Milestones in Health Care: Chapter 3

8/14/2019 Milestones in Health Care: Chapter 3

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SCII/oJ/ht'Em/irMllllt'II/I1/Pru/a/ia" A.\?Cllcy.

C hapter 3Enviromnental HealthLooking Back

A ir pcl/lllitm cper Lower M(III/ lr lt t( iI l ill NlJlwmbrr 195J.l-li Sto fl Jns willlikdy regard Earth Day In April 1970 asa signal achievement in awakcllln g the American publicto ellviron llletHal issucs. Several months Liter, Congresspasscd significant JmcndmctHs to the Clean Air Act of1967, imposing statU fQry deadlines for starcs ro complywith federal emission standards. The previous approach,allowing regions to set their own air quality standa rd s, hadproduced little headway against air pollution. Earth Dayprovided the illlpenls to enact the amendments. Theseamendments were strengthened furthe r in 1977, andCongress has continued to keep environmcmal protectionat the forefront of its concerns, The year 1 )70 also saw thecreation of the En vironmental Protection Agency (EPA),consolidating under one roof a hm t of federal bureaus and

"/71


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, ~ ~ : ' = ' ~ " l i I ? t i . ~ & : . : . . t f I I ; "I 3H '1 Md"'01"'" ( ] " p t , ' r ) Emlf


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I ~ I I ( I I ( ' I Cam'".1962, il l ,\Iainr.

,Unlike Otherinsecticides rhatwere narrow 1t ltheir targets,DDT killedhundreds ofspecies at once.

industry, led by Monsanto, cha ra cterized Carson's findingsas o n c - ~ i d e d for failing to point ou t how pesticides hadeliminated mal,lfia, typhus and othe r hum,l11 scourges. Inmounting a public rebtions campaign to alleviate thepublic anxiety caused by Si lmt Sprill,',!, however. the chemi-cal industry suffered a backlash when the public llnplicitlyrecognized Carson's solid research and the interconnected-ness of the natural environment.R:lchel Carson, a trained marine bio logist, worked forthe u.s. Fish and Wildlife Service writing educationalbrochu re s. She earned a reputation as a meticulousresearcher and evocative writer able to make science seempoetic. In the 19505, she wro t t" two popubr n:Hure books,-nil' Sea AroHlld Us and Tile Ed)!t! of Ih(' SCII, which sold wellenough to give her financial independence. The books alsoimroduced her readers to ecology. Carson llt'xt tllrned herattention to the effects DDT had on the environment. Amir:lcle insecticide that saved American serviceillen frommalaria in the Pacific islands dllTing World War II , DD Tfound iilllllediate ;'llld widespread usc In :lgriculmre I I I theyears following the wa r. .. . Unlike other IlISecticidesthat were narrow in their targets, DD T killed hundreds ofspecies at once. Carson observed the dTl'CCS of DDT onwildlife, specifically ho w it thinned the eggshells of raptors- eagles, falcons and hawks - leading to a decline in theirpopulations, which. in turn. threw the ecosystem out ofbalance.

Figlln's in partS per million.Tcnbryf Or)SI1111l'rs 13.8 ppmS e r o n d ~ r y consumers

I'nmaryconsumersI'mciUtTrS

.- ' 0.23 ppm0.04 ppm

DDT /Jl'(ulnCS iocrcas;',.,!/>, ( ,III(Clllrtl/cd as IIIIi""'/5 prq' Oil '/'(>S(' loweri" IIlf .f


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"For ea(h !?I liS, (/S for Ihe robill ill l\1ichi,!!all, II ( Ih(' salmollin Ihe Miramiclli, lilis ;s 1/ pwblem of ecoID.!!)" oj illl('rreilltiollships, oj il1lerdepeudell(l'. We P(I;SOIl the ((/ddi5.flies in the S/re(1l11IIlId Ihe sillmOil (/IllS dwindle alld {fwindle. 11(' spray our dills11/11/ folloUling sprillgs life silcm (:f robill SOIl,!!, / /O( bec(lIIse wesprayed (h(' wbills dir(,Clly bill because the l'(li5(/// (((wried, .\1('17by step, tlmw.!!" tlu' /WI/I fllll/iliar ellll le{if-earlhwM/II-wbill (yele.T/,ese are /lllIlIers oj record, (lbserl/able, parI (lj the visible IIl(Jrld(IWlllld liS. They rdlul the web oj fifl'-M-d/,arh tharSri{'ll(iSfS ki lO//! (/ $ ecolo,!!r"The publication of Silelll S,1fiIlR led [0 public clamorfor a ban of DDT. The government's init ial response, atthe be hest of the Kennedy administration, was to increaseoversight of D DT's lise. Not until 1972. however, did EPAimplement a [Otal ball. U:mning DDT was the first majorvictory of the environmental movement. a

