Summary*

Howard Frumkin

In planning today’s regional workshop on rebuilding the unity of health and the environment in the southeastern United States, the Roundtable posed several key questions to be addressed by the participants and respondents: What is environmental health, and where does it happen? What aspects of environmental health do we have to understand better? Where do we have research needs? Where do we go from here? The information and insights offered by our speakers have provided many answers that are relevant not only to the Southeast but also to the entire country.

WHAT IS ENVIRONMENTAL HEALTH AND WHERE DOES IT HAPPEN?

A definition of environmental health begins with the definitions of “health” and “environment.” The World Health Organization has defined health as more than the absence of disease or infirmity (World Health Organization, 1986); health also comprises physical, mental, and social well-being. In the workshop, many speakers and participants alluded to this definition of health. Further, they discussed health not only in conventional terms, but also in terms of livability, domestic tranquility, and social connectedness. Thus, health extends beyond biological health to encompass the condition of our society and the built communities in which we live. The environment comprises the circumstances, objects, or conditions by which we are surrounded—not only the complex of physical, chemical, and biotic factors, but also the social and cultural conditions that influence our lives and the life of our communities. Environmental health can be viewed as either the well-being of the environment or the health of individuals with respect to environmental exposures and conditions. Although some may see

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The summary is an edited transcript of Dr. Howard Frumkin’s summations at the Atlanta meeting.



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Health and the Environment in the Southeastern United States Summary* Howard Frumkin In planning today’s regional workshop on rebuilding the unity of health and the environment in the southeastern United States, the Roundtable posed several key questions to be addressed by the participants and respondents: What is environmental health, and where does it happen? What aspects of environmental health do we have to understand better? Where do we have research needs? Where do we go from here? The information and insights offered by our speakers have provided many answers that are relevant not only to the Southeast but also to the entire country. WHAT IS ENVIRONMENTAL HEALTH AND WHERE DOES IT HAPPEN? A definition of environmental health begins with the definitions of “health” and “environment.” The World Health Organization has defined health as more than the absence of disease or infirmity (World Health Organization, 1986); health also comprises physical, mental, and social well-being. In the workshop, many speakers and participants alluded to this definition of health. Further, they discussed health not only in conventional terms, but also in terms of livability, domestic tranquility, and social connectedness. Thus, health extends beyond biological health to encompass the condition of our society and the built communities in which we live. The environment comprises the circumstances, objects, or conditions by which we are surrounded—not only the complex of physical, chemical, and biotic factors, but also the social and cultural conditions that influence our lives and the life of our communities. Environmental health can be viewed as either the well-being of the environment or the health of individuals with respect to environmental exposures and conditions. Although some may see *   The summary is an edited transcript of Dr. Howard Frumkin’s summations at the Atlanta meeting.

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Health and the Environment in the Southeastern United States a conflict between the two views, others regard them as two aspects of the same issue. What has emerged as a unifying theme in today’s workshop is the concept that healthy people exist in a healthy environment. As we maximize one, we maximize the other. Where does environmental health take place? The concept of scales, borrowed from the field of ecology, helps us to understand that environmental health takes place simultaneously on many scales, or levels, ranging from microscopic to global. Environmental health takes place on the molecular level. Sam Wilson explained that the combination of an individual’s genetic makeup and environmental exposures determines his or her susceptibility to the ill effects of pollutants. Also, the mechanism of toxicity—the way in which toxic exposures cause harm— is largely a series of molecular and cellular events, which basic research continues to elucidate. Environmental health occurs at the cellular level and at the organ system level. Wayne Alexander described how particulate matter in the air affects lung function, cardiovascular health, and other aspects of our health. As another example, he described how stimulating blood flow in the vessels by walking enhances cardiovascular health. Environmental health takes place on the individual level. In recounting the high rates of automobile crashes and auto–pedestrian injuries, Ricardo Martinez reminded us of an environmental health risk faced by millions of individuals in our urban communities every day. Several participants discussed the connection between environmental conditions in our country and the rising number of individuals with asthma, cardiovascular problems, diabetes, and obesity. Environmental health occurs on the level of family units. Dennis Creech explained the benefits of a well-sealed house in protecting occupants from diseases related to condensation. Environmental health is evident at the community level. Dennis Creech described an office building with features that are not only healthful for workers but also protective of the environment. Michel Kilgallon explained that urban development patterns directly affect people’s life-style and behaviors, such as their level of physical exercise. Environmental health transpires at the regional level. Robert Kerr described regional programs for developing synergistic methods of waste reduction among industries. Several participants discussed regional policies that govern transportation networks, energy generation, air quality, and water quality, all of which directly affect health. Environmental health can be appreciated at the national level. Reverend Lowery mentioned national laws mandating clean water, clean air, and waste disposal that were milestones for environmental health in our country. Other speakers discussed the regulatory agencies that work at the national level to protect the environment.

