5
Human Health and the Social Environment

Human behavior stands as the most immediate proximate cause of many of the adverse consequences to the environment. Thus, any solution will come from some constellation of changes in human attitude, knowledge, capacity, behavior, and perhaps incentives. According to the speakers in this session, one area that historically has received considerably less attention is the role of people and social activity as part of the environment and as part of the basis on which an environment may be salutary or the source of harm. Human behavior itself is an aspect of the environment that may benefit or harm our health.

SUSTAINABLE DEVELOPMENT, ENVIRONMENT, AND HEALTH

At this time, our ability to deliver public health or environmental quality is being overtaxed, said Nicholas Ashford of the Massachusetts Institute of Technology. Part of our inability lies in the fact that science is increasingly uncovering problems that we never thought existed, such as endocrine disruption or low-level chemical exposure associated with behavioral problems.

There is a dynamic nature to the trends in industrial development and the diverging impact that this development is having on public health and the environment, said Ashford. Moreover, there is a disconnect between the industrial encouragement of more production and more consumption and industries’ alleged commitment to sustainable development. For example, the manufacture and promotion of sports utility vehicles—currently 50 percent of new cars being



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5 Human Health and the Social Environment Human behavior stands as the most immediate proximate cause of many of the adverse consequences to the environment. Thus, any solution will come from some constellation of changes in human attitude, knowledge, capacity, behavior, and perhaps incentives. According to the speakers in this session, one area that historically has received considerably less attention is the role of people and social activity as part of the environment and as part of the basis on which an environment may be salutary or the source of harm. Human behavior itself is an aspect of the environment that may benefit or harm our health. SUSTAINABLE DEVELOPMENT, ENVIRONMENT, AND HEALTH At this time, our ability to deliver public health or environmental quality is being overtaxed, said Nicholas Ashford of the Massachusetts Institute of Technology. Part of our inability lies in the fact that science is increasingly uncovering problems that we never thought existed, such as endocrine disruption or low-level chemical exposure associated with behavioral problems. There is a dynamic nature to the trends in industrial development and the diverging impact that this development is having on public health and the environment, said Ashford. Moreover, there is a disconnect between the industrial encouragement of more production and more consumption and industries’ alleged commitment to sustainable development. For example, the manufacture and promotion of sports utility vehicles—currently 50 percent of new cars being

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sold—does not conform with the automobile industry’s assertion that it is interested in sustainable development. Some believe that innovation and commitment to sustainable development will not occur without deliberate directive policies, stated Ashford. There is an important role for government to provide a solution-focused, technology-based approach to addressing and setting priorities for environmental and public health problems. However, government actions must not rest on the false assumption that cost–benefit analysis, including risk assessment and rational choice theory, is the way to plan public policy. We need to shift attention from problems to solutions. We need to shift our attention from problems to solutions, from what we are doing to what we can be doing. —Nicolas Ashford Health and the environment do not drive industrial and economic systems. In the United States, trade is considered the engine of economic growth. An economy based on trade tends to keep its industrial plant and sell as much as it can of the old product to the rest of the world. It cannot be assumed that the industries that have caused the problems are the industries that will come up with the solutions, stated Ashford. Industries that have a technological fix and a narrow view are not capable of displacing themselves in the significant ways needed to achieve sustainable development. Who is going to give us the pollution control device—the pollution control industry, which constitutes half of the environmental export industry in this country? The regulated firm may be able to change some things, but it takes other respondents—new entrants—to displace the products and change the nature of services. Regulation is another positive force for change. Technological responses to regulation have produced such innovations as end-of-pipe pollution control, changed inputs to production processes, or entirely new products or services. The history of regulation in this country has forced the formation of new technologies, concluded Ashford. Thus, said Ashford, achieving sustainable production and consumption requires (1) a shift in policy focus from assessing and characterizing problems to designing solutions; (2) an appreciation of the differences between targeting technological innovation and diffusion as a policy goal; (3) the realization that the most desirable technological responses do not necessarily come from the regulated or polluting firms; (4) understanding that comprehensive technological changes are needed that co-optimize productivity, environmental quality, and worker/public health and safety; and (5) an appreciation of the fact that in order to change its technology, a firm must have willingness, opportunity, and capacity to change (Box 5.1).