,"They rtif/ect theweb tj'lije-or-deathtl/(/( sciell/ists kllol/las eco/(lgy. "


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/1clJjllmili rflwklill

Case StudyLead Poisoning"TI/(' hisillry ,if child lead p"is{)//illg i l l Iii" pm! (('I/lln)'ill Ihis CO/IJI/f)' i _ a xood eXflmple (if /I(JIII /){IlIlcrful I.'COllomiciI/leresIS WII prl.'l1('/ll 1/'1' imp/l.'lI/l.'lIfllfio/l 4 I 1 - , ~ f H I Tnllh .' "- Uenj:nllin Fran klin[n [786, Oenj:J.lllin Franklin listed in a letter to a friendcvery p r o f e s ~ i o n for which lead posed a health hazard.He thcn predictcd that years would P:J.ss before the trmhof a public health tragedy would be confronted . [n f."lct,long after the lead and lead-palllt industries became awareof the hazards posed by Icad, particularly in young children,they cont inu ed [Q market their produc ts aggressively. Theylobbied legislatures to forestall regulation. su ppressedr e ~ l ' ; l r c h finclings and advertised f.1lsely and, in doing so,crcated a public health problem that grew to major proportions over d e e ~ . Uenjamin F r a n k l i n ' ~ prediction provedcorrect.Lead-poison in g, o ne of the most cO l11l11on environmentalhea lth problems affecting yOtl llg children, is a preve ntabledisease. Normal hand-tO-mouth behavior r n ~ h : s childre nunder six particularly at risk for ingeSting lead from theenvirOllment . Exposure to even small ;ltllounts of lead can;ldvcrsely affect chi ldren 's growth and dcvdopment.Lead- poisoning symptoms include severe stomach cramps,joint ;lnd muscle pain, ex treme weakness in the ankles andthe wrists, blindness. co nvulsions, coma and death. T hesesy mptoms have all been wc ll-docullIent


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liS[ CVl'ry profession for which lead posed a hazard andevery health condition caused by exposu re to lead.

Still, as Franklin predicted, the remedies were yearsin rhe fmure - nearly 200 years. in faceThroughoLl t rhe 19205 and 19305, public healrh took aback seat to the belief that health ca re should focus on theind ividual. Cha rl es Chapin, the health commissioner ofProvidence, Rhode Island, exp ressed this viewpoi nt in rhelate 19205 as follows:" I flilh minor exreplion, mUllicipal dealllil/{'ss does lillie toprevenl illJeelioll ar dl'(fease tile death rate. lvllll1icipal cleanlillessis 110 pal/area. II II/i l/wake 110 demollslrable differellu ill a city'smortalilY whetller its streets lire deall or 1101 , wlle/ller the g a r b ( ~ f ! e is relll{wed promptly or allowed to aC{lIIIWlllle, ar whether il hasa plumbing lal/l. "As shocking as this stateme m seems today, it reflects theprevailing view of health Cl re professionals of the tim e. Th epublic health community's lack of success in addressing apopulation-based tragedy can readily be seen. In addition,doctors often t:1 iled to diagnose childhoo d lead poisoning,compounding the problem.The tragic case of the gasoline addi tive tetraethyl lead(TE L), closely related to white lead, illustrates how industty cOlltrolled the terms of debate and determllled theoutcome of a co mroversy. General Moto rs, under the substantial control of DuPom,joined with Standard Oil ofNe w Je rsey (now known as Exxon Mobil) to form theEthyl Corporation. T he com pan y's l11ain focus was ro produce TE L to reduce engine "k nock " while boosting enginepower. Ethanol . produced from corn, cou ld have reducedengine kn oc k equ ally, bllt royalties from such a commonproduct would nOt have been as lucrative to the cor porations. When several TEL production workers died and Ne wYork City sub sequently banned the lead additive, the Eth ylCorporation sought ways to ca lm the public.With th e full knowledge of GM , DuPont and StandardOil, the Ethyl Corporation engineered a fraudu lent researchagenda tlur produced the desired result - proof that TELwas a safe product. In 1924, with the public increaSInglyworried by worker deaths, Ethyl colltractcd with the U.S.13l1reau of Min es to conduct animal studies ofTEL. Ethylcontrolled both the content and the release of results, and

