Con- struction, and Commissioning (ASHRAE, 2009). ASHRAE standards for building ventilation and thermal comfort are often incorporated in building codes. DOE works with ASHRAE, other professional organizations, in- dustry, and state and local officials on the development and promulgation of building energy codes (DOE, 2011a). ASHRAE, the International Code Council, the US Green Building Council, and the Illuminating Engineering Society of North America joined together to produce an “International Green Construction Code” for potential adoption by regulatory authorities (US Green Building Council, 2010). The committee recommends that these cooperative efforts on codes be extended to encompass climate-change issues. Most residential and commercial buildings have useful lifetimes that are measured in decades. Promoting research on and development and adoption of regionally ap- propriate building codes that account for the possibility of future climatic conditions not only will protect the well-being of occupants but could pro- duce economic benefits in the form of longer building lives, lower building insurance fees, and avoided retrofitting costs. The Environmental Protection Agency and other public agencies and private organizations should join to develop model standards for ven- tilation in residential buildings and to foster updated standards for commercial buildings and schools. The standards should B e based on health-related criteria. • A ccount for the effects of weatherization and of other climate- • change–related retrofits of existing buildings. P rovide design and operation criteria for mechanical ventilation • systems in new construction. I nclude consideration of ventilation system hygiene and ventilation • effectiveness. A ddress how to maintain proper ventilation throughout the life of • the system. C ontain “fail-safe” provisions that allow for sufficient air exchange • with the outdoors to sustain occupant well-being in the event of ventilation-system breakdown or an extended power outage.

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249 KEY FINDINGS, GUIDING PRINCIPLES, AND PRIORITY ISSUES A chieve the objectives mentioned above in an energy- and cost- • efficient manner. This report has highlighted the central role that ventilation plays in determining IEQ and occupant health. Current ventilation standards, how- ever, are not based on maintaining the health and productivity of occupants and do not account for the potential effects of climate change on building design and operation and on occupant behavior. The committee believes that action should be taken to address this. There are still information gaps, but the epidemiologic literature makes it clear that poor ventilation in homes, offices, and schools is associated with occupant health problems and lower productivity. Climate change may make ventilation problems more common or more severe by stimulating the implementation of energy-efficiency and weatherization measures that reduce the exchange of indoor air with outdoor air. Because standards are often applied or evaluated only during the initial design process, later changes in the building envelope and the inevitable aging of heating, ven- tilation, and air-conditioning systems may produce problems in buildings that were initially deemed to have good ventilation. Some states—including California, Connecticut, New York, Minnesota, Vermont, and Washing- ton—already require mechanical ventilation in at least some new construc- tion. That helps to ameliorate ventilation and health concerns but creates a safety risk in circumstances in which failures in building systems or power outages disable mechanical ventilation; this may happen more often if climate change leads to more instances of extreme weather conditions or unsustainable loads on the electric grid due extreme outdoor temperatures. New ventilation standards should take into account all the consid- erations listed above. The committee recommends that EPA foster the development and implementation of standards in cooperation with other stakeholders. The Environmental Protection Agency and other federal agencies should put into place a public-health surveillance system that uses existing environment and health survey instruments to gather informa- tion on how outdoor conditions, building characteristics, and indoor environmental conditions are affecting occupant health and on how these change over time. Chapter 1 lists a number of survey instruments that EPA, DOE, CDC, the Department of Housing and Urban Development, and other government agencies and departments use to gather information on housing character- istics or the health of occupants. Outdoor pollution concentrations, envi- ronmental conditions, and climatologic information are separately tracked.

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250 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH Lack of general population information on the influences of buildings on occupant health hampers the setting of priorities and the development of effective interventions. The committee believes that it is important to start collecting such data. The ideal surveillance system for assessing how climate change affects indoor environment exposures and related health effects would collect data from across the nation and have this clear focus in mind. However, there are substantial logistical hurdles in mounting such an effort, and its high cost may not be tenable under current federal budget circumstances. The committee therefore recommends that EPA cooperate with its col- laborating agencies to identify means for adapting existing environment and health survey instruments to meet the need. All the existing instru- ments have weaknesses as potential sources of information on the effects of climate change on the indoor environment and health. However, the committee believes that it is possible to identify ways to modify and add to existing instruments such as the National Health and Nutrition Examina- tion Survey (NHANES) and Behavioral Risk Factor Surveillance System (BRFSS) to generate useful data and facilitate combining of databases to perform novel analyses. The Environmental Protection Agency should exercise a strong level of commitment to educate the public on issues of climate change, the indoor environment, and health. Its efforts should I nclude materials tailored to those involved in the design, construc- • tion, operation, maintenance, and renovation of buildings and to occupants of single-family and multifamily residences. C onsider differences in geography, building type, age, and setting • (city, suburb, and rural area) and in current and possible future climate conditions. C ontain specific advice on actions that will reduce the effects of • climate change on the indoor environment and will improve health. This report began by noting that relatively little attention has been given to the possible effects of climate-change–induced alterations in the indoor environment on occupant health. If adverse effects of climate change are to be prevented, public education and training of professionals will be integral parts of the solution. Education and outreach—especially to those in vulner- able communities and those who provide services to those communities— could have a large role in preventing or limiting adverse effects by making people mindful of potential problems and of the means of addressing them. EPA already maintains a Web site, IAQ and Climate Readiness, that disseminates general information on weatherization, ventilation, and solu-

