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Health and the Environment in the Southeastern United States Howard Frumkin, Richard J. Jackson, and Christine M. Coussens, Editors Roundtable on Environmental Health Sciences, Research, and Medicine Division of Health Sciences Policy THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu
THE NATIONAL ACADEMIES PRESS â¢ 500 Fifth Street, N.W. â¢ 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. Support for this project was provided by the National Institute of Environmental Health Sciences, National Institute of Health (Contract No. 282-99-0045, TO#5); 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 No. 0000166930); National Health and Environment Effects Research Laboratory and National Center for Environmental Research, Environmental Protection Agency (Contract No. 282-99-0045, TO#5); American Chemistry Council (unnumbered grant); and Exxon-Mobil Corporation (unnumbered grant). The views presented in this report are those of the individual presenters and are not necessarily those of the funding agencies or the Institute of Medicine. 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 name of the ditors, with the assistance of staff and consultants, as an individuall authored document. Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Lock box 285, Washington, DC, 20055; (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 2002 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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ROUNDTABLE ON ENVIRONMENTAL HEALTH SCIENCES, RESEARCH, AND MEDICINE (until March 31, 2002) Paul Grant Rogers (Chair), Partner, Hogan & Hartson, Washington, D.C. Lynn Goldman (Vice-Chair), Professor, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD Pauline Abernathy, Program Officer, The Pew Charitable Trusts, Philadelphia, PA M. Brownell Anderson, Associate Vice President for Medical Education, Association of American Medical Colleges, Washington, D.C. Roger Bulger, President and CEO, Association of Academic Health Centers, Washington, D.C. Mark Cullen, Professor of Medicine and Public Health, Yale Occupational and Environmental Medicine Program, Yale University School of Medicine, New Haven, CT Ruth Etzel, Editor of the American Academy of Pediatrics Handbook of Pediatric Environmental Health, Adjunct Professor in the Department of Environmental and Occupational Health at the George Washington University School of Public Health and Health Services, Washington, D.C. Henry Falk, Assistant Administrator, Agency for Toxic Substance and Disease Registry, Atlanta, GA Baruch Fischhoff, Professor of Social and Decision Sciences, Professor of Engineering & Public Policy, Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA Howard Frumkin, Professor and Chair of the Department of Environmental and Occupational Health at Emory Universityâs Rollins School of Public Health, Director of the Southeast Pediatric Environmental Health Specialty Unit, Atlanta, GA Bernard D. Goldstein, Dean, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA Robert Graham, Director, Center for Practice and Technology Assessment, Agency for Healthcare Research and Quality, Bethesda, MD John T. Grupenhoff, President, Science and Health Communications Group, Inc., Bethesda, MD Carol Henry, Vice President for Science and Research, American Chemistry Council Richard J. Jackson, Director, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA Lovell Jones, Professor, Gynecologic Oncology, University of Texas, Houston, TX Patricia G. Kenworthy, Vice-President for Policy and Research and Senior Staff Attorney, National Environmental Trust, Washington, D.C. v
Donald Mattison, Professor, Columbia University, NY Roger McClellan, President Emeritus, Chemical Industry Institute of Toxicology, Albuquerque, NM Sanford Miller, Senior Fellow and Adjunct Professor, Georgetown University, Washington, D.C. Frank Mirer, Director, Health and Safety, International Union, United Auto Workers, Detroit, MI Alan R. Nelson, Special Advisor to the CEO, American College of PhysiciansâAmerican Society of Internal Medicine, Fairfax, VA Peter Preuss, Director, National Center for Environmental Research, U.S. Environmental Protection Agency, Washington, D.C. Lawrence Reiter, Director, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, NC Kathleen Rest, Acting Director, National Institute of Occupational Safety and Health, Washington, D.C. Kenneth Olden, Director, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, N.C. Samuel H. Wilson, Deputy Director, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, N.C. ROUNDTABLE ON ENVIRONMENTAL HEALTH SCIENCES, RESEARCH, AND MEDICINE (Membership April 1, 2002 to present) 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 Jacquelyne Agnew, Professor, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD Jack Azar, Vice President, Environment, Health and Safety, Xerox Corporation, Webster, NY Sophie Balk, Chairperson, Committee on Environmental Health, American Academy of Pediatrics, Bronx, NY Roger Bulger, President and CEO, Association of Academic Health Centers, Washington, DC Henry Falk, Assistant Administrator, Agency for Toxic Substance and Disease Registry, Centers for Disease Control and Prevention, Atlanta, GA Baruch Fischhoff, Professor, Department of Engineering & Public Policy and the Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA vi