,StiU, as Franklinpredicted, th eremedies wereyea rs in thefuture - nearly200 years, infact.


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Dr. Herbal !"\"rrllll"lllllll

not surprisingly, the :lIlill1al studies gave Ethyl a cleanbill o( he:.lth. Workers co ntinued to die, however, and inthl.' (ace of public pani c, the U.S. Publi c H ealth Se rviceheld public hearings. Predictably, industry representativesdominated these hearings and no ac tions wl.' re taken.Worker deaths did nOt abate, however. and dle publicbeca me increasingly agitated. To pu t the colltroversy torest. the Surgeon General appoi nted an advisory cotllmitteeto co ndu ct a definitive study and make recOl1lmendationsregarding the productio n and sa le of tetraethyl (TEL) lead.The study lasted several months, no t long enough to propI.'rly gauge the effens of TE L 01 1 workers. III thl.' I.'nd, TELwas approved for tlllfl.'stri c tl.'d usc.Almost SO years later, in th e 1970s, a study by Dr. HerbertNeedleman at H a r v ~ r d Medical School providl.'d the firstclear ev iden ce that lead, even at very low levels, couldaffect a child's lQ. In a series of follow-up studies, hedetermined that lead poisoning affected a child's attentiveness, behavior and school success with long- tl.'rlllnnplications. Th e leld industry attacked Dr. N eed1elllan sfindings, accusing him of scientific fraud and lllisconduCl.He fought back sllccessfully, however, winning exonerationand thl.' right for all scientists accused in this way to havean open hearing with legal reprcse ntation. Dr. Need leman'sfindmgs prompted CDC to issue guidelines for the diagnosIs and managcment of lead poisoning in children.EPA took note, and Dr. Ne edleman's studics becallle thebasis for the mandatc to remove lead frolll gasoline.TheConsumer Product Safety Commission also rook noteand called for a ball 011 lead in interior paints, while theDep artment o( Housing an d Urban Development (H UD)began to removc lead from thousands of hOllsing unitsacross the cOlin try.By 1976, alltO and fllel malluf,1cturers had made thcchan ges necessary to begin to climinate lead from gasoline.Th e U.S. phaseout of lead began that year when the firstcatalyti c co nverte rs in automobiles were introduce d to till"markct. In 1986. a complete ban finally tOok e ffe c t, andall gasoline was unl ead ed. This phaseollt \ V a ~ strikinglysuccessful in reducing child blood lead levels. Before the banwas implctllt'ntt'd, 88 percent of children in the United Stateshad blood lead levels (BLL) higher than 10 /lg / dL.After wards, only nllle percent had elevated blood lead levels.


