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Ensuring Environmental Health n Postindustrial Cities Workshop Summary Bernard D. Goldstein, Baruch Fischhoff, Steven J. Marcus, and Christine M. Coussens, Editors Roundtable on Environmental Health Sciences, Research, and Medicine Board on Health Sciences Policy INSTITUTE OF MEDICINE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by National Institute of Environmental Health Sciences, National Institute of Health (Contract No. 282-99-0045, TO#5); National Center for Environmental Health and Agency for Toxic Substances and Disease Registry, Centers for Disease Control and Prevention (Contract No.200-2000-00629, TO#7); National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention (Contract No. 0000166930); National Health and Environment Effects Research Laboratory and National Center for Environmental Research, Environmental Pro- tection Agency (Contract No.282-99-0045, TO#5); American Chemistry Council (unnumbered grant); and Exxon-Mobil Corporation (unnumbered grant). The views presented in this report are those of the individual presenters and are not necessarily those of the funding agencies or the Institute of Medicine. This summary is based on the proceedings of a workshop that was sponsored by the Roundtable on Environmental Health Sciences, Research, and Medicine. It is prepared in the form of a workshop summary by and in the name of the editors, with the assistance of staff and consultants, as an individually authored document. International Standard Book Number 0-309-09061-X (Book) International Standard Book Number 0-309-52717-1 (PDF) Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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"~(nowin,g is not enough; we finest outplay. Willin,g is not enough; we waist do." Goethe .................................. - - . ............ .... . ::::::: INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health

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THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of ~ . . engmeermg. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www. nationa l-academies.org

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ROUNDTABLE ON ENVIRONMENTAL HEALTH SCIENCES, RESEARCH, AND MEDICINE Paul Grant Rogers (Chair), Partner, Hogan & Hartson, Washington, DC Lynn Goldman (Vice Chair), Professor, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD Jacqueline Agnew, Professor, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD jack Azar, Vice President, Environment, Health and Safety, Xerox Corporation, Webster, NY Sophie Balk, Chairperson, Committee on Environmental Health, American Academy of Pediatrics, Bronx, NY (membership expires June 30, 2003) Roger Bulger, President and CEO, Association of Academic Health Centers, Washington, DC Henry Falk, Assistant Administrator, Agency for Toxic Substance and Disease Registry, Centers for Disease Control and Prevention, Atlanta, GA Baruch Fischhoff, Professor, Department of Engineering and Public Policy and the Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA John Froines, Professor and Director, Center for Occupational and Environmental Health, Southern California Particle Center and Supersite. University of California, Los Angeles, CA Howard Frumkin, Professor and Chair of the Department of Environmental and Occupational Health at School of Public Health, Emory University's Rollins, Atlanta, GA Michael Gallo, Professor of Environmental and Community Medicine, University of Medicine and Dentistry, New Jersey-Robert Wood Johnson Medical School, Piscataway, NJ Bernard D. Goldstein, Dean, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA Robert Graham, Director, Center for Practice and Technology Assessment, Agency for Healthcare Research and Quality, Rockville, MD (membership expires June 30, 2003) Charles Groat, Director, U.S. Geological Survey, Reston, VA Myron Harrison, Senior Health Advisor, Exxon-Mobil, Inc., Irving, TX Carol Henry, Vice President for Science and Research, American Chemistry Council, Arlington, VA John Howard, Acting Director, National Institute for Occupational Safety and Health, Washington, DC Richard Jackson, Director, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA v

