Designing intervention strategies for environmental risks can be difficult. There often is not a clear-cut option between modifying the environment or targeting the intervention to the individual with the disabling condition. In some cases, such as the inaccessibility of public accommodations, a legislative approach—one that requires modification of the environment—is the solution. The recent passage of the landmark Americans with Disabilities Act is an excellent example. Unfortunately, not every environmental risk lends itself to such a solution. In many cases interventions require a careful balance of modifications to the physical and social environments (e.g., altering the workplace and increasing educational efforts) and interventions designed to assist people with disabling conditions in adjusting to the environment (e.g., rehabilitation and retraining). These issues are discussed in more detail in Chapter 7.

Lifestyle and Behavioral Factors

Lifestyle and behavioral risk factors consist of personal decisions and habits that affect one's health and over which one has considerable control. Lifestyles and behaviors that are detrimental to health create self-imposed risks. Research has made it clear that unhealthy lifestyles contribute to mortality and morbidity in affluent, industrialized countries. The Centers for Disease Control has estimated that 50 percent of the deaths attributed to the 10 leading causes of mortality can be directly related to ''lifestyles." Foremost among these behavioral risk factors, according to Hamburg (1984), are smoking, excessive alcohol intake, illicit drug use, poor dietary habits, insufficient exercise, reckless driving, noncompliance with medication regimens, and maladaptive responses to stressful experience. As Hamburg notes, "A new awareness has dawned: much of disease and disability is related to human behavior, and therefore the role of behavior in keeping people healthy must be understood scientifically. In this direction lies the possibility of preventing much disease and promoting health. This promising approach affects the well being of people everywhere."

Because Hamburg's list of risk factors was published in 1984, it did not include unsafe sexual behavior as a major contributor to mortality and morbidity. With the AIDS (acquired immune deficiency syndrome) epidemic, however, unsafe sexual behavior must be added to the list of behaviors that contribute to disability and mortality in the United States. Moreover, Hamburg points to cigarette smoking as the most important environmental factor and alcohol abuse as the most serious drug problem in America, but the toll taken by cocaine abuse also now must be taken into account. For example, Hahnemann University Hospital in Philadelphia reports that 40 percent of a consecutive series of 500 mothers who delivered babies and who were insured by Medicaid had evidence of cocaine in urine or blood samples at the time of



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