9

Environmental Health Policies and Opportunities

An afternoon session on the workshop’s second day offered a panel discussion on environmental health policies and opportunities. The panel’s three speakers focused on assessments of health and sustainability as ways to inform policy making concerning biofuels. The panel moderator, John Balbus, National Institute of Environmental Health Sciences, noted that such assessments are crucial tools in determining how to weigh the different issues involved in the production and use of biofuels, which can run the gamut from environmental issues, such as fertilizer runoff and soil erosion, to social issues, such as the health of communities, to economic issues, such as the costs of food and fuel.

A FRAMEWORK FOR ASSESSING HEALTH IMPACTS OF BIOFUELS

The first speaker was Lynn Goldman, dean of the School of Public Health at George Washington University. She discussed some factors that should be taken into account when assessing the health impacts of biofuels.

There have been a number of health policy drivers for biofuels production, she said. These include reducing air pollution, including greenhouse gas emissions from biomass fuels and coal; increasing fuel security; benefiting rural economies; and increasing energy availability, both for today’s growing populations and for future generations. She addressed each of these in turn.



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9 Environmental Health Policies and Opportunities An afternoon session on the workshop’s second day offered a panel discussion on environmental health policies and opportunities. The panel’s three speakers focused on assessments of health and sustainability as ways to inform policy making concerning biofuels. The panel moderator, John Balbus, National Institute of Environmental Health Sciences, noted that such assessments are crucial tools in determining how to weigh the different issues involved in the production and use of biofuels, which can run the gamut from environmental issues, such as fertilizer runoff and soil erosion, to social issues, such as the health of communities, to economic issues, such as the costs of food and fuel. A FRAMEWORK FOR ASSESSING HEALTH IMPACTS OF BIOFUELS The first speaker was Lynn Goldman, dean of the School of Public Health at George Washington University. She discussed some factors that should be taken into account when assessing the health impacts of biofuels. There have been a number of health policy drivers for biofuels production, she said. These include reducing air pollution, including greenhouse gas emissions from biomass fuels and coal; increasing fuel security; benefiting rural economies; and increasing energy availability, both for today’s growing populations and for future generations. She addressed each of these in turn. 137

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138 THE NEXUS OF BIOFUELS, CLIMATE CHANGE, AND HUMAN HEALTH Reducing Air Pollution Goldman noted that there are a variety of considerations to take into account when reducing air pollution, specifically, levels of ozone, particulate matter, volatile organic compounds, nitrous and sulfur oxides, and metals like mercury. For example, policy makers should consider how fuels burn, and whether one fuel is cleaner than another. “We add fuel oxygenates to motor vehicle fuels to increase octane and make them burn more cleanly, and ethanol has substituted for MTBE (methyl tertiary-butyl ether) and some of the other oxygenates,” she said. Second, she noted that diesel fuel combustion creates a great deal of air pollution. The U.S. Environmental Protection Agency (EPA) and other regulatory authorities have sought to develop cleaner diesel fuel, and biodiesel has been thought to be a pathway to development of cleaner alternatives. Third, she identified the problem of indoor air pollution from burning biomass fuels for household heating and cooking. Such fuels are very dangerous in terms of the pollution they produce indoors. Alternative fuels that burn more cleanly could replace the biomass fuels or could be used to generate electricity for households thus reducing exposures within the home environment. At the same time, Goldman said, it is important to take into account the life-cycle effects of the various potential energy sources. Thus, when considering air pollution levels, it is important to take into account not only the air pollution that is generated by fuel combustion, but also the air emissions that occur across the entire life-cycle of growing the plants, producing the fuels, and transporting the fuels. Unfortunately, she said, “that is not generally how we perform risk assessment.” Reducing Greenhouse Gases A second major policy goal is reducing air pollutants that act as greenhouse gases. “We know that global climate change already is having a profound impact on the public’s health,” Goldman said. However, as Timothy D. Searchinger, Princeton University, pointed out in his talk, it now seems that some of the early assessments of the potential of biofuels to reduce greenhouse gasses were overly optimistic, largely they did not take into account land-use changes. She asserted that although it was once thought that biofuels would play a significant role in efforts to reduce greenhouse gases, no clear