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Health and the Environment in the Southeastern United States Finally, environmental health is a global phenomenon. The Reverend Lowery reminded us that our health in the largest sense emanates from, and is safeguarded by, a deep reverence for the entire creation and all who inhabit it. From the molecular to the global, each scale is intimately connected with all of the others. Consider, for example, an individual who is involved in an automobile crash at a busy urban intersection. The crash may have occurred because of inadequate regional policies governing the design of the highway. Yet the man’s life is spared because his automobile met national safety standards and he was obeying local laws mandating seat belt use. Healing of his injuries will be compromised on the molecular and cellular levels because he has diabetes. He has difficulty controlling this condition because the design of his community inhibits exercising. He might not even have been driving his car if he had been able to bicycle safely to his destination or if public transportation had been available. This example suggests the myriad ways in which environmental factors are linked with our health on every level. To improve our health we need to adopt a holistic view—one that considers all levels of environmental health at once. We need to address the complexity inherent in environmental health and embrace it. An important way of doing so is to expand the concept of who our environmental health “officials” are. Health promotion and disease prevention are not just the province of physicians, nurses, and public health officials. Urban planners and transportation engineers, landscape architects and developers, local elected officials and mortgage bankers—all of these people, and many others, make decisions that affect the shape of our built environment, the integrity of our natural environment, and the quality of our social environment. Each can contribute in important ways to building a healthier, more sustainable country. The same principle applies at the level of organizations. Although the Department of Health and Human Services is our main federal health agency, the Environmental Protection Agency, the Department of Transportation, the Department of Energy, the Department of the Interior, and the Department of Housing and Urban Development should also be recognized as health agencies. All of these agencies, and their counterparts at regional, state, and local levels, affect the way we use our natural environment, design our built environment, and behave as individuals and as a community. WHAT ARE OUR RESEARCH NEEDS? Traditionally, research in environmental health has focused on toxic exposures. Although research is still needed in this area, we must move beyond environmental toxicology to broader issues of environmental health. We must study the environmental determinants of behaviors that affect health. For example, we need to examine our children’s exercise patterns and nutritional habits. How much exercise are our children getting, and what impediments to exercis-

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Health and the Environment in the Southeastern United States ing does the urban environment pose? What are our children eating, and what environmental factors contribute to healthy eating patterns and unhealthy ones? Are there environmental determinants of obesity in children? We also need to examine the factors that determine consumer decisions in areas that impact our environment. For example, what determines whether drivers buy large sports utility vehicles or small, ecologically sound, hybrid cars? Probing behavioral issues such as these may yield much information that will potentially change behaviors and benefit environmental health. We need research on technical issues. As in the past, engineering interventions are important potential determinants of public health. A century ago, key environmental determinants of health were sewage treatment and water provision. Today, main determinants include clean energy generation, clean and safe transportation, and the use of industrial ecology to convert the waste stream of one industry into the raw materials of others. Health officials must work with engineers in these areas to develop synergistic research agendas. We need research on healthful design and architecture. Bringing the issue of health into research on architecture, transportation, land use, and resource use will help us make better decisions for creating and restoring our built environment. For example, research is needed on community and regional interventions that will improve opportunities for physical activity, increase the safety of automobile travel, reduce pollution, and develop low-impact environmental materials. Finally, we need policy research. Environmentalists and industrialists have shown great interest in moving beyond the “end-of-pipe” regulatory atmosphere to develop incentives and other innovative methods of changing behavior toward the environment. Research is needed to determine which methods will work, and under what circumstances. WHERE DO WE GO FROM HERE? In charting our course as we rebuild the unity between environment and health in the Southeast and throughout the country, we must consider what we need to know, what we need to value, and what we need to do. What do we need to know? Knowledge is based on research and built through education. We need to educate the public about the multidimensional links between health and environment and how decisions in one area directly affect the other. Educating the public is the key to inspiring environmental health advocacy. The media have an important role in informing the public that, as Paul Rogers has often said, environmental laws are health laws and environmental decisions are health decisions. The more that health issues and environmental issues become fused, the greater will be the progress made in both areas. Several colleges and universities in the Southeast and elsewhere have introduced innovative curricula that emphasize the interdisciplinary nature of environmental education and the importance of environmental literacy for all students. This educa-

