Environmental Aspects: Problems and Priorities

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vironmental contamination with selenium rather than the dietary content of polyenolic fatty acids may precipitate a deficiency in vitamin E. The inter-action between environmental agents and micro-nutrients, it is clear, may be complex and forces us to look at issues we have just barely perceived.

FUTURE CONDUCT OF RESEARCH

My final note will be the same as my beginning note-the need for research. Our research posture

at the present time is becoming increasingly com-promised by our temporary inability to deal with

the issue of the conduct of research among sub-jects who cannot give informed consent. As per-ceived by the press and the communication media, the most critical subject is the abortus. I am con-cerned about our ability to do pharmacologic re-search in the newborn and the infant, and even the child. I am persuaded that we must do research

KEYNOTE ADDRESS

on the fetus in utero. We probably must do re-search on the abortus. There is legislation cur-renfly in Congress that plans to deal with this

issue in a legislative fashion, simply precluding all research. If this were to happen, and if we are not prepared to oppose these forces as a scientific community, we might find ourselves fully aware of the need for beneficial research yet totally

un-able to approach the issue with confidence and effectiveness unless we retain our ability to do research among the subject classes I have

identi-fied. This challenge must be met if we are to move and meet the second challenge, that of evaluating the environmental impact upon the growing human

organism.

REFERENCE

1. Toxicants Occurring Naturally in Foods. Publication 1354. Washington, D.C.: National Academy of Sciences,

1966.

Environmental

Aspects:

Problems

and

Priorities

Paul Kotin, M.D.

From Temple University Health Sciences Center, Philadelphia

Man is increasingly creating most of his environ-ment. In the process he has created significant hazards to his health. Some of the adverse effects are longstanding but related to rapid technologic change. There has been an accumulation of con-taminants and waste products. Not only is popula-tion increasing, but there is also mounting per capita consumption. People continue to concen-trate in urban centers. All these changes have great-ly magnified the threats and complicated the prob-lems of keeping adverse effects down to acceptable limits.

This Conference is specifically addressed to threats arising from chemical pollutants, with spe-cial emphasis on the susceptibility of the fetus and child. It would be misleading, however, to believe that discussions can be limited to these important segments of the population, inasmuch

as adverse effects of chemical pollutants following exposure in utero and childhood may not become manifest until late in adult life.

Man’s continued drive for material progress has produced many by-products and wastes, some of which are disadvantageous or clearly threatening to his health. A series of crises has resulted at a rapid rate from unforeseen consequences of en-vironmental changes. Solution of these crises has been restricted by the traditional regard for the environment as a series of isolated compartments rather than as a highly integrated continuum of

ADDRESS FOR REPRINTS: Vice President for Medical

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SUPPLEMENT 783

strongly interdependent factors. Multiple factors

act singly or in combination, sequentially or simul-taneously, in their threats to human health. Such threats occur, furthermore, through exposure to low

concentrations of environmental agents over long periods of time and call for action on the basis of sound presumptive evidence well before overt dis-ease is established. There is no way to quantify

the real cost of environmentally induced disease for the fetus and child. However, some estimates are possible for the population as a whole.

THE COST OF ENVIRONMENTALLY

INDUCED DISEASES

The dimensions of the present costs for medical care can be glimpsed from the following figures.

The cost of health services is over $70 billion a year-of this, $12 billion is from Federal and $58 billion from non-Federal services. It is estimated that about 10% of these services is attributable to adverse effects of the environment, at an annual cost of about $7 billion.

The loss in wages and production brought about by the worker’s illness attributable to the work environment is $25 billion annually. This is ap-proximately one third the total cost of $75 billion, which when added to the expense of health services reaches a total of $32 billion a year as the cost

of environmentally induced disease. To this figure, enormous though it is, must still be added the funds needed for compensation and rehabilitation. Again, assuming that one third of the total cost of $10 billion is attributable to the environment, the annual expenditure is approximately $3.3 bil-lion. Figures are not readily available for the cost of rehabilitation. By comparison, it appears to be

minor-about $100 million.

The final estimate, therefore, of the cost of en-vironmentally induced disease

(

i.e., health service, loss of wages, compensation, and rehabilitation

)

is

about $35 billion a year. This constitutes a sub-stantial burden tolerated only because it is hidden

in an increasing annual bill for medical attention of all kinds.

One must conclude, on further dissecting the problem, that a crushing burden will develop from relying on traditional approaches to medical care

for environmental effects. The environmental con-tribution to the total medical care bill, still largely unidentified, can only rise, probably drastically. The awesome consequence will become unaccept-able, and some alternative must be found.