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ENVIRONMENTAL HEALTH POLICIES AND OPPORTUNITIES 139 benefits have been demonstrated by current alternatives. This clearly underscores that it is crucial to do a careful life-cycle assessment when considering the benefits of using biofuels. Increasing Fuel Security According to Goldman, fuel security is an important public health issue. For example, she said, “Increasing fuel security could potentially increase national security and thereby prevent adverse health impacts that are related to regional and global conflicts.” Such impacts occur as the direct result of conflicts, she said, but they can also occur indirectly because of the displacement of civilian populations during conflicts and morbidity and mortality impacts on such populations. However, Goldman said, U.S. energy use per capita is so massive and the potential production of biofuels so small by comparison that, to date, conventional biofuels have had very little impact on fuel security in the United States, nor is there evidence that biofuels have had a major impact on fuel security in most other countries in the world. Of course, she added, there is always the hope that newer technologies will produce biofuels more efficiently and thus change the fuel security equation. Benefiting Rural Economies Another way that biofuels could affect health is through the benefits they provide to rural economies. This is not something that would normally appear in a risk assessment framework, Goldman said, but it is certainly reasonable to believe that biofuels production could support efforts to rebuild the economies in some rural communities, which would lead to improvements in health not only by rebuilding health care systems but also by supporting other basic infrastructure needs like trans- portation and education systems. However, she added, the outmigration of young people is thought to be responsible for many of the negative impacts on rural communities. Economic development that enables young people to live and work in rural communities is an important policy objective but, as other speakers had pointed out, evidence to date indicates that biofuels production is resulting in dramatic increases in jobs that would serve as a strong incentive for retaining young people in these communities. Yet another factor—which is almost never considered in a risk assessment context—is the potential effects that boom-and-bust cycles

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140 THE NEXUS OF BIOFUELS, CLIMATE CHANGE, AND HUMAN HEALTH can have on health. Such a situation can arise when an industry expands rapidly and creates jobs creating a boom, and then contracts quickly because of changes in incentives, subsidies, or mandates or resource constraints, resulting in a bust. She said that this can ultimately have a negative effect on the health of the community’s members. One other factor that Goldman considered is the potential depletion of soil and water resources caused by biofuels production. Soil resources can be damaged by overfarming in marginal areas. Depletion of water resources has been of greatest concern in areas dependent on groundwater sources like the Ogalalla aquifer, which is very slowly renewable. Depletion of soil and water resources could damage rural economies and the health of people who live in those parts of the country, now and in the future. Increasing Energy Availability Another factor to consider concerning biofuels is the effects on health of increasing energy availability, both now and for future generations. This is another factor that is not usually considered in risk assessments, Goldman said, but for people who live with little available energy, major health benefits are associated with increasing energy supplies. There is evidence that increased availability of energy improves health only up to a point, however (Wilkinson et al., 2007). “There is very little evidence that the level of energy consumption that we have in the United States, for example, is actually beneficial to our health,” she said. “It is possible that we have some health impacts from overcon- sumption.” At the lower range of energy availability, however, the health benefits of increasing energy availability appear in several ways. Having light available in households helps to promote reading and literacy. Sources of energy that do not require a great deal of manual labor by children and women—e.g., gathering firewood and fuel—makes it possible to spend more time and effort on education and economic activity. Availability of electric-powered refrigeration both improves food safety and makes it possible to deliver immunizations to more people. Many parts of the world need more clean energy, Goldman said, and biofuels have the potential to provide local sources of such energy in those countries. However, legal mandates in places like the United States and the European Union may be making biofuels less affordable in

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ENVIRONMENTAL HEALTH POLICIES AND OPPORTUNITIES 141 developing countries by artificially increasing demand for biofuels in industrialized countries. Furthermore, if biofuels production leads to increased food prices, that could offset any benefits to health. The availability of energy for future generations—the “well-being of our children and our grandchildren”—is of particular concern to Goldman. An important question to ask in this regard is whether biofuels are actually renewables. “Many people seem to assume that they are,” she said, but the presentations and discussions in the workshop had indicated that may not actually be the case in the long run. A number of factors bring into question just how renewable biofuels are: requirements for chemical fertilizers and pesticides, soil losses over time, and the increased use of water for growing the crops and producing the biofuels. Sustainability of water use is particularly doubtful when the water is coming from fossil water supplies, like the Ogallala aquifer, bringing biofuels production into competition for the water with other human and environmental purposes, and with preserving the water for future generations. Given the need to expand future production, there may be serious limitations on how much biofuels production can be expanded, she said. “That is the reality with growing populations as well as increasing development worldwide—we will need to produce more food as well as more energy.” Again, she noted, the development of new technologies might lead to a situation in which biofuels production is more sustainable. In conclusion, she said, the governments of the Brazil, the European Union, and United States, and other countries have moved forward rapidly with mandates and subsidies to promote the development of biofuels with very little consideration of the potential health impacts, either today or in the future. A more important challenge, she said, will be reengineering the policy process so that it supports the conduct of health assessments before policy decisions are made, rather than after the fact. “I think that is an enormous challenge that lies before us, not only as a country, but for the world. I don’t have the answer, but I think it is fundamental to the problem that we are looking at today,” Goldman said. A SUSTAINABILITY ASSESSMENT METHODOLOGY The next speaker, Bernard Goldstein, emeritus dean and emeritus professor at the University of Pittsburgh Graduate School of Public