John Froines, Professor and Director, Center for Occupational and Environmental Health, Southern California Particle Center and Supersite, University of California, Los Angeles, CA Howard Frumkin, Professor and Chair of the Department of Environmental and Occupational Health at Emory Universityâs Rollins School of Public Health, Atlanta, GA Michael Gallo, Professor of Environmental and Community Medicine, University of Medicine and Dentistry, New JerseyâRobert Wood Johnson Medical School, Piscataway, NJ Bernard Goldstein, Dean, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA Robert Graham, Director, Center for Practice and Technology Assessment, Agency for Healthcare Research and Quality, Rockville, MD Charles Groat, Director, U.S. Geological Survey, Reston, VA Myron Harrison, Senior Health Advisor, Exxon-Mobil, Inc., Irving, TX Carol Henry, Vice President for Science and Research, American Chemistry Council, Arlington, VA Richard Jackson, Director, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA Lovell Jones, Director, Center for Research on Minority Health; Professor, Gynecologic Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, TX Alexis Karolides, Senior Research Associate, Rocky Mountain Institute, Snowmass, CO Donald Mattison, Chairperson, Division of Epidemiology, Statistics, and Prevention Research, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD Michael McGinnis, Senior Vice President and Director of the Health Group, Robert Wood Johnson Foundation, Princeton, NJ James Melius, Director, Division of Occupational Health and Environmental Epidemiology, New York State Department of Health, New York, NY James Merchant, Professor and Dean, College of Public Health, Iowa University, Iowa City, IA Sanford Miller, Senior Fellow, Center for Food and Nutrition Policy, Virginia Polytechnic Institute and State University, Alexandria, VA Alan R. Nelson, Special Advisor to the CEO, American College of PhysiciansâAmerican Society of Internal Medicine, Fairfax, VA Kenneth Olden, Director, National Institute of Environmental Health Sciences (NIEHS), National Institutes of Health, Research Triangle Park, NC Peter Preuss, Director, National Center for Environmental Research, U.S. Environmental Protection Agency, Washington, DC vii
Lawrence Reiter, Director, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, NC Kathleen Rest, Acting Director, National Institute of Occupational Safety and Health, Centers for Disease Control and Prevention, Washington, D.C. Samuel Wilson, Deputy Director, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC IOM Health Sciences Policy Board Liaisons Mark Cullen, Professor of medicine and public health, Yale Occupational and Environmental Medicine Program, Yale University, School of Medicine, New Haven, CT Bernard D. Goldstein, Dean of the University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA Study Staff Christine Coussens, Study Director Dalia Gilbert, Research Associate Jennifer Zavislak, Senior Project Assistant Division Staff Andrew Pope, Division Director Troy Prince, Administrative Assistant Carlos Gabriel, Financial Associate Timothy J. Teyler, Consultant Laurie Yelle, Consultant viii
REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures ap- proved by the NRCâs Report Review Committee. The purpose of this indepen- dent review is to provide candid and critical comments that will assist the institu- tion in making its published summary 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 confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Dr. Ed Arnold, Executive Director, Physicians for Social Responsibility, Atlanta, GA Dr. James E. Dale, Director, Environmental Health Services, Jefferson County Department of Health and Environment, CO Dr. Camille Grayson, Director of Health Policy, Medical Association of Georgia, Atlanta, GA Although the reviewers listed above have provided many constructive com- ments and suggestions, they were not asked to endorse the remarks made nor did they see the final draft of the summary before its release. The review of this report was overseen by Melvin Worth, Scholar-in-Residence, Institute of Medi- cine, 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 summary rests entirely with the editors and the institution. ix