The question we face, therefore, is to what extent we should seek to reduce the economic and

social burden of medical care by prevention rather than by therapy, as is currently the mode. In fact our first priority should be the application of

pre-ventive medicine to the problems of environmental

health.

ENVIRONMENT AND LIFE EXPECTANCY

How realistic and factual are the bases for this

sober introduction? The evolution of the human

race from a relatively simple biological system to

its present complex state has been the product of

the interaction between the total environment and heritable traits. The changes in the characteristics

of species, both beneficial and adverse, occurring over the millennia were responses to increasingly

complex environmental stimuli. For the most part, the rate of change was sufficient to permit adapta-tion. During the past half century, however, the pace of change in the environment has accelerated rapidly. This phenomenon has in part been re-flected by changing patterns of morbidity and mortality as well as life expectancy.

Life expectancy at birth has increased from 47 years in 1900 to 54 years in 1920, and to 70 years in 1964. These figures are misleading if used to

reassure that the environment is innocuous. Ac-tually, if one measures life expectancy beginning at 40 years, the picture is entirely different. A 40-year-old white male in 1900 had 28 more years of life ahead of him; in 1920 he had 30 years; in 1964 he had only 32 years. Virtually no change!

On the other hand, the 40-year-old white female now has a life expectancy of 38 additional years, significantly longer than the male. Does this reflect differences in environmental experience? Quite probably it does, because only in the last two

decades have women entered more hazardous work

environments.

During the same period of rapid environmental change, the causes of mortality have changed radi-cally. Acute bacterial infections have been replaced as principal causes of death by a series of chronic ailments insidious in onset, protracted in course, and all too frequently debilitating enough to con-sume the victim’s resources and impair the integrity of the family as a functional and social unit.

Potential determinants of disease can be demon-strated in all interfaces between man and his en-vironment. Rapid changes in the environment come from two major sources of pollution. The first is

an inadvertent accumulation of waste products, such as smoke, in a closed system represented by the earth. The second, and no less important, source of potential hazard is the purposeful intro-duction of synthetics in consumer products, pesti-cides, and pharmaceutical agents. The problem of man living in a satisfactory relationship with his environment is not new, but the enhanced dimen-sions of the current problem require the generation of new approaches to achieve mastery over them.

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Changing patterns of morbidity and mortality, be-gun during the past several decades, are now proceeding at an ever-accelerating rate. An indis-pensable first step is what might approximately be called “modern” or “neopreventive” medicine.

THE ENVIRONMENT AND

CHRONIC DISEASE CONTROL

Chronic degenerative diseases, as well as cancer of the parenchytnal organs, are in the ascendancy.

They differ from acute diseases of the past as to etiology, natural history, medical management, and causes of death. Specifically, chronic diseases are long-term in their development, multifactorial in their origin, and, when clinically manifest, are as-sociated with structural changes in the target

or-gans. These diseases are at best minimally, if at all, reversible and at worst progressive despite ther-apy. At first there are functional changes followed

by reversible structural alterations, which, unfortu-nately, may occur before clinical disease becomes apparent in consequence of significant tissue de-struction. The long sequence of events offers hope for remedial steps. Prophylaxis is the goal in the optimal medical approach to control of disease. The objectives are to identify etiological agents and elucidate mechanisms of action; then either eliminate the agent from the environment or protect the host from the agent.

Our ignorance is not limited to specific definable diseases, but extends to an array of harmful agents in our environment. To the extent that such agents

are biological-viruses, bacteria, yeasts, molds, fungi, or parasites, including insects-the scientific community is already engaged on a reasonable scale in controlling their spread and combatting their effects. A substantial experience with many physical agents has also achieved some degree of control over the major hazards, exempting the auto-mobile and, under certain circumstances, ionizing

radiation. Colossal areas of ignorance also surround our use of chemicals that improve our supply of food and consumer products-of chemicals that pol-lute the biosphere by combustion of fossil fuels or by the effluvia of industrial processes. Many

of these chemicals are noxious in certain concen-trations, and at the acute level their toxic effects have been described and in some cases even under-stood. On the other hand, their potential for pro-ducing chronic effects is either largely unknown or known only as end-points of disease rather than by prodromal functional changes, which can be

stopped or perhaps even reversed.

My first priority, preventive medicine, is so broad that if successfully implemented would preclude the need for additional ones. However, other

pri-orities can be identified among the variables that

change over time.