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Th e blood lead levels of all Amer icans declined 78 percentbetween 1978 and 1991 , falling in exact proportion to thedeclining levels of lead in the overall gasoline supply. Asa result of EPA's regulatory efforts [ 0 remove lead fromgasoline, between 1980 and 1999 em iss ion s of lead fromthe t ransportation sec to r declined by 95 percent, and levelsof lead in the air decreased by 94 percent.Following years of heated debate, Congress banned leadbased paints for use in hOLlsing in 1978. 13y the time theban went into effect, the industry no longer opposedthe ban, reeling from negative publicity and a precipi[Ousdecline in sales of lead-based paint. However,approximate ly 24 million housing units in the UnitedStates still have deteriorated leaded paint and elevatedlevels of lead-contaminated house dust. Young childrenlive in more than four million of these homes. Roughlytwo-thitds of homes built before J940 and one-balf ofhom es built from 1940 to 1960 contain lead-based paint.R esponding [ 0 this cO lHinliin g threat, Congress passedthe R esidential Lead-13a sed Paint Hazard Reduction An ,known as Title X, in 1992.The law requires that homesellers and landlords provide known information onlead-based paint hazards during sales and rentals ofhousin g built before 1978.In 2001, the U.S. government se ttled cases against landlords in Chicago, Los Angeles and New York that resultedin 16,000 apartments across the cou ntry being made leadsafe. Th e Depanment ofJu stice (DOJ), HUJ) and EPAco llaborated in pressing the cases, basing them on TitleX and the obligation of landlords to divulge hazardousconditions. Also in 2001, H U D and DO) brought thefirst-ever criminal case based on Title X. A landlo rd inthe Washington. D.C., area wh o had failed to notify tenantSof lead-based paint hazards pleaded guilty to obstructinga HU D investigation and f:1lsifying documents. The landlord agreed to serve two years in prison and pay morcthan one million dollars in tines for six felony counts.Prior to the 19505, only l3altimore, Marybnd, had a prog ram to reduce blood lead levels in children. III the 1940s,a h ~ l f - h e a r t e d ef for t by the federal government thrOlighthe C hildren 's Bureau to alert the public to the dangersof lead paint dissipated in the f.1ce of industry opposition .Although medical journals add ressed the issLle p e r i o d i c ~ l l y ,

....approximately24 million housing uni ts in tbeUnited Statesstill have deteriora ted leadedpai nt and elevated levels oflead-contaminated house dust.

IlIspccrors ciu'cl.! forlearl ill pllilll i,1a.HIIII/ lII l1all aparimelli.


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," . R.hode Islandleads the way inreducing the incidence of childhood lead poisoning, pushed to doso because a disproportionateIllllllber of th estat e's familiesst ill live in olderhomes.

the record shows that public health journ:tls virtuallyIgnored the subject. The American Public HealthAssociation did nO t take a public stand a l l childhoodkad poisoning lImil 1969.

Today, R.hode Island leads the way in reducing theincidence of childhood lead poisoning, pushed to do sobec:luse a disproportion:Hc number of the state's familiesstill live in older homes. R.hode Island owes its success , inlarge part, to the nonprofit Ch i ldhood Lead Action Project.founded in 1992, which serves as a catalyst for lead poisoning prevention. The project provides leadership to the Getthe-lead - Our Co:!.lition. a statewide network of environment:!.l, hOllsing, health, social $( 'fvice and church groups.and othe r advocates promoting public policy changes.Community -based approaches to preYCnt childhood leadpoisoning, as in Rhode Island , have proven highly effective.In 1995 in North Carolina, Edgecombe and Nash counties:lIld the city of Rocky Mount initiated a comprehensive.cOrllmunitywide program to prevent childhood kad poisonin g. In a population of 143,000 in rhe comb ined coun ties at that time, 17 percent of falllllies lived in poverty, androughly 90 percent of children with lead poisoning lived illRocky Mount. This cOIIHllunity- bascd approach providesa Illodel that call bl' emulated anywhere children arc at riskof kad poisoning.

I. Crell/I ' 11 Imllld-illlsl'd ((JuIIUlw i / )' (o(l l i / i(J 1I (Jr(/(/JlislIr), grollp.A task force of 50 members meets quarterly to mobilize the entire community to eliminate the environmental sources that cause kad poisoning ill children.

2. f l l l l(l/!!!' (Olll/ lllI/ l i ly lII ell l bers IIIMI (1/ i ~ ' k ill (11/ sWJ!es( ~ r Ii iI' /mJ.I!fIIi/I .In a 1()-block :1.rea 111 the cemer of R ocky Mount,education and cleanup activities became watchwords,spearheaded by a local chapter of United Parl'IHSAgainst Lead (U PAL ).

J. Semrt' dipers!' 111111 dedi(ll /ed sources 4 . fllll dill,e.Funding came fi-olll coumy and state health dcpartmems, the city of Rocky MOUTH, HUD and, indirectly.C DC through the North Carolina Div ision ofEnvironmental He:tlrll. Mos! importantly.:t regional


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Smarr Scarr Agency, the Down East Partnership forChildren, allowed for program planning and thehiring of a conHlHlIlity development spcc i:llist.