Preface At a workshop sponsored by the Institute of Medicineâs Roundtable on Envi- ronmental Health Sciences, Research, and Medicine in June 2000, Rebuilding the Unity of Health and the Environment: A New Vision of Environmental Health for the 21st Century, many participants expressed the view that for a long time the world of environment, environmental regulation, environmental control, and en- gineering had moved in one direction, while the world of health had moved in another. From this realization arose the concept of holding a series of workshops on rebuilding the unity of health and the environment in various regions of the United States. The purpose was to bring representatives from the two worlds together to address issues of health and environment specific to each region. The southeastern United States, which includes North Carolina, South Caro- lina, Georgia, Florida, Alabama, Mississippi, Tennessee, and Kentucky, was cho- sen to be the site of the first regional workshop. The Southeast was selected to spearhead the series of workshops because the region has a long history of con- fronting environmental health problems, leading environmental justice struggles, and facing new environmental challenges. The first regional workshop, Rebuild- ing the Unity of Health and the Environment in the Southeastern United States, was held in Atlanta, Georgia, on June 27, 2001. The history of the environment and of environmental health in the Southeast is unique and very different from that of other areas of the United States. It is complex and intricately intertwined with the rise of agriculture, plantation life, industrial development, the environmental movement, the civil rights movement, and the environmental justice movement. It is also closely tied to the hot, humid climate of the region. The natural environment of the Southeast has changed dramatically since precolonial times. Before colonization, forests of long-leaf pine and other spe- cies, pristine waterways, and a diverse topography from mountains to coastal plain dominated the landscape of the South, providing a thriving habitat for birds and a diverse range of other wildlife. The pursuits of the early colonists brought xi
xii PREFACE few changes to the environment, but in the eighteenth century, the untamed forests and grasslands gave way to large agricultural tracts. In the nineteenth century, agriculture was gradually overtaken by industrialization and the growth of cities. By the twentieth century, industrialization had begun to reshape the landscape of the Southeast and signaled unrelenting environmental deterioration. Large-scale agriculture and industrial development evolved after the Civil War and into the twentieth century, further transfiguring the southern land. Na- tional corporate interests drove regional practices, from large-scale farming of single crops such as cotton to low-wage industries that relocated from the North. Much of the topsoil in the Piedmont, the hill region of the Southeast, was eroded as a result of poor farming practices. Forests were further decimated as the lumber and mill industries flourished. The marked industrial growth brought rapid population growth, which later spawned urban ghettos and noisy manufac- turing towns. The post-World War II years brought the expansion of compact cities and towns into modern urban areas of economic prosperity and immense sprawl. A giant technological step for the South was the introduction of air conditioning, which led to the âSunbeltâ phenomenon, characterized by a land boom, industrial and economic development, and growth of the recreation sector. Recent changes in the regionârapid population growth, rapid suburban de- velopment, and economic prosperityâhave profoundly transformed resource use. An emerging megalopolis (dubbed âCharlantinghamâ by some) stretches along interstate highways from North Carolina to Alabama and includes the metropoli- tan areas of Charlotte, Atlanta, and Birmingham. In contrast to other major urban centers, economic and population growth is unimpeded by immediate geographi- cal constraints, such as coastlines, water bodies, or mountains. While cities throughout the country have grown in a âsprawlingâ manner, the Sunbelt cities, stretching from Charlotte and Atlanta across to Phoenix, Houston, and Los Ange- les, have led this trend. Despite far-reaching changes in the environment throughout the centuries, people in the South have maintained a deep connection to the land and the waterways, which are evocative and uniquely beautiful. The southern American writer William Faulkner acknowledged this connection when he suggested that the South was âthe only authentic region