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1 Introductions The members of the Roundtable on Environmental Health Sciences, Re- search, and Medicine hail from academia, industry, and government. Their per- spectives range widely and represent the diverse viewpoints of researchers, fed- eral officials, and consumers. They meet, discuss environmental health issues that are of mutual interest (though sometimes the issues are very sensitive) and bring others together to discuss these issues as well. For example, they regularly convene workshops to help facilitate discussion on a specific topic, and one such occasion is the subject of this report, which summarizes the "Ensuring Environ- mental Health in Post-Industrial Cities," workshop that took place in Pittsburgh, Pennsylvania, on March 19, 2003 (see Box 1.1~. A few years back, when the Roundtable began, it hosted a workshop called "Rebuilding the Unity of Health and the Environment: A New Vision of Envi- ronmental Health for the 21st Century." Ever since then, the Roundtable has been promoting a broader definition a "new vision" of environmental public health. This definition encompasses not only toxicology the knowledge of how toxic substances might affect people but also recognizes the very important roles of the natural environment and our health, the built environment and our health, and the social environment and our health. The Pittsburgh workshop was the second in this series, and its summary has been prepared by the workshop rapporteur to convey the essentials of that day's events. It should not be con- strued as a statement of the Roundtable which can illuminate issues but cannot actually resolve them or as a study of the IOM. *This chapter was prepared from the transcript of the meeting by Steven J. Marcus as the rappor- teur. The discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics. 4

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INTRODUCTION s CHARGE TO SPEAKERS AND PARTICIPANTS Baruch Fischoff A couple of years after I moved to Pittsburgh, I had the opportunity to accompany a film crew, for a NOVA special on risk that went to southern Poland. This was a place where Andrew Carnegie would have felt right at home; actually, we visited some mills that Andrew Carnegie would have wanted to modernize! The Poles were aware of that need as well. Nobody was interested in my being something of an expert on environment and risk. They were intrigued, however, by my being a Pittsburgher. They kept asking me "How did you do it?" Some dramatic things had indeed been done here to clean up the air and the water. But these efforts had also incurred some tremendous costs in jobs and economics: a lot of the cleanup had come through deindustrialization. We are still struggling with that issue. But we're also struggling with the environmental and health consequences of some of the successors to the heavy industries. Though we hear quite a bit today about the environmental problems associated with brownfields legacies of the steel mills, among other industrial sources environmental impacts are also associated with institutions such as universities. Academia has come a long way in the past 10 years toward recog- nizing its role not just in studying the environment but in taking responsibility for its own environmental impacts, though much remains to be done. For one thing, more people need to see that environment and health must be addressed in an integrated way and that the benefits and costs are fairly shared throughout the community.

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6 ENSURING ENVIRONMENTAL HEALTH IN POSTINDUSTRIAL CITIES If we think back to the origins of public health, 150 years ago, environ- mental and health issues essentially arose together; but then some separation occurred as the fields specialized and established their own terrains. Now, how- ever, people are increasingly seeing there's a need for the fields to come back together again. I see this in my own research, which involves risk taking, risk decision making, and risk communication both in health and environmental areas. Much of my health work has to do with adolescents, particularly regarding sexually transmitted diseases, and I realized just a year or so ago that in talking to kids you often find them spontaneously bringing up the environment even if you're talking to them about, say, HIV/AIDS. Pittsburgh is an unusual kind of place, because despite its environmental degradation there are little pockets of nature scattered throughout the city, and many kids appreciate them. There are spots, they will tell you, "where I can go and it's quiet. I can go there and no one will hassle me. I can go there and it's an escape from my daily environment." I'd like to know what these kids have to tell us about the kind of environ- ments we are leaving for them. If we're pursuing various policies in their names, we ought to respect their notions of the kinds of environmental education they desire, of needs they see for preserving wild lands, of their attitudes toward economic notions like discount rates. But even now they tell me, whether they realize it or not, that for those of us who are concerned with environment or with health there is an opportunity to think through how they fit together. And putting my Pittsburgher hat back on, although this is a region that has a lot to be proud of, I must say that it also needs to hold more conversations between people who specialize in different (though complementary) areas. We should do this not only for our own good, but also because of the symbolism that is Pittsburgh's. This area has been a pioneer in so many things that people are watching us. If Pittsburgh can do it, other heavily industrialized places can do it as well. If Pittsburghers are successful, then other people will be happy to know about it and find inspiration in our example. OVERVIEW OF THE WORKSHOP The protection of the environment is protection of health, according to Lynn Goldman, Bloomberg School of Public Health, Johns Hopkins University. Envi- ronment and health are so inextricably intertwined, so strongly linked, that we should not even talk about the environment without also talking about health. And conversely, we should not talk about health without recognizing the impor- tant role of the environment. For this meeting today, Goldman said, the Roundtable saw in particular the opportunity to understand the environmental health challenges that face this

