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Institute of Medicine (US). Rebuilding the Unity of Health and the Environment: A New Vision of Environmental Health for the 21st Century. Washington (DC): National Academies Press (US); 2001.

Cover of Rebuilding the Unity of Health and the Environment

Rebuilding the Unity of Health and the Environment: A New Vision of Environmental Health for the 21st Century.

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Abstracts of Talks


Nancy Adler

The best single predicator of a person’s health is his or her socioeconomic status (SES); the lower individuals are in the socioeconomic hierarchy, the shorter is their life and the greater is the likelihood of their experiencing a wide range of diseases. SES effects are pervasive; increasing socioeconomic resources are associated with better health not just for those in poverty, but on all levels of the socioeconomic ladder. Two of the pathways by which SES influences health will be considered.

The discussion of SES determinants of health must be grounded in consideration of what is known about the general determinants of health. The Centers for Disease Control and Prevention has estimated that 10 percent of premature mortality is due to deficiencies in health care, 20 percent to environmental exposure, 20 percent genetics, and 50 percent to behavior and life-style. This is necessarily oversimplified since there are obvious interactions among these categories, but it gives some idea of the magnitude of the effects. The analysis did not include socioeconomic factors as direct contributions to death, but SES underlies risk in most of these areas: SES influences health care, environmental exposures, and health behaviors.

The most obvious health-related effect of SES is access to health care. However, health care overall contributes relatively little to premature mortality. Other evidence also suggests that health care is not the major factor in socioeconomic disparities in health. For example, the SES health gradient emerges in countries with universal access to health care and in diseases for which health care is relatively ineffective.

The second pathway is through environments associated with socioeconomic levels. This includes work and residential environments inhabited by those at different levels of the SES hierarchy. SES environments differ in the relative exposure to carcinogens and pathogens. Poorer neighborhoods have higher rates of toxic exposure; similarly, lower-SES jobs are more likely to involve such exposure. If one expands environment to include the social environment, SES has even greater effects. A key aspect of environments is the extent to which they are experienced as stressful by those who inhabit them. At both work and home, higher-SES individuals are less likely to confront uncontrollable stress. Research on British civil servants has shown that a sense of control over work varies directly with occupational grade and accounts for much of the effects of occupational level on mortality. Community-based research has shown that in urban environments, neighborhoods that demonstrate a sense of “collective efficacy” and social cohesion have lower rates of violence as well as lower mortality from other causes of death; these associations hold even when controlling for traditional socioeconomic level.

Another pathway from SES to health is through health behaviors. Health-risking behaviors, including cigarette and other substance use, high-fat diets, and sedentary life-style, vary inversely with SES; lower SES is associated with higher rates of all these behaviors. Although these are individually based behaviors, they are shaped by physical and social environments. Neighborhoods constrain the choices individuals can make; poorer neighborhoods provide more access to health-damaging goods (e.g., alcohol, tobacco) and less access to goods that foster health (e.g., fresh fruit and vegetables, low-fat food). Poorer areas also have fewer recreational facilities and safe areas for walking and jogging, thus discouraging exercise.


Nicholas Ashford

Progress in environmental health is hampered by the balkanization of the knowledge base. People and organizations are working on pieces of the problem, but they are not connected and communicating. The role of the government has focused on regulation, but it has past information rather than the state of the art. States such as Massachusetts, New Jersey, and Minnesota have taken a lead by requiring industries to talk about what they could be doing rather than what they are doing.

In order to address and set priorities for environmental and public health problems, there is a significant need for industrial transformation or displacement of technologies and sectors that give rise to serious environmental and public health problems. This is especially true for those industries that have remained stagnant for some period of time and are ripe for change. Achieving sustainable production and consumption requires (1) a shift in policy focus from assessing and characterizing problems to designing solutions; (2) an appreciation of the differences between targeting technological innovation and diffusion as a policy goal; (3) the realization that the most desirable technological responses do not necessarily come from the regulated or polluting firms; (4) understanding that comprehensive technological changes are needed that optimize productivity, environmental quality, and worker/or public health and safety; and (5) an appreciation of the fact that in order to change its technology, a firm must have the willingness, opportunity, and capacity to change.