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BOX 5.1 Sustainable Business, Economy, and Health— A Case Study The Dow Chemical Company has 40 manufacturing sites globally. The Midland, Michigan, plant is the third largest, with 550 buildings and 40 chemical production plants in a 1,900-acre facility. The air emissions of the facility have declined over time as it shifted from high-volume, commodity-type chemical processes to more of a specialty batch-based process. In 1994, the Dow Chemical Company set a goal for 2005 to cut all wastes and emissions by 50 percent, said Jeffrey Feerer of Dow Chemical Company. The attitude and belief inside the company by the late 1990s were that no further gains could be made in emission control at this facility. Two new goals were set: (1) to have capital accrued by April 30, 1999, to essentially cut waste and emissions by 35 percent, and (2) to start to foster institutional changes within Dow to shift the corporation’s thinking from compliance to pollution prevention and to further integrate health and environmental concerns into core business decision making through the Michigan Source Reduction Initiative (MSRI). Working with the community, activists, and pollution control consultants, Dow engineers identified pollution prevention opportunities and brought these opportunities to the entire group for consideration. The company decided early on that since its had a goal of reducing all chemicals by 50 percent, it did not care which chemicals the group decided to work on first. Of the chemicals identified by the group, it turned out that essentially 18 million pounds were produced a year: 81 percent were incinerated, none were land filled, 13 percent went to a wastewater treatment plant, 4 percent went up the stack as air emissions, and 2 percent were fugitive emissions. So the MSRI process was deceptively simple, but the interactions were very complex. Every plant that had an MSRI chemical in it participated in the study and came up with pollution prevention opportunities for the group to consider. One of the boundaries of the project was that Dow was looking for cost-effective pollution prevention. A key attribute of the process was direct interaction of environmental activists with Dow’s key business and manufacturing leaders. The resulting projects reduced waste and emissions by 12 million pounds per year. MSRI wastes were reduced from 17.5 million to 11 million pounds per year, a 37 percent reduction. MSRI emissions were reduced from 1 million pounds a year to slightly more than a half a million pounds per year, a 43 percent reduction. Non-MSRI waste and emissions were reduced by another 5 million pounds per year. In this facility, the common belief had been that there were no cost-effective pollution prevention projects left to pursue. In the end, 17 projects were identified with a combined return on investment of 180 percent, or a savings of $5.4 million per year. The total one-time capital expenditure was $3.1 million per year, so the company is saving $5.4 million a year.

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HEALTH AND THE URBAN ENVIRONMENT: THE FORGOTTEN ECOSYSTEM A photographic essay of environmental hazards in a number of cities was presented. Until the 1980s, the swamps of Newark Bay in Jersey City, New Jersey, contained 4 billion pounds of chromium slag, used as “clean” fill for a good part of the past century throughout the city. During the 1960s, Jersey City underwent what was called “urban renewal,” which basically meant knocking down housing and filling in with chromium slag, reported Thomas Burke of the Johns Hopkins School of Public Health. In the 1980s, the city realized that it had an environmental hazard on its hands, in addition to rampant drug abuse. Those working within the public health infrastructure had to worry about the physical safety of the field crews. Upriver, the Diamond Shamrock plant in Newark produced Agent Orange and other chemicals, as well as some of the nation’s highest levels of dioxincontaminated soils. Further south is the oldest refinery complex in America, in South Philadelphia, in close proximity to the neighborhoods of South Philadelphia. Still further south, in east Baltimore, a waste incinerator sits near a major housing project, Armistead Garden. These scenes are repeated in every city in America, said Burke. Often, urban areas are polluted because of neglect of the simple basics of sanitation, siting of facilities such as coal- and oil-burning generating stations in close proximity to housing, sewage treatment, and abandonment of factories containing hazardous materials. A direct result of efforts on a national scale to control pollution is neglect of the ecosystem in the cities, said Burke. Fragmentation of environmental health definitions of environmental regulations has resulted in an inability to deal with these broad public health problems, which are very much tied to the economics and the social and behavioral aspects of public health. This has resulted, in part, from the scientific community’s distancing itself from the local community, said Burke. Communities have a good idea of the kinds of things that are troubling them. They also are realistic about this, not looking to close down business, but, rather, seeking a fair enforcement of existing laws. Citizens in these communities are concerned about cancer rates, asthma and respiratory disease, chemical sensitivity, and the general health of their children. Sometimes by trying to solve one problem—for example, ocean dumping— we create another, such as enormous composting operations for solid waste. These shifts in the problem inevitably land next to poor neighborhoods. For example, legislation that required the removal of underground storage tanks necessitated the construction of rotary kilns to bake out the volatile components of petroleum-contaminated soil. These kilns were placed in already environmentally and economically stressed areas, such as those found in South Philadelphia. Although disease rates show these urban areas to be unhealthy communities with ecosystems in trouble, indicators of health are difficult to obtain for most major cities. In an era of unprecedented economic growth there is an opportunity