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INTRODUCTION country's postindustrial cities fac- tors such as air quality, water quality, and the quality of our daily lives. The workshop provided an opportunity to have a broader discussion on environ- ment and public health and learn from local, regional, and national partici- pants of the problems to be confronted in these urban environments. 7 The protection of the environment is pro- tection of health. Environment and health are so inextricably intertwined. Lynn Goldman WHAT IS ENVIRONMENTAL HEALTH? Kenneth Olden The responsibility of the National Institute for Environmental Health Sciences (NIEHS) located within the National Institutes of Health (NIH), a research-agency federation comprising 19 institutes and some 7 centers is to determine the role of the environment in the development of human diseases. Once risk factors are identified, we have the further responsibility of formulating strategies prevention, intervention, diagnosis, and treatment strategies to man- age those conditions. That is a huge mandate. It turns out that virtually any human disease one can name cancer, Alzheimer's, Parkinson's, osteoporosis, rheumatoid arthritis, and diabetes, just to cite a few has an environmental component. Human diseases are in fact caused by the interaction of three things one's genetics, environment, and behavior as functions of age or stage of development. So, for example, children are more susceptible in most cases to environmental exposures because their organ systems, such as the brain and the heart, are devel- oping very rapidly. And senior citizens are more susceptible as well: their immune systems have been compromised to some extent, and they have likely formed a number of genetic lesions over the course of some 50 to 80 years. Despite human beings' inherent vulnerabilities, diseases can still be prevented. And that is the emphasis at NIEHS. In addition to its important contributions to diagnosis and treatment, the agency focuses on preventing cancer, preventing Alzheimer's, and preventing Parkinson's, among other diseases which also means safeguarding the environment. As Judith Stern once said, "Genetics loads the gun, but environment pulls the trigger." This quotation drives home the point that one can inherit a genetic predisposition to a disease but never express it unless exposed to the environ- mental "trigger." Therefore it' s hard to say which the genetics or the environ- ment is more important. Francis Collins, my colleague at the Human Genome Research Institute, likes to say that diseases are 100 percent genetics and 100 percent environmental!

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8 ENSURING ENVIRONMENTAL HEALTH IN POSTINDUSTRIAL CITIES This implies that we have to make research investments across the board if we're to understand the interactions between genetics, the environment, and behavior. It won't do us any good as a nation to clone or sequence the human genome without knowledge of how genetic elements interact with the environ- ment and behavior (which NIEHS regards, actually, as an aspect of environment). In fact, we define "the environment" as a great deal more than synthetic chemicals and pollutants. It is the natural environment, industrial chemicals, agricultural chemicals, physical agents (e.g., heat, radiation), by-products of com- bustion and industrial processes (e.g., dioxin), foods and nutrients, pharma- ceuticals, lifestyle choices and substance abuse, social and economic factors, and biological agents. In other words, the environment is everything other than genetics; it is all the compo- nents of the world that interact with our genetics to make us more or less susceptible, and it plays a major role in the development of disease. It's fair to say that at NIH in gen- eral, and at NIEHS in particular, we put a lot of emphasis on social and econom- ic factors. They are very important components of the environment. Consider the abundant evidence that poor people especially racial and ethnic minorities- have a disproportionate burden of diseases that are preventable or curable. There is no explanation for why they have these diseases except for lifestyles, behav- iors, and socioeconomic factors. In other words, poor people tend to live in the most hazardous environments and work in the most hazardous occupations be- cause they are poor and uneducated and have limited options. Identifying the risk factors, of course, is a top priority. But once they've been identified, we must formulate strategies to reduce or eliminate exposure to, or the action of, those risk factors. Even that is not enough. By developing the knowledge and technologies to prevent undesirable outcomes, we incur the responsibility of making sure that the knowledge and technologies get translated and transmitted to the public, into public health practice, and into the practice of medicine. This is an area, I believe, in which we have not been as aggressive as we could be. The fruits of science must be properly interpreted and be made widely available. The same is true for conveying the importance of the environment in the development of human disease. Still, in that regard we have started to come of age; the lay public, and certainly the press, are finally realizing their critical role. Therefore, the tasks that face us in environmental health are too important to be left to scientists or to federal employees like me. We need partnerships with The environment is everything other than genetics, it is all the components of the world that interact with our genetics to make us more or less susceptible, and it plays a major role in the development of disease. Kenneth Olden

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INTRODUCTION 9 the public, with industry, unions, parents and teachers, civic organizations, and state and county health agencies. And we need to regularly get out of our offices in Research Triangle Park, North Carolina or Bethesda, Maryland, or Washington, DC, or wherever, and meet and talk with have a dialogue with the American public. That's what environmental health is all about.