J. Christian Bollwage

Public policy on the environment impacts our cities. Like other communities, the city of Elizabeth, New Jersey, was an industrialized area until the 1970s and the 1980s when manufacturing jobs were leaving the Northeast. The city needed to undergo revitalization to become a service economy.

Revitalizing a land tract from a landfill into a usable piece of land requires strategic planning and collaboration between public and private stakeholders. In Elizabeth, this planning created 5,000 jobs while cleaning a previous hazardous waste site. Other activities in the city include redeveloping vacant brownfields into ballparks, supermarkets, and so forth. The revitalization of brownfields raised revenues while preventing further destruction of invaluable green space—a precious commodity in cities.


Robert Bullard

Health is more than the absence of disease. When we discuss healthy people, homes, and communities, environmental justice is the starting point. Environmental justice embraces the principle that all communities are entitled to equal protection of environmental laws, housing laws, et cetera. Integration of the environment is not about profits, protecting or regulating corporations, and providing permits. There is a false view that a dichotomy occurs such that it must be jobs versus the environment or jobs versus health. There does not have to be a trade-off. Our society and court system put the burden of proof on the victims and the community to prove that chemical X caused Y disease.

There is a direct correlation between per capita income and waste generation. Further, individuals with higher incomes do not live near toxic waste sites or waste dumps. This results in an uneven distribution of exposure to potentially harmful environments and a need to relocate the entire community.

Urban sprawl is creating additional problems throughout the United States. The effect on the environment is dramatic. Ground-level ozone and the creation of a heat island are two of these problems. Identifying the problems is not enough. One must also identify the strategies to solve them. Environmental justice is needed to ensure that the national agenda reflects the diversity of this nation.


Thomas A. Burke

Public health concerns can be approached from many points of views or perspectives. When grappling with issues and determining what has been done for public health, the community as viewed by its members must be examined. Across the United States—whether in New Jersey, Philadelphia, or Baltimore—one can find neighborhoods or pockets in which the environmental health infrastructure has collapsed. These communities have realistic concerns about sewage treatment, air emissions, uncontrolled solid waste, et cetera. They have concerns about their health—cancer, asthma, and other respiratory ailments; chemical sensitivity; and lead poisoning.

Areas in our communities in which the greatest opportunities for redevelopment and revitalization exist, are also the sites where the most improvements to public health are needed. As part of any revitalization and redefinition efforts, we have to include a public health approach. We need to study population health status and realize that the health of communities can inform us about where the ecosystem must be protected.


Donald Conroy

Environmental concerns are not new to modern society. Since earlier times, overgrazing and misuse have resulted in people abandoning grazing sites and moved westward. The decline of ancient cities in Iraq and Chaldea may also be connected with environmental problems. In modern times, we are moving away from industrial capitalism and moving rapidly toward the electronic era and globalization of trade.

The approach to medicine has been “male dominated,” focused on surgery and other invasive techniques as the approach to cure disease. This type of approach is needed when the focus is on the individual as a result of warfare, industrial accidents, car accidents, and so forth. However, a more feminine or communal emphasis is another valid approach to health care at the community level. Using noninvasive techniques to cure, including diet and nutrition; holistic types of body, mind, and soul techniques; and meditation and reflection, may be important to address a dynamic, ever-changing awareness of well-being and health.

Religion also plays a major role in the well-being of the individual and the community. Many religions are shifting from individual anointing of the sick toward community well-being. Some research has shown that individuals who incorporate religion into their treatment plan recover at a faster rate than those who do not. Incorporating religion and a feminine or communal emphasis in medicine are necessary aspects of community health.


Bill Dietz

The physical environment has always had a link to health and chronic disease prevention. Exposure to sunlight and the addition of green spaces at the turn of the 20th century led to a decrease in ricketts. In modern life, we have a new epidemic of chronic diseases related to obesity due to an increased sedentary life-style. A number of comorbidities are associated with obesity, including diabetes, cardiovascular disease, hypertension, gallbladder disease, and cancer.