4. s ( ~ I / { / l e (I1l1r("lIr/l IIlId {'dum/IIII/ u'!ff.The leader of the Edgecombe and N:lsh co untiesprogr:ull ha s a background in environmental hea lthand has also wo rked in re:ll est:lte. She edu ca teslords :lnd l11ortg:lge offi ce rs, an important constituency

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Lead encephalopa thy (a metabolic disorder ca used by theingestion of lead compounds) and death from lead pOIsoning have been vll"wally eliminated in the United Statesove r the past 20 years. . . A combi nation of prevemiveapproaches - screening high- risk children, medica lly treating children with elevated blood lead levels and intcrveningto reduce environmental lead exposure - colltributt:d tothis success story. Most llnportalH, the removal of lea d frOIllgasoline and paint manufact ured fo r residential use hasdramati ca lly reduced childhood lead exposure. At the startof a new century, public health should continue buildinga winning coalition - government, community-basedorganizations, cIty planners, developers and private medicine - to prevent disease and deaths caused by unnecessaryle:Jd exposure. 1:1

,A co mbinationof preventiveapproaches contributed co thissuccess story -sc reen ing high risk c hildren ,m edi ca lly tteating ch ildren wit he levated bloodlead levels andintervening toreduce environmental leadexposure.


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VignetteAsbestosAsbestos ell l be found in nearly eve ry COlllmerci al and residentialstructure built in the U nited States from the early to l 1 1 i d - 1 9 0 0 ~ . Pri zed for its insuLHing and fire-retardant character istics, asbestos wasadded to concrete blocks, wallbo:ud, insulation, gaskets and flooringmaterials. to name ollly a few building materials. Not until th{: 19605did asbesTOs become a public health conce rn , roo late for thousandsof people who had eithe r died or suffered frOIll lung disease andothe r t:1tal illnesses caused by asbestos exposure. 111 1964, an aurh orit:ttive report presented by Dr. Irving J. Selikoff at the Ne w YorkAcademy of Medicine underscored what h:ld become cOlllmonknowledge - with asbestos. the magical properties to retard fireand insulate from heat came with a gr:tve human cost.Asbestos is a generic name for six naturally occurring minerals thathave been mined since before recorded history. Ordinary silica boulders bre:tk apart first into rocks, then into stones, pebbles, grit andfinally dus t, always with a harmless quality of roundness. Asbestos,on the other hand, yields fibers when pulveflzcd. Th ese fibers, eachcomposed of thousands of even smaller fibers woven tightly together,in turn, yield fibrils that are invisible to the human eye even underpowerful microscopes. Asbestos causes h:lTln on ly when it crumblesand releases submicroscopic fibrils into the air as a cloud of dust thatis then breathed in or swallowed.Lung disease can begin by chance when a single fibril e m b c d ~ in alung cell, somethin g akin to a javdin thrown from one end of a football field landing in the exact center of a mattress at the other end.Since a single fibril call kill, thete is no known Safe level of exposureto asbestos. Unfortunately, asbestos is found everywhere in indoorenvironment s, from acollstic ceiling tiles to duc twork insulation totaping compounds to vinyl floor tiles. Its usc II I exterior shingles andsiding and in road-building materials is also pervasive. In the UnitedStates, laws dId nOt cu r tail the use of asbestos as a fire-retardant andheat insulatOr in building materials until the late 19705. Althoughasbestos remains harmless if left intact and undisturbed, once disturbed, its safe removal becomes a costly and laborious undertaking.Untold billions of dollars would need to be spe nt before all asbestoscould be safely removed.Meanwhile, the toll of f.1tal illnesses caused by submicroscopicasbestos fibrils continues to mount. Foremost in concern IS mesothelioma, a rare form of lung cancer. Othet debilitating lung illnesses

