E N V I R O N M E N T A L J U S T I C E

If nature doesn't discriminate, humans do; causingdisparities in health where we live, work and play

HEALTHDISPARITIES IN

BLACK AND WHITE

ecognizing the need to servethe poor and medically underserved, the Department of Health and Human Services initiatives set as a goal theelimination of health disparities among different segments of the population by the year 2010. This is our nation-al policy on health promotion and disea.se prevention. In some sense, this policy is self-serving. Obviously, thenation cannot effectively compete in an increasingly global economy if significant segments of its workforcecannot participate in the production of goods and services because of illness, physical or mental.

Health disparities are caused by numerous factors, including, on the one hand, affluence and overabundance.

and on the other, poverty and unequal access to health care, bothpreventive and curative services.

Evidence is mounting that environmental factors contributesubstantially to most diseases of major medical and public heiilthsignificance. In fact, most of the principal causes of death in theUnited States (cancer, chronic lung disease and diabetes) have sig-nificant environmental causes. In addition, environmental effectson usually nonfatal conditions {birth defects, asthma, nervous sys-tem dysfunction and reproductive problems) are well documented.

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From polluted air and water to toxic substances in soil, food andin workplaces, schools and homes,environmental pollutants canpose both direct and indirect threats to human health.

As far back as 1906, W.E.B. Du Bois. in his report on "TheHealth and Physique of the Negro American." recorded thatBlacks in the U.S. had markedly worse health status than

By Bailus Walker Jr.

Whites. In that period, environmental health problems were byand large in their effects and short in duration. Today the impor-tance of "place" in determining health status has becomeincreasingly clear. The places in which people work and livehave an enormous impact on their health. The characteristics ofplace include the social and economic environment, as well asthe natural environment — air and water, for example — and the"built" environment, which may include transportation, roadsand other infrastructure. In this setting, environmental problemsare more persistent and widespread. They are long-term and arenot amenable to "quick fixes." Their resolution require moreactive comtnunity and societal engagemetit. including the partic-ipation of policymakers, health care providers, business execu-tives and educators.

Even in this era when emphasis is placed on genetic factorsfor disease and disability, resulting in huge investments in genet-ic research, solid lines of evidence show that environmental fac-tors play a role. This evidence makes clear that the ways inwhich the environment affects disease and health conditions dif-fer from individual to individual depending on age. what you eat,where you live and where you work.

Historically, federal and state agencies have set pollutionstandards and developed regulations to protect all citizens fromenvironmental pollution. Air and water quality standards, for

Professors Paul Mohai and Robin Saha at the University ofMichigan and University of Montana respectively, through theirresearch, have answered that "chicken and-egg question:" poorand minority population.s lived in the areas before the wastefacilities arrived. Mohai's and Saha's findings support the long-held view that poor and minority communities are targeted forhazardous waste facilities, incinerators and other facilities notwanted in more affluent neighborhoods.

In addition, heavy vehicular traffic routes are frequently rout-ed through minority neighborhoods. A prime example is the dis-ruption of the Meharry Medical College and Fisk Universityneighborhoods in north Nashville. Those neighborhoods are nowrife with air and noise pollution from cars, trucks and buses onthe interstate highway that intrudes on the quality of life of thesemainly poor minority communities. Highway "planning" inother cities has followed a similar pattern.

These examples are not to suggest a lack of progress in airpollution improvement. In fact, over the past three decades thenation has devoted substantial efforts to improve air quality.Despite the progress (for example, removal of lead from gaso-line), the problems posed by pollutant emissions, from motorvehicles and power plants in the U.S. are by no means solved.Future economic and population growth, along with theincreased needs for electricity and transportation, will undoubt-

Even in this era when emphasis is placed on geneticfactors for disease and disability, resulting in huge

investments in genetic research, solid lines of evidenceshow that environmental factors play a role.

example, are set to protect the nation as a whole. Be that as itmay. a number of reports, including a widely publicized analysisby the United Church of Christ in 1987, brought national atten-tion to the fact that exposure to environmental and occupationalhazards is not shared equally. Minority and low-income commu-nities bear a disproportionate share of the nation's air. water andtoxic waste pollution problems.

In general, the poor and underserved segments of the popula-tion are the most vulnerable to the health impact of environmen-tal pollution in the community and in the workplace.Socioecotiomic disparities in the U.S. are large, persistent andincreasing despite the general improvements in many health out-comes. The most advantaged American men and women experi-ence levels of longevity that are the highest in the world.However, less advantaged groups experience levels of healththat are unacceptable, given the nation's medical and scientificknow-how. The poor and underserved populations are typicallymore exposed, in terms of residential and occupational locations,and often have inadequate resources for taking preventive, pro-tective, or adaptive action.

During the past 20 years, environmental advocates haveargued that hazardous waste facilities arc built in politicallypowerless, poor and minority neighborhoods. Others disagreedand argued just as forcefully that the hazardous waste facilitieswere there first and that the neighborhood changed as a richerWhite population fled.

edly increase the potential for more air pollution.African Americans and Hispanic-origin populations are more

likely than Whites to live in areas with reduced air quality or ina so-called non-attainment area. That is. an area that does notmeet national air quality standards. This disproportionate expo-sure contributes to the incidence of disease, including a reduc-tion in lung development of children, an increase in the risk ofdeveloping asthma and increase in school absences due to respi-ratory illnesses, and heart disease problems for all age groups.What is more, the effects of air pollution are not limited to lungsand the heart, but may cause inflammation of the brain.