in the United States, because [in the South] a deep indestructible bond still exists between man and his environmentâ (Meriwether and Mitigate, 1988). A dominant theme throughout many of Faulknerâs stories is that human life can harm the environment and that people face the choice of destroying nature or respecting it. During the early centuries of this countryâs history, health in the South was deeply connected to the natural environment. Natural conditionsâlong summers with high heat and humidity, mild winters, and undrained ponds and swampsâ enabled insects and other disease-bearing organisms to thrive. Both white and black southerners were vulnerable to epidemics and endemic diseases. Yellow fever and malaria were both serious killers. Diseases such as smallpox and tuber-
PREFACE xiii culosis were major problems for people of all socioeconomic levels. Pulmonary diseases such as pneumonia and pleurisy were also common. Further, the harsh working conditions on the plantations often contributed to the early deaths of the slaves. Physicians were in short supply, and medical knowledge was poor. By the early part of the twentieth century, environmental disease had become stratified by socioeconomic level and occupation. The establishment of textile manufacturing in North Carolina, South Carolina, and Georgia brought increased urbanization and pollution. People lived in cramped conditions in compact areas with poor sanitation, and they suffered from inadequate nutrition and fatigue. Diseases such as smallpox, tuberculosis, and malaria continued to plague mem- bers of the lower socioeconomic classes, partly because of inadequate treatment. Other common diseases were uncinariasis (hookworm), caused by poor sanita- tion, and pellagra, caused by poor diet. Workers also suffered from occupational disorders, such as hearing loss caused by exposure to noise from heavy machin- ery, and byssinosis, a lung disease caused by the inhalation of cotton dust in textile mills. The environmental movement in the United States began in the second half of the nineteenth century, as both the public and government officials awoke to the need to save the nationâs wildlife heritage, restore disturbed environments, and set aside forestland and open land either for future use or for its aesthetic values. These reflections led to the organization of conservation clubs, such as the Sierra Club in New York and the National Audubon Society in Massachu- setts. Much of the conservation initiative arose in the upper strata of society in the Northeast, and there was little environmental activism in the South. By the 1960s and early 1970s, a large segment of the American public had come to realize that open spaces and wilderness areas were shrinking dramati- cally. The American writer Rachel Carson, in Silent Spring, impressed on the public that the preservation of wilderness areas and wildlife refuges would not protect the natural environment from the harmful effects of pollution. She also posited a strong link between pollution, natural resources, and human health. Within the conservation movement in the United States, environmentalists often described environmental issues as affecting everyone equally, in an attempt to build the broadest possible constituency. Their view was that all people lived in the same biosphere, breathed the same thin layer of air, ate food grown in the same type of soil, and drew water from the same aquifers. As these issues were examined more closely, however, massive inequities in environmental exposures became evident, as did injustices in the policies used to control them. Though created equal, all Americans were not being poisoned equally. People of color throughout the United States had long suspected that indus- try was targeting their neighborhoods for the most polluting businesses. By 1982, it was time for them to prove their case. The selection of a poor, predominately black community in North Carolina for a massive toxic waste dump led to public demonstrations that resulted in more than 500 arrests. Among those arrested was