49


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50 Mi ll-SIQ '' ' ' ' Chapler J. "" ,rom" c tl lo l HClhh ViJ.:".'lll

cau sed by asbestos include asbesto sis (:I sca rring o f th e lungs withfibrou s tissue), pl eural plaques , pl eural thi ckening. asbes tos pl eurisyand lun g can ce r. Al so, in gested fibril s can cause gastri c tumors.Me sothelioma causes parti cular pain to its' vi ctims and their fami lies.N early always f:1tai unl ess it is di scovered early, usually by cbance,and t reated agg ress ive ly, th e usual co urse o f the disease after diag nos isis an exceptio nally painful two-year decl ine in lung fun c tion. Th esymp toms typica lly appea r 20 to 30 yea rs aft er th e first exposure.Beyo nd constr uctio n workers, mincrs and shipya rd workers w ho arcknown to be at r isk, most peo ple do no t know wh e ther th ey havebee n expose d. Consequ ently, th e d isease o ften takes peopl e by sur -pr ise. Long-ago expo sure to any mater ial con taining asbesto s thatc rumbled or became a powder fro m sawing, scraping o r sa nd ingcreates th e co nditio n fo r the disease.While in cidence of th e disease in th e United States remains relativelylow, with 14 cases per milli o n people per yea r, a th ree fold increase inm eso th elioma in males be tween 1970 and 198 4 caused alarm ill pub-lic healrh circles. Health officials traced th e increased incidence toworkplace conditions, espec ially in shipyards, and th e legal communi -ty respo nded by filing class actio n lawsuits aga inst manu fac tu rers andmine own ers. Currcml y, asbestos li tiga tion wends its way throughcou r ts across th e CO Lllltr y. In the case o f Jo hns Manville, th e world 'sla rgest asbestos compan y, bankrup tcy proceed ings fur ther complicatepending lega l remedies.Tests in 2000 determined tha t eve n cra yon s con tained un safe leve lsof asbestos, a resul t o f seve ral leadi ng crayo n manufac tu rers using talcmined fro m on e site in up state N ew York .Th e mine's ow ner, backedby powerful membe rs of Con gress, had fought gove rnment regulato rsto a stand still fo r years. Meanw hile. workers in th e cra yon manu facturing plants co nt inu ed to be exposed to fi bril s made airbo rn e in th etalc. As publi c hCl lth luth orities accumulated ev idence of th e healthrisks from crayo n manufacturing and from cra yo ns th emselves, a batt lewith th e mining industry and its powerful con gress io llli suppo rtersloo med. Onl y wh en evidence of th e health r isks beca me ove rwhelm-ing were enfo rceable regul ati o ns enacted . Publi c he:l lth balances n skand precaution in add ressing enviro nm entll publi c health issues, andth e crayon issue illustrates how hea lth threats o ften need to escalatebefore ac tion is taken . D


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-

,... one I II fourchildren in Ne wYork City'sHarl em sec tionhas asthma ....

M,1.>'IOIIC' Chapter 3 Envlronment,l Hcalth LOllkmg Ahc,.!

Looking AheadAsthma

[nnamed

Normalb r o n d

bronch us L - ' : : ~ ' I I ! I I I I ! ! ~ ~ U An cstim:Hcd 31 million Americans have asthma raday.morc than triple the number in 1980, :lccording to theU.S. Centers for [)isc:lsC Control and PrcvcmiO!l (C DC).Characteri zed by a ch ronic inflammation and swelli ng ofthe :1 lrways that restrict breathing, asthll1:1 thn::atens thelives of people wh o have it and creates I1llccn;l!llty intheir daily lives. During a serio us asthnu attack, brea thingbecollles so comtrictcd dtat the feeling is sinHl;!r to drown-illg. At this stage, an emergency rQOIll vis it for life-savingtn:atllll'IH becomes essential.Asthma debilitating and costly to the health care ~ y s t e 1 1 1 . Although anY011l' can have asthma, regardless of age.income or ethnicity, the disease is particularly prevalentamong I O \ v ~ i n c o 1 1 1 e children in the inner cities. .. . Tile)\'1'11' York Tillles reported in 2003 that on e ill fouf child renin Ne w York City's Harlem section h;ls asthma, double therate expected by f e ~ e a r c h e r s and om ' of the l11ghcst ratesin the nation. In the early 19705. because few people diedfrom asthma c k ~ , they we re not even reported. Now,just 30 y t ' a r ~ later, the disease C ; l l l ~ ( ' S 5.000 deaths a yeJfand disproportiollJ.tely affects African - Americans.