The United States relies heavily on the car, using it in 85 percent of all trips; 25 percent of these trips are less than 1 mile but 75 percent are made in the car. By contrast, in the Netherlands, 30 percent of trips are by bicycle, 20 percent by walking, and 45 percent by car. Suburbs are building shopping centers, schools, and so forth, near major traffic arteries, which promotes the use of cars. Increasing the connectivity in the environment will increase the probability of walking or riding a bicycle. This means that going to the store or school must be by streets and sidewalks that are easy and safe to travel. To enhance the livability of communities, environmental health will have to rely on coalitions to achieve these objectives.


Jeffrey Feerer

“Hey, there is a $100 bill on the floor over there!”

“That can’t possibly be a real $100 bill. If it were, someone would have already picked it up.”

Most environmental policymakers and business leaders believe that opportunities to reduce pollution and save money at the same time would be implemented without hesitation if such opportunities were ever discovered. The fact that such opportunities are seldom trumpeted leads to the belief that they must be very rare. Therefore, many people subscribe to the “dollar bills on the floor” theory, which holds that if such opportunities really existed, they would have already been seized.

This project, the Michigan Source Reduction Initiative (MSRI), shows that this widely held impression is wrong. Over only a 2-year time frame, the project found opportunities to reduce nearly 7 million pounds of wastes and emissions at the Dow Chemical manufacturing site in Midland, Michigan, while saving the company more than $5 million annually. In the course of this project, Dow committed capital to these projects, and the reduction and saving have already largely taken place.

Perhaps more incredibly, by the reckoning of Dow managers, the reductions and cost saving identified and approved in this project would not have occurred without the unique involvement of a group of outside environmental activists. Thus, this success defies a second piece of conventional wisdom, which holds that only company experts themselves can accomplish pollution prevention successfully. To the contrary, the MSRI experience shows that companies can benefit substantially from interaction with informed critics drawn from the community and from regional and national environmental organizations.


Howard Frumkin

This talk will focus not so much on redefining the definition of environmental health but more on suggesting a broader approach and research that is a result of that approach. Many people have studied the environmental hazards that have negative effects on our health. However, a broadly conceived natural environment can also enhance life. Contact with the natural world may be directly beneficial to health. Our connectivity to nature is not new and has a long and fascinating history in philosophy, art, and popular culture. Four aspects of the natural world demonstrate the enhancement of our health: animals, plants, landscape, and wilderness experiences.

Animals have always had a major role in our lives and contribute to human health. Animals comprise more than 90 percent of the characters used in language acquisition and counting in children’s preschool books. Numerous studies show that household animals are considered family members: we talk to them as if they were human, we carry their photographs, we share our bedrooms with them. Preserving the bond between people and their animals, like encouraging good nutrition and exercise, appears to be in the best interests of those concerned with public health.

People feel good around plants. Individuals report that working in an office with plants makes them feel calmer. A 1989 National Gardening Study found that flowers and plants at events, theme parks, and so forth, increased the enjoyment of visitors. In urban settings, gardens and gardening have been linked to a range of social benefits, from improved property values to greater conviviality. Indeed, the concept that plants have a role in mental health is fairly well established. Horticultural therapy evolved as a form of mental health treatment, based on the perceived therapeutic effects of gardening. It is also used today in health care, rehabilitation, and educational settings.

The third positive enhancement of human health viewing involves natural landscapes. To return to an evolutionary perspective, human history probably began on the African savanna—a region of open grasslands punctuated by scattered copses of trees and denser woods near rivers and lakes. Today, this pattern repeats itself in our choices in parks, cemeteries, golf courses, and lawns. When offered a choice of landscapes, people react most positively to savanna-like settings, with moderate to high depth or openness, relatively smooth or uniformlength grassy vegetation or ground surfaces, scattered trees or small groupings of trees, and water, a finding that is consistent across every culture in which it’s been tested.

Wilderness experience—entering the landscape rather than viewing it—is my fourth topic; this also may be therapeutic. Most published studies relate to mental health end points. In one report, for example, a group of emotionally disturbed boys attending an outdoor day camp was compared to a group of similar boys who did not attend camp. The campers’ self-ratings of their emotional adjustment, and their teachers’ ratings, were significantly better than those of the controls, although neither parents’ ratings nor scores on formal psychological testing showed an improvement. This research has some limitations such as selection bias and lack of randomized trials. However, many published accounts do suggest some benefit from wilderness experiences.