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251 KEY FINDINGS, GUIDING PRINCIPLES, AND PRIORITY ISSUES tions to indoor air-quality problems (EPA, 2011b). The committee recom- mends that EPA expand its efforts by creating and disseminating specifically tailored messages that speak to the specific circumstances and needs of the diverse audiences listed above and that are focused on steps that these audi- ences can take to improve IEQ in the spaces that they occupy. It’s Tools for Schools initiative provides a number of educational products for building professionals, school staff, and the general public aimed at maintaining “a healthy environment in school buildings by identifying, correcting, and pre- venting [indoor air quality] problems” (EPA, 2011c). These products could be supplemented to cover climate change–related issues. Tools for Schools also provides a template for broader outreach on climate change, indoor environment, and health issues for other building types and audiences. Public health professionals also have a need for education on the issues raised in this report. The public health community is well-versed in how to respond to crises caused by acute circumstances like hurricanes, floods, or heat waves. However, in general, less is known about prevention and con- trol measures for more widespread and chronic issues like building damp- ness (IOM, 2004). If sanitarians are sensitized to building-related issues and instructed in how to anticipate, identify, and address problematic indoor environmental conditions resulting from climate change, they can add ap- propriate interventions to their practice and better serve their communities. Cross-training of those involved in public health and in the design, construction, maintenance, operation, and renovation of buildings in the determinants of good IEQ will help to avoid problems and improve interventions. The Environmental Protection Agency should continuously evaluate actions taken in response to climate-change–induced alterations in the indoor environment to determine whether they are enhancing occupant health and productivity in a cost-effective manner, should identify ini- tiatives that fail to achieve these objectives, and should take corrective steps as needed. There is little available research on how changes in climatic conditions may affect the indoor environment. It will therefore be especially important to follow up on the measures taken to lessen adverse effects to determine whether they are effective and whether there are more efficient means of achieving the desired outcomes. The committee therefore recommends that intervention programs include the collection of data that will allow evaluation of whether the programs are materially affecting the health of occupants. The committee notes that this recommendation is in line with those already offered by the National Research Council’s America’s Climate

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252 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH Choices: Panel on Informing Effective Decisions and Actions Related to Climate Change. That panel recommended that the federal government “establish information and reporting systems that allow for regular evalu- ation and assessment of the effectiveness of both government and non- governmental responses to climate change” and indicated that “decisions and policies should be revised in light of new information, experience, and stakeholder input, and use the best available information and assessment base to underpin the risk management framework” (NRC, 2010c). The Environmental Protection Agency should spearhead an effort across the federal government to make indoor environment and health issues an integral consideration in climate change research and action plans and to coordinate work on the indoor environment and health. The serious gap in the scientific literature concerning the relationships among climate change, IEQ, and occupant health identified in this report is a barrier to effective action on the issue. In the committee’s judgment, there is a clear lack of recognition of this topic at a level commensurate with its importance. At the US federal level, the research gap is emblematic of a more fundamental problem regarding indoor environmental health concerns: that responsibility for the integrated environmental, public-health, energy- conservation, housing, urban-planning, and worker well-being issues that make up IEQ do not fall neatly under the aegis of any federal department or agency. Because several organizations have interests in some subjects, yet no entity has the lead responsibility, research needs go unrecognized and unmet, and opportunities for efficient action are unrealized. The committee believes that this situation must change. Several of the priority issues listed above recommend that EPA either initiate or deepen their cooperation with governmental and other entities on some specific urgent issues, and achievement of their goals will be predicated on building and sustaining robust partnerships. The committee believes that these initia- tives should be part of a larger effort to entwine indoor environment and health considerations into the fabric of research and action plans. Because it is difficult to separate the effects of climate change from other influences on the indoor environment, a broad approach to IEQ issues is needed. There are several potential approaches to addressing the problem. One is for EPA to initiate action within the US Global Change Re- search Program (USGCRP)—in which it participates—to address the ef- fects of climate change on indoor environmental quality and on the health and productivity of occupants. The USGCRP, which involves 13 federal departments and agencies, serves as the coordinating body for federal re- search on climate change and its effects on society (CCHHG, 2011). Major