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Why does the United States face this frightenll1g publichealth epidem ic, and what should be done to address it?Asthma can be characte rized as a disease of lIldusrrializaciOIl. Epidemiologists, physicians. social workers :l!ld medical researchers have been hard at work tr ying to uncove rthe environmental causes and aggravarors of as thma. I IHarlem, the surprisingly high incidence of the diseaseamong ch ildren may stem from chronic pollution causedby truck and automobile t raffic, second-hand tobaccosmoke, unhygieni c living co nditions or a combinationof these factors. The research is nOt yet conclusive. Other:lsthma tri ggers include in dustr1:1l air pollution, dust mitt's,cock roach and mouse droppings in tightly insulated homes.and severe allergic reactions to common substances, suchas animal dander :lnd pollen.The exact causes of :lstbm a in any particular person arc stillsubject to speculation. H eredity is thought to be a factor,as children of as thmatics arc more likely to develop thedisease. Atopy is a proven factor - people susceptible toallergies are more likely to sutTer from asthma. R:lce and

III Seplfmvn 2002 , lIIore 1//(/11 400 ellildr('/! 1J't"f(' SfffcllcdJor a.Hlm,a(I { Public SrI,,,,,1 242 ii, i\-I,m!rtl/l(l/I .et lmicity also appear ro playa roll - African-AmericamsuITer from rhe disease at all increased rate (5.S percentcompared with 5.1 percent in whites) and arL' more likelythan whites to be hospitalized and die (rOI11 asthma attacks.[n r.1ct, the death rate from asthma in African-Americanchi ldren is more than four times the rate in white children.


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,P:trents andcaregivers mustbe exceptionallyattentive to th etrigge rs that caliseasth ma in th echildren in thelfcare.

Cirlll.


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by allergen exposure. Another new lIu?"rapeuri c approach.de termining how to co ntrol lung acid levels in asthmapatients, also promises to reduce symptoms. During anarrack, asthma sllfferers experience levels of lun g acidup to J ,000 times higher than people withol][ asthma.Resl'archers have di scovered specific reaso ns for thisimbalance and will soo n make available therapemicsto prevent it and thus redu ce symptoms.Another promising avelllle for therapeutics is geneticre search. Although a singk "asthma ge ne" has yet to bediscovered, genetic studies have yielded significant advancesin pinpointing the many genes thought to be involved inallergies and asthma. Understandi ng how lIll'SC genes arcinherited in f.11llilies will enable researchers and physiciansto better predict wh o is at risk for the dIsease and initiateth erapies to control the sy mptoms. Many asthmaresearchers believe it is only a matter of time beforeadvances in D NA technology and knowledge of thehum:l1l genome will uncover the roots of asthma.Effe ctive new trea tment options will sllrely follow.Th e publi c hea lth community views asthma and relatedbreathing diso rde rs as a key challenge in the new ce ntury.Moreover, asthma is a complex disease that requires a co ordinated and multifaceted response from many o rgan iza tions including those 111volved with transportation , llrbanplanning, the ellv ironment, health care, and public health.The public health re spo nse to asthma involves a llumber ofactions. all eq ually important. First, su rve illance revea ls thedistribution and occurrence of asthma. Second, ed uca tionhelps ameliorate the severity of asthma attacks. Third. co ahtiollS [hat foster co llaborative approaches to strategic directions, structure and proces s in asthma treatment reducebarriers and make go als achievable. Fourth , advocacyaddresses the suspected ca uses of asthma in cO lll1l1l111ities.Fi nally, Inte rvent ions - medical, environmental and sc hool based - create healthie r environments and ca n lead to adecline in the prevalence o f :lsthma. Wh en public healthrallies educators, government, industry, and the publi c toadopt these five steps, asthma begins to be addressed inways that lead to long-term solutions.From an enviro nmental standpoint , anyone with asthma or someone living with a person with aHhm;J. - should take

Many asthmaresearc hersbelieve it is onlya matter of timebefore advancesin D NA technolof,'Y and know ledge of thehuman genomewill uncover theroots of asthma.