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Lovell ,Iones, Director, Center for Research on Minority Health; Professor, Gynecologic Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, TX Alexis Karolides, Senior Research Associate, Rocky Mountain Institute, Snowmass, CO Donald Mattison, Senior Adviser to the Directors of NICHD and CRMC, National Institutes of Health, Washington, DC Michael McGinnis, Senior Vice President and Director of the Health Group, Robert Wood Johnson Foundation, Princeton, NJ James Melius, Director, Division of Occupational Health and Environmental Epidemiology, New York State Department of Health, New York, NY James Merchant, Professor and Dean, College of Public Health, Iowa University, Iowa City, IA Sanford Miller, Senior Fellow, Center for Food and Nutrition Policy, Virginia Polytechnic Institute and State University, Alexandria, VA Alan R. Nelson, Special Advisor to the CEO, American College of Physicians-American Society of Internal Medicine, Fairfax, VA Kenneth Olden, Director, National Institute of Environmental Health Sciences (NIEHS), National Institutes of Health, Research Triangle Park, NC Peter Preuss, Director National Center for Environmental Research, U.S. Environmental Protection Agency, Washington, DC Lawrence Reiter, Director, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, NC Samuel Wilson, Deputy Director, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC IOM Health Sciences Policy Board Liaisons Lynn Goldman, Professor, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD Bernard D. Goldstein, Dean, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA Study Staff Christine Coussens, Study Director Dalia Gilbert, Research Associate Bina Russell, Senior Project Assistant (until August 2003) Steven I. Marcus, Consultant al Pi

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REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures ap- proved by the National Research Council's Report Review Committee. The pur- pose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manu- script remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Ann ,Iones Gerace, Executive Director, Conservation Consultants, Inc., Pittsburgh, PA Gerald Markowitz, Professor, Department of Urban Studies and Community Health, John Jay College, New York, NY Suzanne Seppi, Director, Group Against Smog and Pollution (GASP), Pittsburgh, PA Balius Walker, Professor of Environmental and Occupational Medicine, College of Medicine, Howard University, Washington, DC Although the reviewers listed above have provided many constructive com- ments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Melvin Worth, Scholar-in-Residence, Institute of Medicine, who was responsible for making certain that an independent examination of this report was carried out in accor- dance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. vim . .

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Preface In 1753, George Washington recognized the importance of establishing a post along the Ohio River. Both the French and English began plans to establish a fort critical to trade and expansion at the point where the Allegheny, Monongahela, and Ohio Rivers met. Pittsburgh lived up to these expectations by being dubbed the Gateway to the West, as early nineteenth century immigrants went down the Ohio to start a new life. This port gave rise to two of Pittsburgh's first industries: boat building and outfitting. However, it was in 1 811 that a marine engineer from New York, Nicholas Roosevelt, built the first steam-powered boat and estab- lished Pittsburgh's role in industrialization. With its cheap energy sources from water, coal, and oil, nineteenth century Pittsburgh gloried in being the iron foundry of the nation. It welcomed the sight and smell of smoke as signs of leadership and prosperity. Penniless immigrants, such as Andrew Carnegie, made fortunes and were exemplars of the American Dream, inspiring legions of others to believe that the future was boundless. However, there was another side to this prosperity. Poor sanitation, water, air, and working conditions led to many health problems. Even the marble on build- ings was stained dark gray to black. Large tracts of land were contaminated with dumped slag and chemical by-products of manufacturing. This environmental contamination was unjustly distributed in minority and disadvantaged communi- ties. Formerly beautiful rivers were dead to fish and inaccessible to city residents. During his American tour, Dickens described midnineteenth century Pittsburgh as "hell with the lid taken off." For better and worse, the days of intense industrialization have passed for southwestern Pennsylvania. Beginning before World War II and picking up pace afterward, Pittsburghers realized the threat the industrial pollution posed to their physical and economic well-being. In a region known for difficult relations between labor and capital, remarkable collaborations promoted smoke abatement and urban development, converting downtown Pittsburgh's rail yard into park and offices. Manufacturing is now a small part of the region's struggling ix

