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CHAPTER ~
611~1 ~1~11.
The Nature of the Study
The growing public recognition of adverse health effects associated with
exposure to toxic substances in the home, the workplace, and the general
community environment is reflected in an increasing concern that the health
care system is not adequately prepared to address occupational and environ-
mental problems. While the public tends to rely on its public health and
regulatory agencies to protect it from hazardous toxic exposures and dangerous
consumer products, individuals generally turn to the medical community for
help when they are personally affected. Many, if not most, of these concerned
individuals consult primary care physicians, principally general internists and
family physicians. Physicians' limited training in occupational and environ-
mental medicine, coupled with this expanding need, prompted the Institute of
Medicine to examine the role of primary care physicians in occupational and
environmental medicine and to seek ways of fostering their participation in
these important areas of health care.
TARGET AUDIENCE AND FOCUS OF CoNCERN
While recognizing the important contributions of nonphysician health care
providers, the study focuses its efforts on physicians in order to examine specific
problems and offer specific recommendations for one health care discipline.
Although there are specialists in occupational and environmental medicine,
they are not the main targets of this report. The committee was primarily
concerned with primary care physicians, or, more accurately, physicians of first
contact. These include genera internists, family physicians, osteopathic primary
care physicians, emergency room physicians, and pediatricians. To the extent
that other specialists, for example, cardiologists, gynecologists, and surgeons,
provide general as well as specialty-specific health care, they, too, are part of the
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study's target audience. Some primary care physicians provide occupational
medicine services through formal or inform Dial relationships with companies or,
to a lesser extent, with labor unions. These physicians constitute a special subset
and are addressed in this report. Although the report limits its discussion to
physicians, many of its recommendations will apply and be helpful to other
health care providers as well.
The specific focus of the study raised difficult issues that were more than
semantic in nature. Some committee members favored use of the term health
over the term medicine because the former emphasizes the broader preventive
activities that are so important to the field. The term medicine was chosen because
it more accurately reflects the activities of the study's target audience.
The borders of occupational medicine and environmental medicine were
more difficult to define. For the purposes of its study, the committee opted for
a broad definition of occupational medicine and a more limited contemporary
definition of environmental medicine. Occupational medicine considers all
aspects of the relationship between work and health. It includes the impact of
disease on the ability to work as well as the impact of work on the development
or exacerbation of existent medical disorders. The broad goal of "humane work
conditions" described by the World Health Organization is included in the
committee's definition of occupational medicine.
The definition and scope of environmental medicine are more complicated.
In the literal sense, the environment is at least in part responsible for all diseases,
except those determined solely by genetics. Thus, environmental medicine in
that sense touches almost every aspect of medicine.
Environmental health has had a long history in public health and preventive
medicine. At the turn of the century, the major environmental health concern
was drinkable water, a function of sanitary engineers and the new sciences of
epidemiology and infectious disease. At that time, the major threat to water
supplies in the United States was bacterial contamination. The epidemiologic
component of environmental health can be traced directly from John Snow's
identification of the Broad Street water pump as the source of a major cholera
epidemic in London. The transmutation of environmental health from a focus
on infectious disease to its present-day almost complete exclusion of diseases
caused by microbial agents has been based primarily on two trends. One is the
development of epidemiology and infectious disease into specialties that extend
well beyond an initial focus on waterborne diseases. The second is the success of
sanitary engineers in developing highly successful approaches to preventing
such diseases. At the time the modern environmental concerns developer! in the
late 1960s, the focus of public health was to a large extent on infectious disease,
as exemplifieciby the name change in 1970 of an arm ofthe Public Health Service
from the Communicable Disease Center to the Centers for Disease Control. The
term environmental health has evolved from its previous connotation and is now
used as a designation for relatively new concerns.
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Currently, the popular conception of environmental disease is related to
illness caused by external chemical or physical agents. This definition excludes
conditions that are a direct consequence of inheritance; infectious disease;
nonoccupational violence, advertent or inadvertent; and iatrogenically caused
illness and injury. The committee interpreted its charge from the Institute of
Medicine to narrow this definition even further to exclude diseases caused by
nicotine, alcohol, diet, and other life-st:yle factors. This decision in no way
denigrates the important contribution of these "environmental" factors to
serious disease. Rather, it reflects a concern that non-life-style environmental
factors, that is, toxic exposures, are less often considered and are equally
desewing of study and attention. In short, the committee's use of the term
environmental medicine includes caring for individuals who are exposed to toxic
substances in their homes and neighborhoods through such media as contami-
nated soil, water, and air.
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Chemists boast that they
have mastered the art of subduing every kind of
mineral, yet; they l;hemselves do not come o~scot-free
from their pernicious influence.
Representative terms from entire chapter:
care physicians