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142 THE NEXUS OF BIOFUELS, CLIMATE CHANGE, AND HUMAN HEALTH Health, discussed a sustainability assessment methodology proposed by a National Academy of Sciences committee in response to a request from Lisa Jackson, the head of the EPA, who had asked the committee to come up with an effective way to assemble the various issues affecting sustainability into a formal framework. The resulting publication, Sustainability and the U.S. EPA (NRC, 2011a), is often referred to as the Green Book, as compared to the Red Book, a 1983 National Research Council publication that laid out a framework for risk assessment (NRC, 1983). The Red Book gave a major push to the field of risk assessment, but even so, Goldstein said, it took a while for risk assessment methods to be broadly adopted. He expects something similar from the Green Book and its influence on the frameworks that people use to assess sustainability. As the committee that would produce the Green Book was forming in November 2010, the EPA received a report that it was late in responding to a congressional mandate for a risk assessment of biofuels. The committee members took that as an example for the development of the framework, Goldstein said, because “we had in mind that in the future Congress would ask the EPA and other agencies for a sustainability assessment of biofuels, not for a risk assessment.” Such a sustainability assessment extends well beyond the issue of risk and examines many different types of trade-offs. “That is what I will be talking about,” he said. The Evolution of the EPA To set the stage, Goldstein offered a brief history of the EPA’s approach to environmental protection policies. When the agency began in the 1970s, it used a command-and-control approach to environmental protection—“basically looking at the very dirty air and dirty water and how to deal with that,” he said. The agency’s move to a risk assessment approach was, in a sense, “a response to the recognition that even though we couldn’t see it and touch it, there were risks out there that we had to measure to be responsive to [demands for] effective environmental policy and to what society was demanding of us,” Goldstein said. In time, Goldstein said, the agency will move into a sustainability period. “Perhaps we are in it now.” There is already great work being done in this area, he said, such as life-cycle assessment. That is clearly one of the tools that will be needed for sustainability assessments.

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ENVIRONMENTAL HEALTH POLICIES AND OPPORTUNITIES 143 This evolution was driven in large part by the sorts of problems the EPA was facing, he said. The agency is no longer looking just at regulating such simple issues as the effluents from a single pipe or a single smokestack. Instead, it is facing multidimensional problems, and it needs tools that allow it to look across those dimensions instead of focusing on just one. The Green Book The committee that produced the Green Book was asked to answer four specific questions. They were 1. What should be the operational framework for sustainability for the EPA? 2. What scientific and analytical tools are needed to support the framework? 3. How can the EPA decision making process rooted in the risk assessment/risk management (RA/RM) paradigm be integrated into this new sustainability framework? 4. What expertise is needed to support the framework? The committee did not spend significant time in defining “sustainability,” Goldstein said. Instead, it “finessed” the definition issue. “As I think we all well know,” he said, “developing approaches to sustainability is sometimes inhibited by people spending a lot of time arguing over what we mean.” Some of the definitions suggested for “sustainability” refer to goals, while others refer to process. The committee, which Goldstein chaired, decided to approach it in terms of process. “What we simply said is that if you go back to the nation’s first major environmental act, the National Environmental Policy Act [NEPA] of 1969, signed by President Nixon, all of the aspects of sustainability are in that act, even though the word sustainability is not mentioned. We did this in part because we wanted to anchor this beyond any particular political party.” But the key was that the 1969 act already explicitly mentioned all of the same issues that the committee was dealing with. Thus, Goldstein said, he “ruled out of order any discussion that had to do with how to define ‘sustainability.’” Instead, the committee simply worked from the 1969 act to define a word that did not actually appear in

