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i Rebuilding the Unity of Health and the Environment A NEW VISION OF ENVIRONMENTAL HEALTH FOR THE 21ST CENTURY Kathi Hanna and Christine Coussens A Workshop Summary for the Roundtable on Environmental Health Sciences, Research, and Medicine Division of Health Sciences Policy INSTITUTE OF MEDICINE National Academy Press Washington, D.C.

ii NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose mem- bers 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 study was provided by the National Institute of Environmental Health Sciences (Contract No. NO1-OD-4-2139, Task Order 43). The views presented are those of the authors and are not necessarily those of the funding organization. International Standard Book Number 0-309-07259-X Rebuilding the Unity of Health and the Environment: A New Vision of Environmental Health for the 21st Century is available for sale from the National Academy Press , 2101 Constitution Avenue, N.W. , Box 285 , Washington, DC 20055 . Call (800) 624-6242 or (202) 334-3938 (in the Washington metropoli- tan area), or visit the NAP’s on-line bookstore at www.nap.edu . The full text of this report is available on line at www.nap.edu . For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu . Copyright 2001 by the National Academy of Sciences. All rights reserved. Printed in the United States of America.

iii “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health

iii The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acade my has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William. A. Wulf are chairman and vice chairman, respectively, of the National Research Council. www.national-academies.org

v ROUNDTABLE ON ENVIRONMENTAL HEALTH SCIENCES, RESEARCH, AND MEDICINE PAUL GRANT ROGERS (Chair), Partner, Hogan & Hartson, Washington, DC MARK CULLEN (Vice-Chair), Professor of Medicine and Public Health, Yale Occupational and Environmental Medicine Program, Yale University School of Medicine, New Haven, CT M. BROWNELL ANDERSON, Associate Vice President for Medical Education, Association of American Medical Colleges, Washington, DC ROGER BULGER, President, Association of Academic Health Centers, Washington, DC MAUREEN K. BYRNES, Director of Health and Human Services, The Pew Charitable Trusts, Philadelphia, PA RUTH ETZEL, Chairperson, Committee on Environmental Health, American Academy of Pediatrics, Washington, DC BARUCH FISCHHOFF, Professor of Social and Decision Sciences, Professor of Engineering and Public Policy, Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA HOWARD FRUMKIN, Associate Professor and Chair, Department of Occupational and Environmental Medicine, Emory University, Rollins School of Public Health, Atlanta, GA LYNN GOLDMAN, Professor, Department of Environmental Health Sciences, John Hopkins University School of Public Health, Baltimore, MD BERNARD D. GOLDSTEIN, Director, Environmental and Occupational Health Sciences Institute, Robert Wood Johnson Medical School, Piscataway, NJ ROBERT GRAHAM, Scholar in Residence, The Robert Graham Center for Policy Studies, Family Practice, and Primary Care, Washington, DC JOHN T. GRUPENHOFF, Executive Vice President, National Association of Physicians for the Environment, Bethesda, MD JAN HEINRICH, Associate Director, Health Finance and Public Health, U.S. General Accounting Office, Washington, DC CAROL HENRY, Vice President for Science and Research, Chemical Manufacturers Association, Arlington, VA RICHARD J. JACKSON, Director, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA PATRICIA G. KENWORTHY, Vice President, Government Affairs, National Environmental Trust, Washington, DC ROBERT I. LEVY, Senior Vice President, Science and Technology, American Home Products Corp., Madison, NJ DONALD MATTISON, Medical Director, March of Dimes, White Plains, NY ROGER MCCLELLAN, President Emeritus, Chemical Industry Institute of Toxicology, Research Triangle Park, NC FRANK MIRER, Director, Health and Safety, International Union, United Auto Workers, Detroit, MI