Confined animal-feeding operations, particularly hog feed-ing, are another source of pollution. Hundreds and hundreds ofanitTials raised for slaughter create a stench that is not only odor-ous but also unhealthy. These animal-feeding farms create, inother words, a hazardous environment. Yet. some are locatedcloser to schools enrolling a higher percentage of economical-ly disadvantaged students. The odor is a harbinger of otherproblems, such as potentially hazardous gases and particles,mold, ammonia and animal dander. Compared to people livingfarther away, residents living near confined animal-feedingoperations report higher prevalence of headaches and respira-tory symptoms.

The Clean Air Act (CAA). passed by Congress in the 1970sand later amended in 1990, is the nation's legal framework forpromoting public health and public welfare through the preven-

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promoting public health and public welfare through the preven-tion and control of air pollution. While a good law in manyrespects, the CAA does not have programs aimed at mitigatingpollution effects thai may be borne disproportionately by minor-ity and low-income communities.

Health concerns about air pollution are not limited to outdoorexposures. Equally important is indoor air quality. The homeremains a major source of environtiicntal contaminants. Stoves.heaters and household cleaning compounds contribute to child-hood respiratory infections and reduced lung function. For thepoor and underserved populations in urban areas, pjesticides tocontrol insects and rats could be added to the list of air pollutants.Often associated with substandard housing, and inadequatemunicipal services such as street cleaning and waste collection,pesticides are a class of chemicals that disrupt nervous systems.They are effective in eliminating insects and other pests.

A New York sttidy found that pregnant African andDominican women were reguUu-|y exposed to pesticides intheir inner-city apartment units where pesticides were used forcockroach and other insect control. The amount appliedincreased significantly with the level of housing disrepair, anongoing problem in many poor neighborhoods. It was notunusual for exterminators to spray pesticides more thati once amonth, thus increasing the duration of the women's exposure.

they are undergoing growth and development.Thus, there is increasing concem about the disproportionate-

ly high rate of disorders of the nervous system, asthma and can-cer in minority and underserved children. While these healthdisparities reflect many factors, it is reasonable to conclude thatthey are caused in part by exposure to certain environmentaltoxins from poor housing quality, industrial operation and dieselemissions, to name only three.

These, then, are examples of issues that must be addressed ifwe are to achieve the goal of eliminating racial/ethnic dispari-ties in health.

The U.S. has taken important steps to strengthen its capaci-ty to address environmental health and disease determinants.Dramatic advances in science, technology and medicine haveenabled us to make strides in our struggle to prevent and controldisease and disability, yet we cannot fall prey to an illusorycomplacency, when significant segments of the population arestill not benefiting from these advances. We must do more toimprove our ability to detect and prevent environmental pollu-tants and other hazardous conditions. For instance, the ongoingplanning necessary for full implementation of the Clean Air Actprovides ample opportunity to incorporate programs and ser-vices to address pollution that might be borne disproportionate-ly by minority and low-income communities.

The increasing attention to environmental influenceson the health of children has made clear thattoday's youth are in a much different environmentthan their parents and grandparents.

The prenatal exposure to pesticide may be more dangerousthan previously thought. Exposure to small doses of some pesti-cides, known as organophosphates, or Ops, at key periods of achild's development can cause permanent change in brain func-tion. Pesticide-exposed children may experience diminished sta-tnina and coordination, impaired memory and reduced creativity.

Other studies indicate that exposure to environmentalagents during development can result not only in death of theembryo/fetus, but birth defects and altered growth, the effectsof which may not be seen until the child becomes school age.

The increasing attention to environmental influences on thehealth of children has made cleiU' that today's youth are in amuch different environment than their parents and grandparents.Today's environment includes technological growth, and anincreased consumption of goods and services. All of these devel-opments increase the potential exposure of children to new prod-ucts and some 8O.(X)O new synthetic chemicals used to manufac-ture them, and other risk factors associated with advances in sci-ence and technology.

Increasing numbers of people and products now crossnational borders and may transfer health risks such as infectiousdisease and chemical hazards. For example, pesticides that arenot registered for use in the U.S. could be imported in fruits,vegetables and seafood produced and shipped from abroad.Children are highly vulnerable to environmental toxins because

However, addressing environmental health disparities callsfor more than tinkering at the edges, or more biomedical researchand scientific analyses. It requires more active participation andleadership of governments at all levels. Governments must bemore sensitive to the importance of having the voice of poor andunderserved groups in decisions that affect their health, environ-ment and quality of life. All too often, governments communicatewith these groups after environmental decisions have been made,and the public is asked to comment on a completed plan.

Government officials and the business community havemany resources on which to draw to shape environmental andpublic health policy, including the ability to access other pow-erful interests. Others, such as national organizations, may alsohave some resources and a degree of infiuence. But the poor andunder-resourced groups in. for example, a "polluted" neighbor-hood generally do not. Yet. these groups, individually and col-lectively, can provide firsthand views of the varied and compli-cated health threats to their neighborhood, information that canbe invaluable in societal efforts to prevent and control environ-mental factors for disease, disability and premature death.

Baiius Walker Jr. is professor of environmental and occupa-tional medicine at Howard University College of Medicine anda member of the Institute of Medicine/National Academy ofSciences.

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