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144 THE NEXUS OF BIOFUELS, CLIMATE CHANGE, AND HUMAN HEALTH the act. NEPA1 states that its goal is “to create and maintain conditions, under which humans and nature can exist in productive harmony, that permit fulfilling the social, economic, and other requirements of present and future generations.” The Sustainability Framework The sustainability framework that the committee developed for the EPA has two levels, Goldstein explained. As can be seen in Figure 9-1, everything starts with the “sustainability paradigm,” which, in essence, sets forth the principles from which everything else follows. The paradigm consists of three separate pieces. The first contains three individual sets of principles—economics, environmental, and social, with “social” including health issues. The second piece consists of EPA sustainability principles and the third of various legal mandates relating to sustainability. “We suggested that the EPA needs a sustainability vision,” Goldstein said, and that vision should be informed by the sustainability paradigm. That vision should in turn be converted into specific goals and objectives, and metrics, using indicators as needed. Industry has done a very good job of developing and responding to sustainability goals and objectives, he said. The other components in Level 1 are organizational and cultural issues, sustainability assessment and management, and periodic evaluation and public reporting. The last piece is very important, Goldstein said. “We need to know if we are meeting these goals. If we are not measuring, we can’t really find out whether this is more than just hand waving.” Level 2 of the framework expands the sustainability and management component in Level 1. It begins with a screening process that examines a particular decision under consideration to determine if it has significant sustainability implications. “We can’t expect every single action of the EPA to be governed by a relatively complex approach,” Goldstein said. “Most actions will probably not need any major sustainability assessment.” Assuming that further analysis is needed, the next step involves scoping and options identification, stakeholder identification, indicator and metrics selection, and assessing collaboration opportunities. Next comes 1 Available at http://www.epa.gov/compliance/nepa (accessed August 20, 2013).

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FIGURE 9-1 Sustainability framework for the U.S. Environmental Protection Agency (EPA). SOURCE: NRC, 2011a. 145

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146 THE NEXUS OF BIOFUELS, CLIMATE CHANGE, AND HUMAN HEALTH the scoping and application of sustainability tools at the appropriate level of effort, followed by an analysis of the trade-offs and synergy involved, providing the results to the decision maker, making and implementing the decision, and evaluating the outcomes in order to inform future decisions. Sustainability Assessment Tools The sustainability assessment process only works effectively with the appropriate tools, Goldstein said. Risk assessment is an important tool, as is health impact assessment (HIA). Life-cycle assessment and cost-benefit analysis are two other well-known tools that are important to sustainability assessment, and a variety of other tools also play a role: ecosystem services valuation, integrated assessment models, sustainability impact assessment, and environmental justice tools. Many more tools need to be developed, he said. It may take a while for some of these tools to be fully developed, Goldstein said. He noted that the 1983 risk assessment framework emphasized exposure assessment as an important tool, but it was not until around 1986 that the first society for exposure analysis was formed, and it was not until the 1990s that the EPA had a formal exposure analysis program. In that case the EPA’s risk assessment forum played a vital role in developing the area of exposure analysis. “It basically sat down with all of the players across the EPA and hammered out an agreement about whether you extrapolate from animals to humans by body area or weight . . . or whatever it was that needed to be considered.” Afterward, exposure assessment was performed uniformly. Other workshop speakers had already mentioned the importance of developing such a uniform approach to life-cycle assessment, Goldstein noted, “and certainly we are going to need that for environmental justice tools and for a lot of the other tools that are needed for the assessment.” In closing, Goldstein said, “I really think we are on the cusp of developing these new tools. We need to, if we are going to face the kind of challenges we have heard about in this meeting.” When the EPA approaches an environmental issue, it should not think about the issue just in terms of minimizing risk. Instead, it needs to think in terms of how to maximize a whole collection of benefits while still minimizing risk. It is a very broad approach to thinking about environmental issues,

