Rebuilding the Unity of Health and the Environment in Rural America

Workshop Summary

James Merchant, Christine Coussens, and Dalia Gilbert, Editors

Roundtable on Environmental Health Sciences, Research, and Medicine

Board on Population Health and Public Health Practice

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary Rebuilding the Unity of Health and the Environment in Rural America Workshop Summary James Merchant, Christine Coussens, and Dalia Gilbert, Editors Roundtable on Environmental Health Sciences, Research, and Medicine Board on Population Health and Public Health Practice INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary 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. This study was supported by multiple contracts and grants between the National Academy of Sciences and the National Institute of Environmental Health Sciences, National Institutes of Health (Contract N01-OD-4-2193, TO#43); 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 0000166930); National Health and Environment Effects Research Laboratory and National Center for Environmental Research, U.S. Environmental Protection Agency (Contract 282-99-0045, TO#5); American Chemistry Council (unnumbered grant); Exxon-Mobil Corporation (unnumbered grant); and Brita Water Research Institute (unnumbered grant). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations and agencies that provided support for this project. 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 names of the editors, with the assistance of staff and consultants, as an individually authored document. International Standard Book Number 0-309-10047-X Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, N.W., Box 285, Washington, DC 20055. Call (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 2006 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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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary 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. Ralph J. Cicerone 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 Engineering. 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. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary 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, The Johns Hopkins University, Baltimore, MD Jacqueline Agnew, Professor, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD Roger Bulger, Advisor to the Director, National Center on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD Yank D. Coble, Immediate Past President, World Medical Association, Neptune Beach, FL Henry Falk, Director, Coordinating Center for Environmental and Occupational Health and Injury Prevention, National Center for Environmental Health/Agency for Toxic Substances and Disease Registry (NCEH/ATSDR), Centers for Disease Control and Prevention (CDC), Atlanta, GA Baruch Fischhoff, Professor, Department of Engineering & Public Policy, 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 Howard Frumkin, Director, National Center for Environmental Health/Agency for Toxic Substances and Disease Registry (NCEH/ATSDR), Centers for Disease Control and Prevention (CDC), Atlanta, GA Paul Glover, Director General, Safe Environments Programme, Health Canada, Ottawa, Ontario Bernard Goldstein, Professor, Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA Myron Harrison, Senior Health Adviser, Exxon-Mobil, Inc., Irving, TX Carol Henry, Acting Vice President for Industry Performance Programs, American Chemistry Council, Arlington, VA John Howard, Director, National Institute of Occupational Safety and Health, Centers for Disease Control and Prevention, Washington, DC Peter Illig, Consultant, Association Internationale pour l’ Ostéosynthèse Dynamique, Trauma Care Institute, Nice, France Richard Jackson, Professor, University of California at Berkeley Lovell Jones, Director, Center for Research on Minority Health, and Professor, Gynecologic Oncology, University of Texas, M.D. Anderson Cancer Center, Houston

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary Alexis Karolides, Senior Research Associate, Rocky Mountain Institute, Snowmass, CO Fred Krupp, Executive Director, Environmental Defense, New York, NY Patrick Leahy, Acting Director, U.S. Geological Survey, Reston, VA Donald Mattison, Senior Adviser to the Directors of the National Institute of Child Health and Human Development and Center for Research for Mothers and Children, National Institutes of Health, Bethesda, MD James Melius, Administrator, New York State Laborers’ Health and Safety Fund, Albany James Merchant, Professor and Dean, College of Public Health, University of Iowa, Iowa City Dick Morgenstern, Senior Fellow, Resources for the Future, Washington, DC John Porretto, President, Sustainable Business Solutions, Dewees Island, SC Lawrence Reiter, Director, National Exposure Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, NC Carlos Santos-Burgoa, General Director for Equity and Health, Secretaria de Salud de Mexico, Mexico D.F. David Schwartz, Director, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC Jennie Ward-Robinson, Executive Director, Brita Water Research Institute, Oakland, CA Samuel Wilson, Deputy Director, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC Study Staff Christine M. Coussens, Study Director Dalia Gilbert, Research Associate Erin McCarville, Senior Project Assistant (until May 2005) Jenners Foe-Parker, Intern (Fall 2004) David Tollerud, Project Assistant (from October 2006) Division Staff Rose Marie Martinez, Board Director Hope Hare, Administrative Assistant Christie Bell, Financial Associate

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose 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 manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Mary Gilchrist, Director, Hygienic Laboratory, University of Iowa, Iowa City Paul Lasley, Professor and Chair of the Department of Sociology, Iowa State University, Ames David Riley, Program Coordinator, Center for Health Effects of Environmental Contamination, University of Iowa, Iowa City Although the reviewers listed above have provided many constructive comments 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, M.D., Scholar-in-Residence, Institute of Medicine, who was responsible for making certain that an independent examination of this report was carried out in accordance 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.

