The Physical Environment As A Determinant Of Health

At least since the time of Hippocrates' essay "Air, Water and Places," written in 400 B.C.E., humans have been aware of the many connections between health and the environment. Improved water, food, and milk sanitation, reduced physical crowding, improved nutrition, and central heating with cleaner fuels were the developments most responsible for the great advances in public health achieved during the twentieth century. These advantages of a developed nation are taken for granted, but in fact, they could deteriorate without adequate support of the governmental public health infrastructure.

Environmental health problems, historically local in their effects and short in duration, have changed dramatically within the last 25 years. Today's problems are also persistent and global. Together, global warming, population growth, habitat destruction, loss of green space, and resource depletion have produced a widely acknowledged environmental crisis (NRC, 1999). These long-term environmental problems are not amenable to quick technical fixes, and their resolution will require community and societal engagement. At the local and community levels, environmental issues are equally complex and are also related to a range of socioeconomic factors. A brief look at some of the evidence on environmental determinants of health may help shed some light on why health is not equally shared.

The importance of "place" to health status became increasingly clear in the last decades of the twentieth century. The places in which people work and live have an enormous impact on their health. The characteristics of place include the social and economic environments, as well as the natural environment (e.g., air, water) and the built environment, which may include transportation, buildings, green spaces, roads, and other infrastructure (IOM, 2001b). Environmental hazards in workplaces and communities may range from tobacco smoke to pesticides to toxic housing. Rural areas may present increased health risks from pesticides and other environmental exposures, whereas some environmental threats to health can occur because of urban living conditions.

More than three-quarters of Americans live in urban areas (Bureau of the Census, 1993). Although rural Americans experience certain health-related disadvantages (e.g., health care access issues due to transportation and availability) (Slifkin et al., 2000; NCHS, 2001), some of the health effects of the inner city (i.e., decay and crime) are often dramatic and may be related to broader social issues. The "urban health penalty"—the "greater prevalence of a large number of health problems and risk factors in cities than in suburbs and rural areas" (Leviton et al., 2000: 863)—has been frequently discussed and studied (Lawrence, 1999; Freudenberg, 2000; Geronimus, 2000). A variety of political, socioeconomic, and environmental factors shape the health status of cities and their residents by influencing "health behaviors such as exercise, diet, sexual behavior, alcohol and substance use" (Freudenberg, 2000: 837). The negative environmental aspects of urban living—toxic buildings, proximity to industrial parks, and a lack of parks or green spaces, among others—likely affect those who are already at an economic and social disadvantage because of the concentration of such negative aspects in specific pockets of poverty and deprivation (Lawrence, 1999; Maantay, 2001; Williams and Collins, 2001). Urban dwellers may experience higher levels of air pollution, which is associated with higher levels of cardiovascular and respiratory disease (Hoek et al., 2001; Ibald-Mulli et al., 2001; Peters et al., 2001). People who live in aging buildings and in crowded and unsanitary conditions may also experience increased levels of lead in their blood, as well as asthma and allergies (Pertowski, 1994; Pew Environmental Health Commission, 2000; CDC, 2001a). These examples illustrate some of the profound effects of the physical environment on health. The places where people live may expose them to harmful factors.

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