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ENVIRONMENTAL HEALTH POLICIES AND OPPORTUNITIES 147 he said, but “that type of breadth of approach is what we need for these kinds of challenges, such as biofuels.” A CALL FOR HEALTH IMPACT ASSESSMENTS The panel’s final presenter was Richard Jackson, professor and chair of environmental health sciences at the Fielding School of Public Health at the University of California, Los Angeles, and former director of the Centers for Disease Control and Prevention’s (CDC’s) National Center for Environmental Health. Jackson began by pointing out that many agencies of the federal government, not just the Department of Health and Human Services but also the Departments of Agriculture, Education, and Transportation and many others, are involved with health in one way or another. This is also true for the various agencies involved with energy. “If we have learned anything from the past 2 days,” he said, “it is that these energy decisions, biofuels, solar, fossil fuels, and the rest have health implications.” Unfortunately, however, there has been relatively little attention paid to the various ways in which energy decisions affect health. “What I was struck by in the past 2 days is that I don’t think we have ever done an adequate environmental impact assessment on biofuels,” Jackson said. “I have probably read 100 environmental impact assessments [EIAs]. What I have found is you review thousands of pages, and the last three pages claim to be about health. For example, the EIA will assert: ‘No air pollution standards, no water pollution standards will be violated, no noise will disturb the neighbors.’ I assert, and the Academy’s committee on Health Impact Assessment asserts: we don’t adequately capture health in the environmental impact assessment process, even though it is required under the National Environmental Policy Act.” Jackson described his experience serving on the joint National Research Council and Institute of Medicine Committee on Health Impact Assessment with Dinah Bear, who was with the Council of Environmental Quality in the White House. She was a very experienced lawyer with 25 years of experience, working on NEPA. When the other members of the committee would say that they wanted HIA required under NEPA, she would counter, “No, we already require health impact assessment in NEPA. We just have not done it.”

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148 THE NEXUS OF BIOFUELS, CLIMATE CHANGE, AND HUMAN HEALTH It is reasonable to expect that virtually all forms of biofuels will have not just environmental impacts, but impact on health, Jackson said. For example, growing corn for biofuels means that various nitrogen compounds end up in the soil and the water because of fertilizer use. Jackson, continued, When the United States produced large quantities of ethanol from immense quantities of corn, we clearly need to examine the impacts on the environment, but just as important are the impacts on health. Did the impact assessment include the health impacts on contamination of surface and ground water with nitrates from fertilizer, a known cause of infant methemoglobinemia? Do we examine the health effects of water contamination of corn herbicides like atrazine and allocholor? How about the loss of 7,000 square miles of prime seafood producing areas of the Gulf of Mexico from eutrophication? Or the air pollution produced by energy neutral burning of fossil fuels to grow the corn? Do we capture the negative impacts of inadequate production of “specialty crops” like fruits and the production of foods we in public health recommend over production of sugars and oils? Jackson also showed some images from the book Portraits in Biodiversity by David Liitschwager. One image shows all the various organisms found in a cubic foot of a meadow in Cape Town, South Africa, while another shows the organisms from a cubic foot in a U.S. cornfield. The difference in biodiversity is striking—there are 10 or more times as many organisms in the image from South Africa than in the image from the U.S. cornfield. “When you think about it,” Jackson said, “maybe that has long-term effects—not just environmental impacts, but health and social impacts.” In 2011 Improving Health in the United States: The Role of Health Impact Assessment was published (NRC, 2011b). Jackson chaired the committee that produced the report. “We had a mix of public health people, also economists, international folks with a lot of experience, toxicologists, and others,” he commented. The committee concluded that health is affected by a broad array of factors, including those that shape the conditions in which people are born, grow, live, work, and age. Public health has been linked, for

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ENVIRONMENTAL HEALTH POLICIES AND OPPORTUNITIES 149 example, to housing policies, transportation policies, urban planning policies, agricultural policies, and economic-development policies. Thus, Jackson said, it is important to make systematic assessments of the health consequences of various policies, programs, plans, and projects in order to protect and promote health. “We asserted the need for ‘health impact assessment,’” Jackson said. The committee defined it as follows: HIA is a systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. HIA provides recommendations on monitoring and managing those effects. (NRC, 2011b) Jackson said he believes that this definition makes HIA quite different from risk assessment. “It not only captures the adverse effects, but it captures the beneficial effects,” he said. “There are beneficial effects to having 40 people have a job year round in an ethanol production plant. There are beneficial effects to many of the changes that occur in these communities.” On the other hand, there are also negative effects, such as the boom/bust cycles that can occur. HIAs also consider various types of evidence—not just toxicological evidence, as in risk assessment, but many other types of evidence as well. It also engages communities and stakeholders early and throughout the deliberative process, not just at the end. In practice, HIAs should not be restricted by a narrow definition of health or restricted to any particular policy sector, level of government, type of proposal, or specific health outcome or issue. Instead, they should be focused on applications that present the greatest opportunity to protect or promote health and to raise awareness of the health consequences of decision making. In short, Jackson said, “It ought to focus on things that are important. Don’t spend a lot of time doing risk assessment or health impact assessment on things that don’t really matter. Worry about the big issues that affect people’s health.” The committee recommended a six-step framework for carrying out HIAs. The steps were screening, scoping, assessment, recommendations, reporting, and monitoring and evaluation. In the case of the use of biofuels, the first five steps were not carried out before decisions were