vi ALAN R. NELSON, Special Advisor to the CEO, American College of Physicians–American Society of Internal Medicine, Fairfax, VA NORINE NOONAN, Assistant Administrator for Research and Development, U.S. Environmental Protection Agency, Washington, DC KENNETH OLDEN, Director, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC LINDA ROSENSTOCK, Director, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Washington, DC SAMUEL H. WILSON, Deputy Director, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC IOM Liaisons to the Roundtable ENRIQUETA BOND, President, Burroughs Wellcome Fund, Durham, NC RICHARD MERRILL, Daniel Caplin Professor of Law, University of Virginia School of Law, Charlottesville, VA Study Staff JONATHAN DAVIS, Study Director (until August 2000) CHRISTINE COUSSENS, Study Director (from August 2000) SARAH PITLUCK, Research Associate (until June 2000) THELMA COX, Project Assistant (until June 2000) DALIA GILBERT, Senior Project Assistant (from September 2000) Division Staff ANDREW POPE, Division Director ALDEN CHANG, Adminstrative Assistant CARLOS GABRIEL, Financial Associate KATHI HANNA, Consultant

PREFACE vii Preface It has been 3 months since the workshop on Rebuilding the Unity of Health and the Environment: A New Vision of Environmental Health for the 21st Century, and the quality of discussions by both the speakers and the participants still impresses me. It is only appropriate that at the dawn of the new millennium, we stop and examine environmental health. Current environmental health concerns are conveying a sense of urgency. The time to act is now before further damage threatens our physical and emotional well-being. The science of environmental health is a broad topic and suffers from the lack of a precise definition; it has different meanings depending on an individual’s perspective. Environmental health has many facets encompassing the natural, the social, and the built environments. The visual images of the different communities and individuals shown by the speakers were powerful and conveyed the essence of the diversity of environments and environmental issues. Where this workshop was successful was in bringing together architects, psychologists, policymakers, regulatory agencies, scientists, community representatives, health care providers, state officials, industry stakeholders, and concerned citizens, allowing them to interact and hear the various perspectives on the relationship between the environment and citizen health. While we strive to correct problems in our environment, we need to continue to reach out to all Americans. It is the public that suffers or benefits as we attempt to reach our goals. Some members of the general public and some in industry may feel that the environment is related to regulation and economics; this is not true. All environmental laws are public health laws! I remember when we passed the Clean Air Act in the 1970s, once people understood the problems

PREFACE viii facing our access to cleaning the air and what could be done, they strongly supported the effort. The Safe Drinking Water Act provided a safe water supply for many cities throughout the United States, including Washington, D.C., and New York City. Although these are only two examples, they illustrate that environmental laws are in reality public health laws. Our communities need to embrace a broader view of environmental health. Combating urban sprawl and CO2 emissions are two of the immediate challenges faced by the human population. Builders, designers, psychologists, scientists, and community leaders need to rethink their approach. Solutions require innovation and forward thinking. Since the landmark legislation of the 1970s, considerable research has been done. The foundation of legislation has been laid, but we need to build on the past. Our approaches should look at what needs to be done and concentrate on how to get there. The overarching message from the workshop stated that we need to work on innovative solutions to properly handle future problems. We have accomplished significant changes in many health-related issues, but more has to be done in the future. The Institute of Medicine’s Environmental Health Sciences Roundtable was formed to provide a neutral place for debates of the current issues in environmental health. This workshop summary, prepared by Kathi Hanna and Christine Coussens, summarizes the discussions that occurred during the 2-day meeting. It is an informational document that provides a message that workshop participants can take back to our federal, state, and local agencies, companies, academic institutions, and other organizations and indeed the public itself. Paul G. Rogers Chair

REVIEWERS ix REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report 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 confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Eula Bingham, University of Cincinnati Medical Center Richard Lynch, Rutgers, The State University of New Jersey Hugh McKinnon, United States Environmental Protection Agency Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Mel Worth, Scholar-in-Residence, Institute of Medicine, 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 report rests entirely with the authoring committee and the institution.