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to do something for the environment of the cities, said Burke. The greatest gains in public health could be made by cleaning up the urban ecosystem. Revitalization calls for a public health approach with a much broader context than the current environmental regulatory approach. SOCIOECONOMIC STATUS AND HEALTH It is common sense to assume that socioeconomic factors contribute to health and illnessaccording to Nancy Adler of the University of California, San Francisco. However, the association between socioeconomic status and health is not simply due to the adversities of poverty, although these are important and pervasive. The predominant view has been one of a threshold effect; that is, better income will bring you better health, up to a certain point but not beyond it. This view has been challenged by results from the Whitehall studies, * which are ongoing investigations of the British Civil Service. The British Civil Service has nine gradations, from the lowest entry level through the top level of management. All of the participants are employed, none are in abject poverty, and all have access to the National Health Service. When Whitehall participants were followed over 10 years it was found that there were significant differences in mortality and that these differences formed an upward gradient. So, the higherlevel administrators had cumulatively lower mortality than the lower occupational grades. What are the mechanisms or pathways by which socioeconomic status affects health? One way to think about this, said Adler, is to study the major causes of early mortality and morbidity ( Table 5.1 ) or the proximal causes of death. Scientists at the Centers for Disease Control and Prevention (CDC) analyzed these in terms of four factors. They found that inadequacy of health care accounts for about 10 percent of premature mortality, genetics for about 20 percent, environment for about 20 percent, and health behaviors and life-style TABLE 5.1 Factors Contributing to Premature Mortality Factor Percent Health care system 10 Genetics and inherited factors 20 Environment 30 Health behaviors and life-style 50 *   The Whitehall studies, which began in the 1960s, grew out of a productive working relationship with the British Civil Service. Involving a large number of colleagues at UCL and other institutions, the study was of great importance in demonstrating the relation between aspects of life-style, biological risk factors, and subsequent disease.

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FIGURE 5.1 Mortality rate by scoioeconomic status level. SOURCE: N.E. Adler. Reprinted with permission. for about 50 percent. There are interactions among these, but the order of magnitude is instructive. Socioeconomic status is pervasive in part because it influences many of these factors ( Figure 5.1 ). Poorer neighborhoods tend to have fewer doctors and pharmacies; inadequate transportation, lack of safe and convenient recreational facilities; and low availability of affordable, healthy food. So even if an individual is motivated to be healthy, it is harder if he or she lives in a poorer area. One implication, then, is that efforts to improve environmental health might be explicitly tied to the very factors that are going to encourage health-promoting behaviors and discourage health-damaging behaviors. Improving access to recreational facilities, increasing the availability of affordable healthy foods, and reducing the easy availability and marketing of tobacco and alcohol would be particularly helpful, said Adler. Similarly, we know that exercise is an important health benefit. A recent survey found that those who viewed their neighborhoods as unsafe were more likely to be physically inactive. So, as we design neighborhoods, if we can design them in ways that will facilitate health-promoting behaviors, this might have a powerful impact on health. The other pathway to health or illness is through differential exposure to stress, said Adler. This has to do less with the physical and material aspects of environments than with the psychsocial environment. Stress follows the same gradient as income, education, and health; that is, the lower one is in the social hierarchy the greater is the stress. There is substantial evidence that stress is