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dysfunction syndrome - affect rescue workers and residentsof the area. The full extent of health problems is not yetknown, but many resc ue workers will likely face lifelon grespiratory illnesses.Answers to env ironmental health problems cannot all beknown today. Time Can be a best friend o r a worst enemywhen measuring environ1l1 ental effects . For example, levelsof carbon mon oxide can be measured in one month andeffective countermeasures taken immediately. On the otherhand , pesticides in the food cham might take years toIlleasure and can cause gre:1.t harm before counrerrlleasuresare even considered. The effect of cli mate ch ange onhumans, which will take generations to measure, posesa particular challenge for environmental health specialistsand other sc ientists who ca re about healthy ellvironments.Th ey mU St convin ce workers who depend for employ men t011 skeptical industries, and the industries themselves, toaccept co unterm easures on faith.How will glob'll cha nge affect fmUTe generations? Mustenvi ronm en tal problems reach crisis levels before we act?C;m we avoid repeating past mistakes? Th e environmentalpicture, still murk y, is one of threats and advances coexist-I1lg. On e million people worldwide die of ai r pollutioneach year, 90 percent of whom are in developing nations.Industrialization and technology creat..: wealth in thed..:vcloping world, measured by growth in urban areasand international travel and trade, bu t at the sallle timegreen house gases cause climate change, ecosystems arest re ssed, chemical hazards multiply, biodiversity is lostand emerging infectious diseases jump continents.Unfortunately, rapidly developing countries contributeto environme ntal depredation, compounding the problemscreated by advanced industrial nations. Coral reefs continueto die off, schools of dolphins continue to dwindle, ozoneholes continue to widen.Government's duty is to prioritize the environmentalhealth agenda. Citizens share a responsibility to becomeliterate about environmental hea lth to help advance thefield. Many adva nces designated smoking areas, recycling,bicycle paths, grecnways are made possible because thepublic engages in advocacy, a driver of government change.

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Dr. a r d j. Jllrbo ll,Ii.lrmc r dirwor oICDC'$ Crll /a forE'HliroIlIllCIlltI/ H CI!'}"

Dr. Ri ch:lrd J.J:lcksoll, former director of CDC's Cente rfor Environment:ll HC:llth , writes :lbout future develop-ments in environment:ll hC:lltb: "The currelH gencr:lt ionnow f:lces its own cbalknges. On e challenge is to bene runderst:lnd the broad impact of Ollr built environment onhealth :lnd then to build future co mmunities that promotephysical and mental health. Public he:llth l1:1s tr:lditionally:lddressed the built environment to tackle specific healthissues such as sanitation, le:ld P:lillt, workplace s:lfety, firecodes :lnd :lCCCSS for people with disabilities. Wl' no w real -ize tlut how we design the built environmeru may holdtremendous po tential for addressing many of the n:ltion'sgreatest current public health concerns, including obesity,asthma , injury, depress ion, violence :lnd social inequities."Perh:lps Jackson best expresses a vision for the futureof he:llthier environme nts: " M:my aspects of the builtenvirolllTlent will re sist rapid clunge, even when re se archb:ls adequately revc:l led key aspects of healthy communities.E f f o r t . to improve pedestrian facilities, preserve green spaCl':lnd upgr:l(\c public rransportation arc ullder w:ly in 11l:lllyco mmunities. Whereas ou r generation may reap so me be n-efits fi'om the new field of the built environment :lndhealth, with :I little vision :lnd a lot of good sc ience :lndhud work, OUI" children :lnd grandchildren will be ableto w:llk or bi cycle horne from their workplaces throughattr:lctive COll1mu nities designed to promote tIlt' physic:lland rncnml health of all people."

l\1iauri Sprill,!!.s, Florida, S;I(' plllll - all eXll lUple (If" WIHlllllllil),plmmcd willi pll'lIlifll/.!!.rrrllfr)' (Iud pl'dCSlrillll 1I1d/bpll),S.


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Photo c redi rsPage 37: N,'w York air quality. 19(,(, 0 Nc.1 [!u"nl!a/Thc New York Till,..'(NYT Photos).I':lge 37: EPA s

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Milestones in Health Care: Chapter 3