REVIEWERS x

FOREWORD xi Foreword Kenneth I. Shine, M.D. President, Institute of Medicine In looking back at the 20th century it is clear that for most of it, science was dominated by the physical sciences, particularly mathematics and physics. It is worth reminding ourselves that it was only in 1955 that Watson and Crick described the double helix, which ultimately led to the revolution in molecular biology. As an undergraduate, I took a seminar from a young assistant professor named James Watson who had just come to Harvard. In the course of that seminar we speculated on how long it would take to identify the amino acids with relation to the DNA code. We were quite confident that it would take 20 to 25 years, which is a good example of understanding something about direction and very little about velocity. The point is that with the evolution of molecular biology in the last part of the 20th century, it has become clear that the 21st century offers remarkable opportunities in the life sciences. In trying to understand the directions that the life sciences will take, it is worthwhile to note that the last part of the 20th century was about reductionism in science, that is, knowing more and more about smaller and smaller components of the biological phenomenon, down to the molecular level. I believe we will see a reverse movement toward looking at systems and organs, for example, understanding the structure of gene products, and using the capacity of powerful computers to model not only proteins, but ultimately the environment in which the proteins live and the organization of the cell, organ, and the human body. A second major trend will be melding other disciplines with the life sciences. We know that much illness is related to behavior, and as a result, the social and behavioral sciences will play an increasing role in preventing and treating disease in the 21st century. Consequently, we have to make substantial

FOREWORD xii investments in research that aims to understand human behavior and its relationship to disease and health. In addition, as the border between public health and medicine becomes increasingly blurred, there is a greater need for the disciplines to work with and understand each other. The same kinds of challenges exist with regard to environmental health; that is, there is a critical need to bring together a variety of medical specialties in activities that will further the science, education, and health of the community.

CONTENTS xiii Contents SUMMARY 1 1 INTRODUCTION 4 Remarks and Charge to Participants, 4 Statement of Workshop Objectives, 5 2 KEYNOTE ADDRESS 7 Environment and Health: A Connection to the Current Debate, 7 3 HUMAN HEALTH AND THE NATURAL ENVIRONMENT 11 The Importance of Contact with Nature, 12 Biodiversity and Human Health, 14 Ensuring the Food Source While Addressing Environmental Health, 15 Summary, 16 4 HUMAN HEALTH AND THE “BUILT” ENVIRONMENT 18 Designing a Better Future, 18 Smart Growth, 19 Coherence in the Built Environment, 21 Embracing Natural Capitalism, 23 Summary, 26 5 HUMAN HEALTH AND THE SOCIAL ENVIRONMENT 28 Sustainable Development, Environment, and Health, 28

CONTENTS xiv Health and the Urban Environment: The Forgotten Ecosystem, 31 Socioeconomic Status and Health, 32 Nutrition, Physical Activity, and Health, 34 A More Communal Approach to Health, 35 Changing the Educational Environment, 38 Summary, 39 6 TOWARD AN INTEGRATIVE APPROACH TO ENVIRONMENTAL HEALTH 41 REFERENCES 43 ABSTRACTS OF TALKS 45 A New Vision of Environmental Health: The Role of Socioeconomic Status, 45 Sustainable Development, Environment, and Health, 46 Planning the Community: City Planning and Human Health, 47 Transportation and Human Health, 47 Health and the Urban Environment: The Forgotten Ecosystem, 48 Community Participation, 48 Nutrition and Healthy Life-Styles, 49 At the Interface of Environmental Integrity and Economic Viability: Michigan Source Reduction 49 Initiative, Redefining Environmental Health and the Natural Environment, 50 The Environment and Public Health, 51 Special Address, 53 Biodiversity and Human Health, 53 Powering the Community: Energy and Human Health, 54 Building the Community: From Construction to City Planning, 55 Industry and the Natural Environment: Reducing Intel’s Environmental Footprint, 55 Education, 56 Environmental Health and the Global Community, 56 Ensuring the Food Source, 57 APPENDIXES A Workshop Agenda, 59 B Speakers and Panelists, 66 C Workshop Participants, 69

xv Rebuilding the Unity of Health and the Environment

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This is a summary of the workshop Rebuilding the Unity of Health and the Environment: A New Vision of Environmental Health for the 21st Century. The goal of this workshop was to emphasize the connection between human health and the natural, built, and social environments. This workshop integrated talks from many fields and created a dialogue among various environmental health stakeholders. The language presented in this respect should not be viewed as an endorsement by the Environmental Health Sciences Roundtable or the Institute of Medicine of what action is needed for the future, but rather as an effort to synthesize the various perspectives presented.

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