There is evidence, then, that contact with the natural world—with animals, plants, landscapes, and wilderness—may offer health benefits. We need to think about a broad vision of environmental health—one that stretches from urban planning to landscape architecture, from interior design to forestry, from botany to veterinary medicine. We need a research agenda directed not only at exposures we suspect to be unhealthy, but at those that we suspect to be healthy as well. Environmental health could become a factor in policy decisions that affect human contact with nature—urban design, land use and regional planning decisions, and even forest policy.


Mindy Fullilove

This presentation will explore the link between the creation of marginalized communities and the spread of many kinds of disease, using for an example of this process the spread of HIV/AIDS. The thesis to be presented has two main parts: (1) concentration of resources and wastes creates a sharp gradient in the life-carrying capacity of places, and (2) it also undermines the psychological connection to the larger unity of human life (i.e., the psychological basis for an ecological consciousness).

The AIDS epidemic in the United States was first located in several epicenters, including San Francisco, Los Angeles, New York, and Miami. AIDS then spread from the epicenters in two ways: (1) through diffusion along the hierarchies of cities surrounding each epicenter, and (2) through spatial contagion/or network diffusion in local areas. The driving force of the national epidemic is the series of local epidemics, which are variously constructed within marginalized communities of displaced persons. In the initial phases of the AIDS epidemic, three types of marginalized communities were identified: innercity communities, gay ghettos, and rural centers of migrant workers.

Dr. Rodrick Wallace, in a seminal series of studies on AIDS in the Bronx, described the ways in which habitat disruption created the niche for the human immunodeficiency virus. As a backdrop to Dr. Wallace’s work, it is important to point out that major social, physical, and economic processes, including the massive building of highways to new suburbs; urban renewal, which decimated older neighborhoods in city centers; and the economic shifts that undermined manufacturing in urban areas of the North and East, led to major population loss in U.S. urban centers after World War II. This “shrinkage” of the cities led some to call for a “planned” process that would guide the downsizing of urban areas. In particular, it was proposed that poor neighborhoods be leveled, concentrating the population elsewhere in the city.

This forced “internal resettlement,” like other experiences of massive displacement, sundered social relationships, undermined community life, and imposed heavy psychological burdens on the uprooted. The abrupt decline in social conditions created preconditions for a series of epidemics that acted synergistically to cause an explosive increase in morbidity and mortality. The epidemics further undermined social functioning. The series of assaults—first from displacement and then from epidemics—led to disintegration of the social functioning of affected communities.

Among other psychological effects of such upheaval is the weakening of the sense of belonging to a given place and, by extension, to all places. Because caretaking is tightly linked to belonging, the ecological consciousness is undermined as well by massive experiences of upheaval.

In contrast to the drastic and deleterious effects that follow forced displacement are the salubrious effects that follow organic community development. This principle of benevolence drove the redevelopment of the Manchester neighborhood in Pittsburgh, the happy result of a partnership between community-level organizations and the Pittsburgh History and Landmarks Foundation. Together, these groups inventoried the resources of Manchester’s built environment and made plans to restore the deteriorating housing stock and revitalize the connections to industry and commerce. Today, the Manchester neighborhood is an intimate and charming place, secure in its history and looking forward to the future. It is a healthful place, and this goal has been reached by meticulous attention to the simple question, What else do we need to consider? Take, for example, the restoration of gardens. A landscape gardener with experience in historical preservation noted that the front yards in Manchester used to have gardens. The gardens were restarted. Quickly, it became the “thing” to have a small garden and to work in your garden in the evenings. Neighbors might stop by and admire your roses, children could help water the plants, and a new way of “neighboring” was introduced.

The reintroduction of gardens is a connection with the past that solidifies the present. By creating a deeper bond with nature, it supports the ecological consciousness that is our only hope for the future. Out of such a series of linkages came another extraordinary linkage: an exhibit about Manchester at the Carnegie Museum of Art. This was an occasion to bring all of Pittsburgh together to celebrate the rebirth of a neighborhood and, in so doing, to restore some balance to the relationships Manchester had with richer enclaves on all sides.