Changing Character of the Environment

1. Current hazards-primarily chemical rather than microbiological.

2. Industrialization and urbanization of society. 3. Multiple sources of insult.

4. Increasing use of synthetic agents.

Changing Character of the Population

1. Increase in size.

2. Increase in percentage at extremes of age.

3. Increase in the numbers and duration of life of persons with decreased physiological reserve.

4. Increased mobility.

Changing Character of the Problems

1. Health hazards associated with long-term

ex-posure to environmental agents in concentrations too low to produce rapid adverse responses.

2. Combination effects of environmental agents

from multiple sources interacting with one another and with man.

3. Hidden and complex nature of specific and in “cause and effect” relationships.

4. Changing patterns of morbidity and mortality resulting from changes in the environment.

5. Public concern over quality of health as dis-tinguished from ill health.

Changing Character of Public Health Responsibility

1. Need for criteria and standards to assure

quality of environment.

2. Need for a scientific basis to establish criteria and standards.

3. Need for fundamental information on which to base predictive criteria.

4. Assessment of interactions of multiple agents in man.

5. Recognition of the effect of environmental agents on man’s behavior.

6. Major social and economic implications of control measures based on a scientific approach to resolving the “benefit versus risk” equation.

As examples, one can cite the need for measures to ensure that products and processes do not re-sult in unacceptable hazards as have arisen from persistent pesticides, cyclamates, radioactive de-vices, and automotive emissions. After evaluation is made of the present status of testing for adverse effects, research must be expanded to increase the reliability and usefulness of procedures for

pre-dicting hazards to man.

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ADDRESS FOR REPRINTS: Monitoring, U.S. Environmental ington, D.C. 20460.

Office of Research and

Protection Agency,

Wash-SUPPLEMENT 785

ensure disposal or reuse of unwanted residues,

and to avoid such hazards as have occurred from combustion, acid mine drainage, and agricultural poisons. We must recognize the essential unity of the environment and its limited capacity to absorb pollutants. We cannot simply transfer pollutants from air to water, or water to soil. We must

under-stand the interaction of environmental contami-nants with each other, as in the production of photochemical smog. Various aspects of

environ-mental effects must be incorporated into the assess-ment of the total impact on health.

We obviously must develop the ability to forecast technologic and sociologic trends. Occasionally, it

may be necessary to settle for a less than desirable environment, as when needs are strategic or control is not feasible or poses an intolerable economic

burden. We have to be aware of variations in sus-ceptibility within the general population, and it should be emphasized that unusual susceptibility may be found in several subgroups in addition to

the fetus and child.

The medical profession must recognize that the

care of individual patients must be joined with con-cern for the general population. The wonders of recent medical progress must be used to the utmost to prevent or postpone coronary heart disease; to reduce the menu of doubtfully useful

pharmaco-logical agents; and, most of all, to identify adverse physiologic changes well before the appearance

of clinical disease.

I close with a restatement of the major thesis of my presentation: prevention of ill health in its

broadest sense should be the objective of environ-mental control. I am tempted to apologize for not limiting myself to the fetus and child and to chemi-cal pollutants. To do so, however, would somewhat

distort an overview by isolating a few among the many elements in the complex relationship of the various compartments of the environment and the population. Alternatively, I hope that I have not confused breadth with diffuseness.

Nature

and Sources

of Pollutants

Vaun A. NewiII, M.D.

From the Office of the Administrator, Environmental Protection Agency, Washington, D.C.

Air, water and soil have always been an

admix-ture of chemicals. Some of these chemicals are capable of profound effects on living systems with which they come into contact. Plant and animal life has always depended on natural

transforma-tions continuously recycling high quantities of chemical substances through the biosphere. Man too has been exposed to and depended upon many of these environmental chemicals since time

im-memorial. Adaptive change has been necessary.

However, a cognitive capability has distinguished man from other living things. This capability has permitted him to develop rapidly and to learn to

use available surrounding resources both to im-prove the quality of his life and at times to

jeopardize it.

In the late 1940s and 1950s, destructive air

pollution episodes occurred in the Meuse Valley, Donora, London, and New York. Thus, seeds of apprehension and fear of air pollution effects were

sown. Such feelings were rekindled by The Silent Spring, the mercury problem, and others.

It is my opinion that the doomsday approach

(

i.e., doomsday caused by environmental contami-nation per se

)

is wrong, and, by sane, sensible, and vigorous environmental control action we shall take care of the problems. Many requisites are neces-sary, one being an understanding of the nature

and sources of pollutants.

There are a number of ways to classify pollu-tants, such as by the medium polluted (air, water, or soil), the polluting chemical (organic, inorganic, etc.), the target organisms (people, plants, wild-life), the nature of effects (odors, respiratory

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1974;53;782

Pediatrics

Paul Kotin