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associated with physiological responses that increase the likelihood of diseases, including cardiovascular disease, metabolic syndromes, diabetes, and infection. Stress occurs when individuals feel that they do not have adequate resources to deal with the challenges that face them. One of the factors that buffers people from the adverse effects of stress is a sense of control. The Whitehall studies have found that the sense of control is closely related to occupational grade; as one moves up the occupational ladder, there is a greater feeling of control. A sense of control also appears to be important in communities. The term “collective efficacy” describes the extent to which a neighborhood shows high levels of the sense that people can control what is happening there. It can be measured in terms of social control—that is, the likelihood that neighbors can be counted on to intervene in different adverse situations—or by social cohesion—how much neighborhood residents feel that others in their neighborhood can be trusted, share their values, and get along with one another. Collective efficacy is highly related to socioeconomic characteristics and shows a direct relationship to rates of violence and health outcomes. These issues speak to the role of nonregulatory communities in addressing environmental health, suggesting not only that greater empowerment of community groups might help through the changes they achieve in the physical environment, but also that the very process may be beneficial to health through increasing collective efficacy, building social capital, and enhancing the social environment. The health effects associated with this process might be equal to or perhaps even greater than those associated with the outcome. NUTRITION, PHYSICAL ACTIVITY, AND HEALTH The relationship between the food supply and health is changing in at least three significant ways, said Bill Dietz of the CDC. First, the biodiversity of the nutritional food supply is narrowing as we concentrate seed production in the hands of fewer and fewer agricultural companies. Second, the opportunity to use genetic engineering of plants to concentrate limited nutrients, such as vitamin A or iron, could address major nutritional deficiencies around the world. Third, increasingly, socioeconomic status, even in the United States, affects one’s access to affordable and nutritious foods. The importance of nutrition and pure water to health has been recognized for a long time, most notably when the prevalence of rickets was determined to be related to the lack of enrichment of milk with vitamin D and of sun exposure in urban areas because of coal smoke and particulates. More than a century ago, the country was swept with epidemics of dysentery, which were eliminated by water sanitation. These basic public health measures had a phenomenal impact. Today, however, the responsibility for water and air purity and quality has moved into a fairly esoteric area, characterized largely by toxics and toxicology. It might be necessary to return to a basic appreciation of the role of the physical environment in chronic disease prevention.