David Hayes

As suggested by the workshop agenda, environmental health is more than pesticides, ozone depletion, or endocrine disrupter issues, and many federal agencies have a stake in it, including the Department of the Interior. As one of the nation’s largest landowners, the Department of the Interior owns more than 20 percent of the land mass of the United States. Many cities, which are now encountering incredible problems with sprawl, look to the Bureau of Land Management as a provider of open space and recreation opportunities. In addition, the Department of the Interior has regulatory responsibility, including the Endangered Species Act and tribal trust issues.

The Department of the Interior and many other agencies are faced with issues of protecting our environment. Americans know and love our physical environment—possibly to death. People have a connection with their environment, possibly from their childhood, and seek out these places. Enjoying nature provides spiritual, emotional, and physical satisfaction. There is concern when cities are involved with urban sprawl, chewing up an acre of land per hour. This provides less green space for people to enjoy. The Department of the Interior has been working to set aside green space in communities to help people, the environment, and other species. This also has a positive effect on the natural water flow, resulting in better drinking water for current and future residents.


Thomas Lovejoy

Biodiversity and human health can be parsed in various ways. There are six major connections or contributions of biodiversity to human health. First, the natural world and diversity contribute to the pharmacopoeia. We have not tested all biologically active compounds for potential benefit. A slime mold from the Zambezi River has recently been shown effective in the treatment of tumors. Cyclosporin, an important medicine for organ transplantation, is derived from a fungus. Without biodiversity, these compounds might not have been discovered. Second, biodiversity contributes to the development of research and diagnostic tools (e.g., polymerase chain reaction). Third, biodiversity is a living library for the life sciences. The study of pit vipers uncovered the role of angiotensin in the regulation of blood pressure. Fourth, endocrine disrupters in wild species may impact human reproduction. Fifth, some organisms help to reduce environmentally caused, or pollution-caused disease (microbes are used to clean up toxic waste or oil spills in the environment). Sixth, biodiversity provides a stable supply of clean water. The summation of these benefits provides a strong argument about how biodiversity has a direct impact on our physical well-being.


Amory Lovins

There is a broader context for thinking about the relationship between business, buildings, and health. It is called “natural capitalism”—a way of doing business as if nature and people were properly valued. Operationally, it wrings enormously more benefit from resources; it redesigns production along biological lines with closed loops, no waste, and no toxicity; it rewards both of these efforts through a “solutions economy” business model in which both customers and providers profit from doing more and better with less for longer; and it reinvests some of the resulting profits in natural capital. It is very profitable to reduce and eliminate waste because there is so much of it. In the United States, the materials flow is more than 20 times the average person’s body weight per person per day.

Some examples of what integrated design can do for an individual follow: I live and work with no heating system at 7,100 feet in the Rocky Mountains where temperatures can drop to minus 44 degrees Celsius. The heating system was not needed because superinsulated construction and highly integrated design made the building thermally 99 percent passive. People are more productive, healthy, and happy in this building than in an ordinary office where they soon get irritable. The building’s 99 percent savings in space and water heating, 90 percent in household electricity, and 50 percent in water all paid for themselves in 10 months with 1983 technology. Another example is the ultralight hybrid-electric vehicles that are being developed and will be widely available within 5 years. Also, advanced resource productivity often improves service quality and boosts human health and performance. For example, office buildings with good day-lighting, air quality, acoustics, and thermal comfort can often increase workers’ productivity by about 6–16 percent, while reducing absenteeism by about 15 percent.

If we follow the four principles of natural capitalism, we will be able to live in a world where a successful business takes its designs from nature. By using integrated design, early adopters of “natural capitalist” principles find greater short-term profitability, stunning competitive advantage, and far more fun.


William McDonough

As designers, we do everything from fabrics to shoes to automobiles to trucks to buildings. In accomplishing these projects, we apply two principles. First, what we do is medicine. We need to design projects that will allow us to love all the children of all species for all time. Two, from a community perspective, the question remains, At what point can we declare ourselves native to this place? As designers work on a project, at what point do they decide that they do not want to participate in the system (e.g., the building of Auschwitz)? In modern times, can a designer participate willingly in building a system that treats nature as its enemy—a system that measures prosperity by how much natural capital we can dig up, bury, burn, or otherwise destroy?

