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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 11

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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. 12

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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. 13

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Ire :~ ~ - s~ =~g c -- - ~A - 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.