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PREFACE economy. The steel barons left a legacy of support for libraries, education, and cultural institutions that contribute to Pittsburgh' s being one of the nation' s most livable cities. More recent developments have included stadiums and museums, including architecturally significant buildings. Some, including a new convention center and the headquarters of Alcoa and PNC, are at the forefront of environmentally sound design. A city that once turned its back on the rivers, as grimy highways or worse, is now developing the riverbanks. Almost dead biologically two genera- tions ago, the rivers support good fishing at the Point and expanding populations of river otter upstream. Bicyclists ride along side active railroad lines and atop abandoned ones. The combination of civic and self interest that brought about those changes was not enough, though, to prevent the collapse of the local steel industry, begin- ning in the late 1970s. The result has been vastly cleaner air, along with a stagnant regional economy. As might be expected, these overall changes have not affected area residents equally. The good jobs for hard-working laborers, with middle- class pay and benefits, have largely vanished. At the same time, the economic potential of the area's world-class hospitals and universities has increasingly been realized, bringing new opportunities. However, those institutions are both close to some economically challenged communities and far from others that once housed thriving industries. Allegheny County long had one of the nation's highest African-American infant mortality rates. It took concerted efforts by the health care community, aided by local governments, citizens, and foundations to bring it down some, although by no means enough. Local research similarly showed the difficult way toward identifying and remedying the risks of lead pollution. The complexity of these problems shows the intertwining of health and environment and their social context. Addressing them requires not only good will and coordinated program- matic efforts, but also solid, interdisciplinary science. For example, a simple correlation of pollution and health does not capture the expression of environ- mental justice issues in this area (or perhaps any other) (Institute of Medicine, 1999~. Neighborhoods that excluded minorities when the local mills hummed became low-income housing when the mills closed, taking jobs away and leaving pollution behind. Access to health services, training, and work requires reducing cultural barriers and providing public transportation. Similarly, complex connections attend the relationship between the region's environmental and economic future. Dickens's image of Pittsburgh is still most nonresidents' association with the area, generations after it is no longer a reality. Thus, the region is paying a pollution tax long after much of the pollution is gone. Both positive and negative images are hard to erase. One can only speculate about the environmental reputations now being created elsewhere and their long- term effects. California's Garden of Eden drew people there long after the area was clogged with traffic and dirty air. The green images that drew people to

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PREFACE Xt Atlanta have been replaced by sprawl, imperiling the greenery and even water supplies (Institute of Medicine, 2002~. California has become a leader in the study and control of air pollution, while the southeastern United States has begun imaginative thinking about regional planning. One might wonder whether the current, sadder images will haunt those regions 20 years after they have turned their respective corners. Of course, the future is not a given. Southwestern Pennsylvania stands at a crossroads. It might become the leader in postindustrial revitalization. It might provide the science needed for effective and efficient cleanup and growth, as well as developing the engineering and institutions needed to realize this potential. The contrast between its new and old images might serve as an inspiration to others facing similar despoliation. One striking image is the ongoing conversion of a giant slagheap from the old Carnegie (and later US Steel) Homestead Works into an upscale housing development. Reflecting a "new urbanist" architecture, its popularity reveals residents' preference for a denser lifestyle (but without the hassles of older homes). A more complex image lies several hundred feet below this development, in Nine Mile Run. One of many such ribbons of green, created by the region's topography, it is also polluted by runoff from aging sewers. Cleaner in other respects, local waters are threatened by leaky sewers, storm water overflow, and septic systems ill-suited to the heavy local soils. Compliance with an EPA order may require billions of dollars and an unprecedented degree of collaboration among the fractured local governments. It may require a combination of top- down efforts and local initiatives, like those benefiting Nine Mile Run. As residents reclaim the environment about them, they will confront other threats to it, some coming from outside the region. Pockets of nature created by steep topography provide natural breathing spaces, even in poor neighborhoods. However, a closer look often shows them to be deeply compromised by invasive species: Japanese knotweed along the now-accessible rivers, tree of heaven replacing native forests, and others. Upstream, there are abandoned mines, surges of whose acidic waters periodically destroy aquatic life below them. The success of local efforts to protect and restore these habitats will critically depend on state and federal policies (e.g., mining laws, plant import regulations). A bit further away, Nine Mile Run's outlet to the Monongahela River may soon be bridged by a highway, running along the riverbank. The Mon-Fayette Freeway's advocates claim that it will bring economic opportunity to the de- pressed Mon Valley. That could improve regional health care and even provide resources for environmental restoration. It could also bring thoughtless develop- ment, increasing air pollution and sedentary lifestyles. It might deplete the central region, leaving its poor and their problems behind. It might undermine the coordination needed to preserve the regional commons and create an area that will attract outsiders and retain its own residents.