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One of the newest health threats to Americans is obesity (Figure 5.2), that is, a body mass index greater than or equal to 30, which is about 30 pounds overweight, said Dietz. Obesity accounted for about 5 percent of the U.S. health care budget in 1995 dollars, mediated through the comorbidities associated with obesity, such as diabetes, cardiovascular disease, hypertension, gallbladder disease, and cancer. Physical activity, or the lack thereof, plays a very important role. From the prevention point of view, the promotion of physical activity—in contrast to a singular focus on the food supply—might go a long way toward weight maintenance. If the entire population started maintaining its weight today, rather than gaining weight with age and time, we could arrest many of the comorbidities associated with the obesity epidemic. Despite the fact that physical activity may not contribute substantially to weight reduction, the promotion of physical activity alone may have an impact on chronic diseases independent of any effect on weight. Thus, the strategy is to understand the factors that contribute to the inactivity of the population so that they might be reversed. In the United States, only 1 percent of trips are by bicycle, 10 percent are by walking, and 85 percent are by car. In addition, 25 percent of all of the trips made in the United States are less than 1 mile, but 75 percent of these are by car. Moreover, one third of all children who live within a mile of school walk to school. All of this is a consequence of the infrastructure of our communities. Thus, the suburbs may now be more hazardous to our health in some respects than urban areas because of the consequences for physical inactivity. In developments where the streets are more densely populated, and there are more ways to get from one place to another (i.e., connectivity), the likelihood of physical activity is increased. Increased walking is an essential strategy for weight maintenance, which will require that many communities retrofit their streets with bicycle paths and sidewalks. Likewise, we cannot expect our children to walk to school unless there are safe crossing areas for them to do so. This requires a community-based strategy (Figure 5.3). There are also opportunities for physical activity within our buildings, for example, through stair use. Passive, inexpensive changes in stairwells can promote physical activity, reported the CDC’s Dietz. We need to employ a social strategy that is based not only in health services and aimed at life-style changes but that also employs the regulatory strategies necessary to influence the political will, concluded Dietz. Perhaps it is necessary to promote these changes not so much for the sake of public health, but because they improve the livability of communities, which creates an alliance of groups not commonly considered partners in public health. A MORE COMMUNAL APPROACH TO HEALTH During the last three decades of the 20th century, industrial capitalism gave rise to an electronic era and the globalization of trade. These trends have influenced medicine, healing, and the environment, in particular. Ancient history

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FIGURE 5.2 Prevalence of obesity among U.S. adults, 1991, 1993, 1995, and 1998. SOURCE: Must et al. (1999). Reprinted with permission.

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reveals how the impact of humans—in terms of overgrazing, or misuse of waer—led to abandonment of the sites of early civilization. This history teaches us that the globalization of the earth is just in its infancy, said Donald Conroy, president of the International Consortium on Religion and Ecology. Over much of this history, a male-dominated view of medicine, which is very mechanistic, as predominated, with a strong emphasis on the individual and less on the spiritual or community involvement in health.

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FIGURE 5.3 Exercise, including walking, is essential to weight maintenance. Many communities will need to retrofit their streets with sidewalks and bicycle paths. SOURCE: W. Dietz. Reprinted with permission. A comprehensive survey of cultures in the history of health care and medicine, however, provides an alternative approach to health care, one with a more communal and “feminine” emphasis. This approach emphasizes the value of various noninvasive therapeutic methods, including diet and nutrition; includes holistic types of body, mind, and soul techniques for curing; views healing within the context of community and family; and is more open to a perspective in which life and death are seen as part of a natural ecological cycle of birth and regeneration. It also relies on nonmechanistic and nonintrusive methods of diagnosis, including a greater emphasis on the patient’s own story and cultural habits. Therefore, treatment is multifaceted, requiring rest, relaxation, reassurance, and a sense of hope to activate the natural healing powers within the person. Conroy emphasized the need to view these approaches as another way of recovering from and dealing with illness and as an alternative to the singular “battlefield” type of medicine practiced today. CHANGING THE EDUCATIONAL ENVIRONMENT Health is a hard word to define. It cannot be reduced in its essence to any kind of single discipline, said David Orr, director of the Environmental Studies Program at Oberlin College. Quoting Richard Levins of Harvard Medical School, Orr said that “the emphasis ought to be on wholeness and process in complexly connected networks of causes that cross the boundaries of disciplines.” Moreover, health is a big subject, not a single discipline, thus, it should not be confined to schools of public health or schools of medicine. Humans cannot be healthy in an ailing ecosystem, said Orr. Human health is related to climate, the loss of biological diversity, soil, and rainforests, increased population, and the death of the seas. This ecological disorder, or the