Looking at the world of tragedies, a designer has to take responsibility for the by-products of the designs. I founded a company based on the following principles: the right of humanity to coexist, recognizing interdependence with the natural world; respect for the connection between spirit and matter; accepting responsibility for the consequences of design; eliminating the concept of waste; relying on natural energy flows. From these principles, we design products with two ideas: (1) waste equals food (i.e., everything is a nutrient), and (2) we must respect diversity. In reaching this goal, we have to imagine what 100 percent “good” looks like and measure progress toward that goal.


Terrence J. McManus

This talk will address how Intel handles overall the issues of environmental health and safety and the performance of these programs. Intel installs a new manufacturing process every 2 years, and this provides a major opportunity for environmental improvements. We target chemical selection, facility design, waste management, ergonomics, and overall manufacturing equipment selection. We view the use of chemicals as part of either end of a bell-shaped curve. Chemicals need to be consumed in the products or borrowed from the chemical company. The latter results in the chemical being returned to the chemical supplier for recycling. Intel has become forward looking by investing in research and development and developing a five-generation road map to identify potential opportunities to further reduce the environmental impact of its manufacturing processes. This results in planning for manufacturing occurring in the next decade. The results of this planning are promising. Of the generated chemical waste, currently 37 percent goes to recycling; 17 percent goes to energy recovery; and 46 percent goes to landfill, incineration, and other treatment. The use of water has remained constant, while the output of operations has doubled. The goal is sustainability, which has to be implemented regionally.


David Orr

There are four hypotheses about health. First, health is a broad topic composed of a multitude of disciplines. Second, humans cannot be healthy in an ailing ecosystem. Third, ecological disorders (planetary disease) reflect a prior disorder of mind and how we think. Fourth, it is a matter of great importance to educational institutions that purport to improve how we think.

Colleges and universities need to take this broad view of health services. Institutions and organizations do not have the right to undermine the stability, integrity, and beauty of the natural system. In recent years, there has been a slow-growing trend to change the policies on purchasing food, materials, and papers that are utilized by the campus. Further conversations are occurring in the classroom addressing what is needed in 2050 to make a world that is sustainable. For this to be realized, health in the fullest sense of the word needs to be an integral part of education.


Rafe Pomerance

There are human impacts on three major global resources that affect our health: the ozone layer, biodiversity, and climate change. Society was close to destroying the ozone layer through the use of chlorofluorocarbons. The United States Clean Air Act and international policies (the Montreal Protocol) stopped further depletion of the ozone layer. Biodiversity is another resource on which humans have a negative impact. Globally, we are rapidly losing species that could be a source of agricultural products and medicines. Humans are also having an impact on the climate. There is an urgency to getting greenhouse gas emissions under control. Many analysts see the doubling of CO2 levels in 2050 (predicted by modeling) as a problem to be solved decades in the future. We need to solve the problem now because it will be too late when we experience the impacts of global warming. For example, in 1998, coral bleaching occurred due to the increased ocean temperatures. In Palau and other great reef sites around the world, bleaching resulted in massive coral death. Coral reefs are one of the two ecosystems with the largest source of biodiversity. They are sources of nutrition, serve as fisheries habitat, and protect island nations from storms. Climate change will impact our health. Water resources (flooding, drought, etc.) are influenced by the climate system. The location of diseases such as malaria is affected by the climate change. A warmer climate will aid the spread of diseases into new areas.


Richard Rominger

There is a disconnect between the American public and a true understanding of today’s agriculture and how it impacts human health. Agriculture affects human health in two major ways: through environmental and ecosystem changes of farm production and through an available supply of food. The United States Department of Agriculture (USDA) is committed to putting food in hungry stomachs and promoting new technologies to protect the environment. One way is to encourage the shift to lower-risk pesticides or pesticide alternatives. Another is to help private landowners with conservation practices. The farmer is a steward of the environment and a guarantor of the nation’s future ability to produce an adequate supply of food. We need to keep pushing the frontiers of our knowledge by researching ways to eliminate waste and improve food safety. One example is the use of low-phytase corn that when fed to chickens and pigs results in 50 percent less phosphorus in manure. The result is cleaner water. For the future, we need to believe in the promise of biotechnology to help us achieve food security and environmental benefits globally.

Copyright © 2001, National Academy of Sciences.
Bookshelf ID: NBK99596


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