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary Preface Throughout much of its history, the United States was predominantly a rural society. The need to provide sustenance resulted in many people settling in areas where food could be raised for their families. Over the past century, however, a quiet shift from a rural to an urban society occurred, such that by 1920, for the first time, more members of our society lived in urban regions than in rural ones. This was made possible by changing agricultural practices. No longer was it necessary for each individual to raise his or her own food, and the number of person-hours and acreage required to produce food has steadily been decreasing because of technological advances. The result has been a changing rural landscape: once dotted with small family farms, the landscape is now being replaced by larger-scale operations. For better or for worse, the reality is that agribusiness has firmly taken over the traditional family farm. The good news is that through research we have learned about pesticide and chemical applications, so that our ecological footprint is now smaller. The bad news is that considerable research on new technological advances (e.g., contained animal feeding operations) and their impacts on human health is still needed. As people have moved from the farm to the city, the demographics of the rural population have changed. Currently, the rural population tends to be older and poor, and lacks access to adequate health care coverage or services. Although the common perception has been that most people living in rural America are farmers, the reality is that only a small percentage of individuals living in rural regions are farmers. The majority commute to jobs in neighboring cities. In fact, often one or both spouses living on a traditional family farm are often employed at a job away from the farm. Like many regions in the country, environmental health is a large concern for individuals in rural areas. Whether it is related to preserving the natural environment, addressing adequate housing, providing safe drinking water, protecting migrant workers’ health, or creating a healthy social environment, the environ-

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary ment in which people live influences the status of their health. The population living in rural America (collectively across the United States) makes up a significant proportion of the U.S. population, and its environmental health concerns are distinct, although those concerns do have some overlap with those of the rest of the population. The Institute of Medicine’s Roundtable on Environmental Health Sciences, Research, and Medicine held a regional workshop at the University of Iowa on November 29 and 30, 2004, to look at rural environmental health issues. This workshop was a continued outgrowth from the Roundtable’s first workshop, at which 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 environments. The Roundtable chose to focus this workshop on rural America and concentrated on Iowa as the basis of its discussions. The members of the Roundtable realized that rural America is not homogeneous and that the environmental health challenges in one region of the United States may not be the challenges in other areas of the country. Water was one example, as some regions of the country face problems with water quality issues while other rural regions are experiencing drought conditions. This workshop was not meant to cover environmental health in all rural areas in depth but was conducted to obtain an overview of some of the key environmental health concerns in rural America by using the Midwest as a starting point for discussion. Early in the planning process, Roundtable members realized that the process of engaging speakers and developing an agenda for the workshop was an important part of the enterprise. In their efforts to encourage the participation of a breadth of participants, the Roundtable members sought the input of individuals from diverse fields—industry, health care, foundations, environmental groups, government, citizen groups, and others. Their input helped shape the agenda. We would like to thank these individuals for their contributions to making this meeting a success. This workshop summary captures the two-day meeting discussions where the speakers and participants identified areas in which additional research was needed, the processes by which changes could occur, and the gaps in our knowledge. Although the Roundtable defines environmental health in broad terms, not all aspects of environmental health could be discussed in their entirety during the limited time of the meeting. The views expressed here do not necessarily reflect the views of the Institute of Medicine, the Roundtable, or its sponsors. James Merchant, M.D., member Roundtable on Environmental Health Sciences, Research, and Medicine

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary Contents     Summary   1     Introduction   11 1   Environmental Health in Rural America   15      What Is Rural?,   15      Challenges to Life in Rural America,   16      The Farm Bill and Environmental Health,   20 2   The Social Environment in Rural America   25      Rural Mosaic in America,   25      Population Change in Rural Areas,   27      Health Care in Rural Areas,   28      Socioeconomic Aspects in Rural Areas,   29      Age Disparities in Rural Areas,   29      Ethnic Diversity in Rural Areas,   30      Language, Culture, and Health,   30      Rural Infrastructure: Environmental Health and Beyond,   34      Strategies to Link Health and the Rural Environment,   36      Rural Mental Health: A Multifaceted Issue,   40      Factors Affecting the Mental Health of Rural Dwellers,   40      Rural Mental Illnesses: Depression,   41      Rural Mental Health in Selected Populations,   43 3   Role of the Natural Environment in Rural America   47      Ecological Footprint of Iowa Agriculture,   47      The Future of Family Farms,   50      The Impact of Technology,   51      Economic Impact,   52

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary      Environmental Health Impact,   52      Future Prospects,   53      Farming Practices: From Soil Erosion to Pesticides,   54      Water and Air Quality: Challenges for Environmental Health,   56      Future Challenges,   58      Energy Technology: Evolving Technologies for Improving Health,   59      Incentives for Improving Air Quality,   61      Renewable Energy Production,   62      Linkage Between Sources of Energy Production and National Security Issues,   62      Renewable Energy and Climate Change,   63      Opportunities for Communities: Nebraska Environmental Partnerships,   66      Nebraska Environmental Partnerships Program Activities,   67 4   The Built Environment and Health in Rural Areas   71      The Health Impact of Urban Encroachment on Rural Areas,   71      Is Europe the Answer?,   72      Environmental Issues Associated with Iowa’s Abandoned and Occupied Housing,   73      Abandoned Housing,   75      Occupied Housing,   75      The Built Environment and Opportunities for Rural Health,   77      Investigation of Environmental Exposures and Chronic Disease in Rural Communities: The Agricultural Health Study,   79      The Agricultural Health Study,   80     References   87     Appendixes         A  Workshop Agenda   93     B  Speakers and Panelists   99     C  Meeting Participants   101