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150 THE NEXUS OF BIOFUELS, CLIMATE CHANGE, AND HUMAN HEALTH made, but it is not too late to monitor what happens. “Maybe we should be tracking from a health standpoint as well as an environmental life- cycle standpoint,” Jackson said. Once there are data concerning what is going on, the data should be evaluated, and at that time some evidence- based recommendations could be made. One of the committee’s conclusions was that it is important to be careful about quantitative estimates. “Numbers are helpful,” Jackson said, “but just because you measure it doesn’t mean it is important, and just because you can’t measure it doesn’t mean it is unimportant.” One practical challenge in carrying out HIAs is synthesizing and presenting results on dissimilar health effects in a manner that is intelligible and useful to decision makers and stakeholders. Although summary measures—such as quality-adjusted life years—can be used, the committee recommended that effects be described and characterized separately in a way that allows users to judge their cumulative nature. In closing, Jackson said, “I do think that we in the health world need to be touching on these energy decisions much more profoundly. . . . I think we desperately need more research in the energy world, and we need more research that touches on both health and energy.” DISCUSSION In opening the discussion session that followed the panel’s presentations, John Balbus, National Institute of Environmental Health Sciences, noted that each of the speakers had spoken of the time that it takes to implement changes, but it is clear that there is a certain urgency in the need for these sorts of assessments. So, he asked, “How do we keep a real sustainability and health assessment from becoming the cellulosic ethanol of environmental health, which is just 5 years away and always has been and always will be? Who has the responsibility and how do we get this process started?” Goldstein commented that there is already work being done with various sorts of health assessments, and there is a great deal of support among EPA staff for HIAs. “They just don’t have a framework, a setting, which allows them to move forward as readily as they could, if some sort of framework was in front of them.” Goldman added, “I would say that what needs to happen is that people need to start performing health impact assessments, and not waiting for mandates or waiting for administrative requirements.” An

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ENVIRONMENTAL HEALTH POLICIES AND OPPORTUNITIES 151 approach that might be taken is to leverage private-sector efforts or interest by industry in this area. Visible movement forward on using these assessments, Goldman said, may inspire the administrative changes that need to happen. “I think that you are going to have to . . . lead by example.” An audience member commented that most of the workshop presentations had focused on sustainability, which involves protecting resources for future generations. “I worry sometimes that by focusing on a distant concept of future generations, we can overlook children today.” So, she asked, are any of the tools that had been mentioned in the presen- tations being used to protect children? Goldman agreed that the health of children today is an important issue. She noted that many of the topics discussed, including nutrition and adequate energy supplies, apply to today’s children. Goldman said that freeing children from using all their energy for work is important to protect their ability to learn and grow. Jackson explained that because every action has an impact, the focus of sustainability should be to achieve the maximum positive impact and the least negative impact of each action. He stated that children today deserve a world that is diverse and healthful, and while some things will produce negative impacts, it is important to maximize the positives for them. Luz Claudio asked a question about making HIAs understandable to policy makers and the general public, not just specialists. Jackson commented that an HIA for a new subway was just being finished up in Los Angeles. “It is about 100 pages,” he said. “It is written in absolutely the most understandable language, and it captures multiple domains of both risk and services.” It explains that it is not possible to put a subway in without having negative impacts of various kinds in various areas, but that there will also be positive impacts, and it is important to think about how they balance out over time. “A well-educated lay person can read this quite comfortably,” Jackson said. “It will really, I hope, help inform a big important decision.” REFERENCES NRC (National Research Council). 1983. Risk assessment in the federal government: Managing the process. Washington, DC: National Academy Press.

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152 THE NEXUS OF BIOFUELS, CLIMATE CHANGE, AND HUMAN HEALTH NRC. 2011a. Sustainability and the U.S. EPA. Washington, DC: The National Academies Press. NRC. 2011b. Improving health in the United States: The role of health impact assessment. Washington, DC: The National Academies Press. Wilkinson, P., K. R. Smith, M. Joffe, and A. Haines. 2007. A global perspective on energy: Health effects and injustices. Lancet 370(9591):965–978.