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253 KEY FINDINGS, GUIDING PRINCIPLES, AND PRIORITY ISSUES publications of the program do consider the effects of climate change on public health and, separately, on the built environment.3 However, with few exceptions, public-health considerations are not focused on the indoor en- vironment and health. Discussions of the built environment are centered on threats posed to the infrastructure by flooding and other extreme weather events. The USGCRP is in the process of formulating a new strategic plan with the intent of releasing it in December 2011 (USGCRP, 2011). This process presents an opportunity for EPA to advocate for the inclusion of indoor environment and health concerns into the work of the Program and in particular, the adaptation science; assessments; and communication, education, and engagement elements of the new strategic plan. EPA should also explore options for stimulating action on climate change, indoor environment, and health issues outside and within the gov- ernment. These include the initiatives highlighted in the committee’s recom- mendation above that the agency exercise a strong level of commitment to educate the public on these issues. At the federal level, the committee suggests that EPA promote a broader coordinated effort to address indoor environment and health issues through, for example, the establishment of an interagency working group or a na- tional center. Such mechanisms have been used to effectively coordinate action to identify information gaps, facilitate research, collect data, and catalyze work on other critical issues. An effort to establish a governmental entity to act as a coordinating body will likely require support from the administration or Congress. Nonetheless, the committee believes that con- solidating and focusing indoor environmental health efforts may generate efficiencies that make it worthy of consideration and that any efforts that support collaboration in the pursuit of healthy indoor environments will produce societal benefits. The committee notes that the Public Health Service surgeon general’s 2009 Call to Action to Promote Healthy Homes already calls for a coordi- nated federal effort in research, guidance, and technical assistance regarding healthy homes and notes the need for standardization in evaluating inter- ventions (HHS, 2009). The Call to Action labels safe and healthy homes as having high federal priority and offers some of the same recommendations put forward in this report, including focusing interventions on the most vulnerable populations and using low-emission building materials. The United States is in the midst of a large experiment of its own mak- ing in which weatherization efforts, energy-efficiency retrofits, and other initiatives that affect the characteristics of interaction between indoor and 3 In this context, the built environment comprises not only buildings but also the accompa- nying transportation (roads, bridges, and the like) and public-works (energy, water, sewage, and so on) infrastructures.

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254 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH outdoor environments are taking place and new building materials and consumer products are being introduced indoors with little consideration of how they might affect the health of occupants. Experience provides a strong basis to expect that some of the effects will be adverse, a few profoundly so. An upfront investment in considering the consequences of these actions before they play out and thereby avoiding problems that can be anticipated would yield benefits in health and in avoiding costs of medical care, reme- diation, and lost productivity. REFERENCES ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers). 2009. Indoor air quality guide—Best practices for design, construction, and commissioning. Atlanta, GA: ASHRAE. CCHHG (Interagency Crosscutting Group on Climate Change and Human Health). 2011. Interagency Crosscutting Group on Climate Change and Human Health. http://www. globalchange.gov/what-we-do/climate-change-health (accessed February 27, 2011). DOE (US Department of Energy). 2011a. Building energy codes program. http://www.energy- codes.gov/status/ (accessed February 27, 2011). DOE. 2011b. Residential retrofit guidelines. http://www1.eere.energy.gov/wip/retrofit_guide- lines.html (accessed February 27, 2011). Dyess TM. 1994. Assessment of the effects of weatherization on residential radon levels. EPA/600/SR-94/002. Cincinnati, OH: US Environmental Protection Agency, Center for Environmental Research Information. EPA (US Environmental Protection Agency). 2010. Healthy indoor environment protocols for home energy upgrades. http://www.epa.gov/iaq (accessed November 18, 2010). EPA. 2011a. Environmental and sustainable technology evaluations (ESTE). http://www.epa. gov/etv/este.html (accessed February 27, 2011). EPA. 2011b. IAQ and climate readiness. http://www.epa.gov/iaq/climatereadiness/index.html (accessed February 27, 2011). EPA. 2011c. IAQ Tools for Schools Program. http://www.epa.gov/iaq/schools/ (accessed April 26, 2011). HHS (US Department of Health and Human Services). 2009. The Surgeon General’s call to action to promote healthy homes. http://www.surgeongeneral.gov/topics/healthyhomes/ calltoactiontopromotehealthyhomes.pdf (accessed February 27, 2011). IOM (Institute of Medicine). 1988. The future of public health. Washington, DC: National Academy Press. IOM. 2004. Damp indoor spaces and health. Washington, DC: The National Academies Press. NRC (National Research Council). 2006. Green schools: Attributes for health and learning. Washington, DC: The National Academies Press. NRC. 2008. Global climate change and extreme weather events. Understanding the contri- butions to infectious disease emergence: Workshop summary. Washington, DC: The National Academies Press. NRC. 2010a. Adapting to the impacts of climate change. Washington, DC: The National Academies Press. NRC. 2010b. Advancing the science of climate change. Washington, DC: The National Academies Press. NRC. 2010c. Informing an effective response to climate change. Washington, DC: The Na- tional Academies Press.

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255 KEY FINDINGS, GUIDING PRINCIPLES, AND PRIORITY ISSUES NRC. 2010d. Limiting the magnitude of climate change. Washington, DC: The National Academies Press. Tonn B, Rose E, Schmoyer R, Eisenberg JF, Ternes M, Schweitzer M, Hendrick T. 2011. Na- tional evaluation of the Weatherization Assistance Program during the program years 2009-2011. ORNL/TM-2011/87. Oak Ridge, TN: Oak Ridge National Laboratory. US Green Building Council. 2010. ICC, ASHRAE, USGBC and IES announce nation’s first set of model codes and standards for green building in the U.S. Press release dated March 11, 2010. USGCRP (US Global Change Research Program). 2009. Global climate change impacts in the United States. New York: Cambridge University Press.

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