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disordering of ecosystems, reflects a prior disorder of mind and of the way in which we think, said Orr. Thus, it should be a matter of great importance to educational institutions that purport to improve the way we think. Humans cannot be healthy in an ailing ecosystem. —David Orr Orr believes that those in education have been and are part of the problem. “What would it mean if colleges and universities and public schools took health seriously in this large sense of the word, in the sense of dealing with causes not symptoms?” he asked. No institution or organization has a right to undermine the stability, integrity, and beauty of natural systems—the consequences of which would always fall as a kind of “irrevocable remote tyranny” on students and future generations. The same institutions that purport to induct young people into responsible adulthood ought themselves to operate responsibly. The work of organizations such as Second Nature, the National Wildlife Federation, and the Center for Respect of Life and Environment is leading a revolution in higher education, said Orr. They are effecting a change in the operations of universities and colleges through promoting policies on college and university campuses that govern the purchase of food, materials, paper, and all of the goods that flow through and across a campus. Second, they are working to revolutionize how we build college campuses, constructing buildings that emit no waste products, use solar power, locate materials from sources certified as sustainably managed and sustainably harvested, and develop fabrics that are compostable and free of carcinogens. A third revolution continues in terms of investments and how colleges buy, purchase, and exert financial power in the world. Orr believes that these efforts are beginning to change operations in a way that makes campuses models of ecological designs so that they reflect health in all that they do. If health is not the aim of education, as Orr paraphrased Aldo Leopold, then what is education for? SUMMARY Human behavior stands as the most immediate proximate cause of many of the consequences to the environment that are the basis for environmental health research. If indeed there is to be any solution or change, that too will come from some assemblage of changes in human attitude, knowledge, capacity, behavior, and perhaps incentives, noted Lynn Goldman. Any intervention to change the status quo will certainly involve the role of people in the environment. Several workshop participants discussed that these changes must include involvement (and empowerment) of the community, intentionally designed opportunities for increased activity, freedom from toxic exposures (especially in the poorest neighborhoods), reexamination of the incentives provided by government and industry ( Box 5.2 ) to achieve environmental health, and education of the young by example.

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BOX 5.2 Industry and the Natural Environment: Reducing Intel’s Environmental Footprint—A Case Study Intel, manufacturer of microprocessors, changes its manufacturing process every 2 years as it miniaturizes the next generation of computer chips. During each transition, reported Terrence McManus of Intel, there are major opportunities for environmental improvements, for example, through chemical selection, facility design, waste management, ergonomics, and manufacturing equipment selection. The Resource Conservation Recovery Act, or RCRA, required companies to focus on waste minimization, which resulted in an evolution in the technology. In making changes, Intel often has to make critical choices with different environmental implications, for example, should the chemical be consumed in the product or should the company “borrow” the chemical from the manufacturer and return it for recycling? Other aspects of planning include projecting over 10 years, or five generations of manufacturing, to predict environmental health and safety impacts. Goals are then set that must be integrated into the design development process as opposed to being some appendage to it. Examples exist from improvements made in past transitions. For example, one process uses hydrofluoric acid to etch wafers. Intel reduced the water use in this process by 40 percent and achieved better management of the exhaust, which actually reduced energy use. Other efforts have resulted in the recycling of hazardous waste and reductions in emissions of volatile organic compounds: currently 37 percent of waste is recycled; 17 percent goes to energy recovery; and 46 percent goes to landfill, incineration, or other treatment. Intel has been able to reduce water and energy use per manufacturing unit on each of its last four generations of semiconductor technology. Intel also builds ergonomics into the equipment, going so far as to design a handbook for the people who make its equipment. Intel’s StRUT program, or Students Recycling Used Technology, recycles personal computers, after students have upgraded and cleaned the hard drives, for donation to schools and nonprofit organizations. A key to Intel’s successful environmental record, said McManus, has been the company’s ability to put together a green plan that integrates design for the environment while aiming for sustainable activities of other operations, which often requires partners in diverse fields to make it work. Design, as McDonough, Lovins, and others are defining it, begins by seeing nature as the standard for what humans do: how we farm, how we build, how we work, and how we live. They see civilization as being powered by contemporary sunlight, not ancient sunlight stored as fossil fuel. They see design, when we get it right, as protecting diversity—not just biological diversity but cultural diversity as well. They see an economic system, when we get the design right, characterized by prices that tell the truth about what we do in the world. Finally, when we get design right, said McDonough, we do not just recycle waste, we eliminate the very concept of waste.