xiv PREFACE a prominent civil rights leader, the Reverend Joseph Lowery, one of the speakers at the Southeast regional workshop. The communityâs resistance to hazardous waste disposal was a new phenomenon. It brought to the forefront the issue of the environment and health and its unequal impact on the poor, and it marked the start of the environmental justice movement. Community leaders and academic researchers in the South initiated studies demonstrating that commercial hazardous waste dump sites were disproportion- ately located in communities of color. Such findings shocked the members of these communities, and thousands of people of color turned into environmentalists al- most overnight. Civil rights leaders and activists responded by joining grassroots environmentalist groups or forming new local environmental organizations. Churchgoing, more prevalent in the South than in other parts of the country, provided a further arena in which environmental concerns were addressed. Church leaders often emphasized to their congregations oneâs natural relationship to, and partnership with, the environment. Many churchgoers became involved in envi- ronmental efforts as a reflection of their stewardship of and reverence toward the earth. Today, issues such as resource conservation, wilderness preservation, public health reform, population control, energy conservation, antipollution regulation, and occupational health have become public health concerns in the South and throughout the country. The environmental imagination has touched nearly every institution in American society, and the word âenvironmentalâ has been attached to a range of disciplines such as law, biology, and ethics. Environmental philoso- phy and policy have become the concerns of millions of Americans. Yet we still face enormous challenges, and much work needs to be done, particularly in linking the environment and health. The purpose of this regional workshop in the Southeast was to broaden the environmental health perspective from its typical focus on environmental toxi- cology to a view that included the impact of the natural, built, and social environ- ments on human health. Early in the planning, Roundtable members realized that the process of engaging speakers and developing an agenda for the workshop would be nearly as instructive as the workshop itself. In their efforts to encourage a wide scope of participation, Roundtable members sought input from individuals from a broad range of diverse fieldsâurban planners, transportation engineers, landscape architects, developers, clergy, local elected officials, heads of industry, and others. When approached initially, many speakers questioned whether they had any- thing relevant to contribute to such a workshop. As the workshop unfolded, and as participants spoke from their diverse perspectives and exchanged ideas, it became eminently clear that all were indeed âpublic health officers,â each with vital knowledge and unique insights to offer in solving environmental health problems in the Southeast. We would like to thank this group of individuals for their immense contributions to making this meeting such a success.
PREFACE xv This workshop summary captures the discussions that occurred during the two-day meeting. During this workshop, four main themes were explored: (1) environmental and individual health are intrinsically intertwined; (2) traditional methods of ensuring environmental health protection, such as regulations, should be balanced by more cooperative approaches to problem solving; (3) environ- mental health efforts should be holistic and interdisciplinary; and (4) technologi- cal advances, along with coordinated action across educational, business, social, and political spheres, offer great hope for protecting environmental health. This workshop report is an informational document that provides a summary of the regional meeting. The views expressed here do not necessarily reflect the views of the Institute of Medicine, the Roundtable, or its sponsors. Richard J. Jackson and Howard Frumkin Spring 2002
Contents PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 What Is Environmental Health and Where Does It Happen?, 1 What Are Our Research Needs?, 3 Where Do We Go From Here?, 4 1 PERSPECTIVE ON ENVIRONMENTAL HEALTH . . . . . . . . . . . . . 7 2 REBUILDING THE UNITY OF HEALTH AND THE ENVIRONMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 3 ENVIRONMENTAL HEALTH: A FIFTY-YEAR PERSPECTIVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 The 1950s in Boston, 19 2001 in Atlanta, 20 4 HUMAN HEALTH AND THE NATURAL ENVIRONMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Valuing the Natural Environment, 23 Protecting the Natural Environment: Lessons from Nature, 25 Ensuring the Health of the Natural Environment: Potential Strategies, 26 5 HUMAN HEALTH AND THE BUILT ENVIRONMENT . . . . . . . . 29 Transportation and Healthy Environments, 30 The Built Environment and Health Problems, 32 xvii
xviii CONTENTS Environmentally Friendly Buildings, 36 Partnerships with Academia, 39 Partnerships with Industry: Creating Trust, 40 Building Healthier Cities, 41 6 HUMAN HEALTH AND THE SOCIAL ENVIRONMENT . . . . . . 44 Social Capital, 44 Environmental Justice, 46 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 APPENDIXES A Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 B Speakers and Panelists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 C Meeting Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59