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. . xt! PREFACE Thus, in southwestern Pennsylvania as elsewhere, health, economics, and environment are deeply connected. Central to the connections in this region is a past that has scarred it but has also provided resources. These resources include universities accustomed to integrating research and practice, governmental bod- ies that have long focused on environmental and occupational health, healthcare institutions with a tradition of community service, firms accustomed to working with other groups, and foundations with activist leadership. In this context, the Institute of Medicine Roundtable on Environmental Health Science, Research, and Medicine held a regional workshop at the David Lawrence Convention Center, on March 13, 2003. This workshop was a continued out- growth from the Roundtable's first workshop when its members realized that the challenges facing those in the field of environmental health could not be addressed without a new definition of environmental health one that incorporates the natural, built, and social environment. The Roundtable realized that the industrial legacy is not unique to Pittsburgh. Other cities around the world have seen their industries disappear, and it is only a matter of time before some of the Pittsburghs of today, such as Wuhan, China, (a sister city) will need to address similar problems. One goal for this IOM Environmental Health Roundtable Workshop is to extract lessons from Pittsburgh's experience in addressing the post-industrial challenge, distilling les- sons that might be useful elsewhere. Early in the planning process, Roundtable members realized that the process of engaging speakers and developing an agenda for the workshop was an impor- tant part of the enterprise. In their efforts to encourage a breadth of participation, Roundtable members sought the input of individuals from diverse fields indus- try, health, foundations, environmental groups, engineers, architects, developers, and others. Their input helped to shape the agenda. We would like to thank this group of individuals for their contributions to making this meeting a success. This workshop summary captures the discussions that occurred during the one-day meeting. Although, environmental health is broadly defined by the Roundtable, not all aspects of environmental health (e.g., social environment) or secondary factors (e.g. budgetary constraints) could be discussed in their entirety during the limited time of the meeting. This workshop summary captures the discussions and presentations by the speakers and participants, who identified areas where additional research was needed, the processes by which changes could occur, and the gaps in our knowledge. The views expressed here do not necessarily reflect the views of the Institute of Medicine, the Roundtable, or its sponsors. Baruch Fischhoff and Bernard Goldstein Summer 2003

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Contents PREFACE SUMMARY 1 INTRODUCTION 4 Charge to Speakers and Participants, 5 Overview of the Workshop, 6 Wh at I s Enviro nment al H e alth ?, 7 2 KEYNOTE: ENSURING ENVIRONMENTAL HEALTH IN PENNSYLVANIA 10 3 THE CHANGING FACE OF PITTSBURGH: A HISTORICAL PERSPECTIVE 13 Grime and the Rivers, 14 Clearing the Air, 15 Beyond Celebration, 19 4 SPECIAL ISSUE FOR PITTSBURGH: OUR RIVERS Cradle of the American Industrial Revolution, 20 Polluted Rivers, Sewage Overflows, 21 Rivers As Our Future, 25 ..20 5 IMPROVING HEALTH IN THE BUILT ENVIRONMENT: A DAUNTING BUT DOABLE CHALLENGE 28 "Landscraping" Degrades Environmental Health, 29 Driven to Depression, or Worse, 30 The Hazards of Obesity, 32 Where People Want to Be, 33 . . . x~

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xlv 6 COMMUNITY PAST, PRESENT, AND FUTURE "Active Living" in Walkable Communities, 37 Redeveloping Brownfields: Developer, 38 Redeveloping Brownfields: Regulator, 40 Environmental Justice, 42 Toward Healthy Homes, 44 7 SYSTEMS, BUILT ENVIRONMENT- PAST, PRESENT, FUTURE .......... Health and the Built Environment, 48 Smart Growth, 51 Transportation's Impacts on Environmental Health, 54 Green Building, 56 Revolutionizing Energy Systems, 58 8 WHERE DO WE GO FROM HERE? More and Better Feedback Loops, 61 Information Sharing Gets Results, 62 Making Clear the Connections, 63 Facilitating Progress, 65 The Elements of Success, 66 REFERENCES APPENDIXES CONTENTS - .36 - .47 .61 - .68 A AGENDA 69 B SPEAKERS AND PANELISTS C MEETING PARTICIPANTS - .75 .77