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Health and the Environment in the Southeastern United States tional initiative should eventually permeate the primary and secondary educational levels. What about our values and attitudes? We need to have respect and reverence for the environment, a value that can flourish best when we have respect and reverence for each other. Respect is central to building social capital. We need to value beauty. Appreciation and enjoyment of the beauty of our natural environment should permeate our approach to environment health and form an integral part of all of our policies. We need to value health. The importance of health should be reflected in the behaviors that we adopt and in the policies that we make. Environmentalists should bear in mind that health is a driving force behind the public’s involvement in environmental advocacy. We need to value equity and social justice. We cannot advance our environmental agenda, and thus our health agenda, without also embracing equity. Environmental and health practices that protect some communities at the expense of others, or that affect some members of the community disproportionately, must be rectified. Finally, we need to embrace an attitude of collective solutions to problems and collective action to address them. How about our actions? What do we need to do? We have to join forces across disciplines. Environmental health advocates need to join with architects, planners, engineers, developers, health professionals, epidemiologists, industrialists, members of the clergy, scientists, government officials, activists, policy makers, and the general public. By doing so, we can forge better solutions to environmental health problems; we can also more readily achieve the political majority needed to affect change in environmental and health policies. We also need to join forces across social boundaries. Environmental and health professionals working in “ivory tower” settings have to reach out to communities and incorporate community decision making into institutional decision making. We as individuals need to reach out to all members of society. As a nation, we must overcome the social desire not to live with different kinds of people, which is reflected in the widespread segregation of housing by class and race. Building communities that attract a mixture of people will move society in this direction. Several themes have dominated this workshop and will undoubtedly inform the environmental health debate for the foreseeable future. The first is the overarching theme of this conference—that the health of the environment and the health of people are intrinsically intertwined. No longer can we despoil the environment and believe that we, individually or as a community, will not be affected. No longer can we regard human illness as disconnected from the environments in which we live, work, and play. Human health requires that we maintain a healthy environment. In turn, the richness of the environment can enrich our lives in many ways. The second theme is that traditional methods of ensuring environmental health protection—rules, regulations, and fines—should be supplemented, and in

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Health and the Environment in the Southeastern United States some cases supplanted, by a more enlightened, cooperative approach that brings representatives from many areas together to solve environmental problems as a team. Government regulations should serve mainly as a backstop when other approaches fail. Industry needs to embrace environmental protection, not only because it is the correct thing to do, but also because it will lead to new and more productive ways to do business. Community residents are an immensely powerful force for environmental health advocacy and should not be ignored. A third theme is the interdisciplinary nature of environmental health efforts. Just as health workers and environmentalists have many common interests, so do housing developers and economists, transportation safety experts and scientists, community residents and auto designers, planners and policy makers. All impact, and are impacted by, the environment, and all belong around the “solution table.” The fourth theme is that technology, although not the whole answer, will certainly be a large part of the solution. Just as several decades ago technological advances enabled unleaded gasoline to be used and greatly reduce environmental lead, future advances will result in other giant steps in environmental protection in this country. We can anticipate some of these changes, because research is already well under way. For example, in 50 to 100 years, energy from the sun, used in high-efficiency photovoltaic cells, may emerge as the predominant power source. Technological advances, coupled with cooperative action in the educational, medical, business, social, and political spheres, offer great hope for protection of environmental health in the Southeast, throughout the United States, and around the world.