Principles of Environmental Health (EH202) Spring 2009 Molly Kile, ScD Doug Dockery, ScD .

Principles of Environmental HealthPrinciples of Environmental Health(EH202)(EH202)

Spring 2009

Molly Kile, ScDDoug Dockery, ScD

http://isites.harvard.edu/icb/icb.do?keyword=k37679&pageid=icb.page163101

Top Ten Causes of Death

Low-income countries % of deaths Middle-income countries % of

deaths High-income countries % of deaths

Lower respiratory infections

11.2 Stroke and other cerebrovascular disease

14.2 Coronary heart disease 16.3

Coronary heart disease 9.4 Coronary heart disease 13.9 Stroke & other cerebrovascular diseases

9.3

Diarrhoeal diseases 6.9 Chronic obstructive pulmonary disease

7.4 Trachea, bronchus, lung cancers

5.9

HIV/AIDS 5.7 Lower respiratory infection

3.8 Lower respiratory infections

3.8

Stroke & other cerebrovascular diseases

5.6 Trachea, bronchus, lung cancers

2.9 Chronic obstructive pulmonary disease

3.5

Chronic obstructive pulmonary disease

3.6 Road traffic accidents 2.8 Alzheimer and other dementias

3.4

Tuberculosis 3.5 Hypertensive heart disease

2.5 Colon and rectum cancers

3.3

Neonatal infections 3.4 Stomach cancer 2.2 Diabetes mellitus 2.8

Malaria 3.3 Tuberculosis 2.2 Breast cancer 2.0

Prematurity & low birth weight

3.2 Diabetes mellitus 2.1 Stomach cancer 1.8

World Health OrganizationFact sheet No 310 / November 2008

Dominican Rep.Life Expectancy 74.9 yrs

HaitiLife Expectancy 53.2 yrs

What is environmental health?

“At its most general, it encompasses the study of the health effects of all situation and risk factors outside of genetic factors.

In practice, most environmental health involves the study of exogenous factors over which the persons (or animals) affected have limited individual control.”

Tony Fletcher, London School of Hygiene

Underlying Principles of Public Health

• Disease does not occur at random

• Disease has causal and preventive factors

Behaviors

Genetics

Environment

Patterns of disease change as nations develop

• Infectious diseases decline in frequency and severity

• Life expectancy increases• Infant mortality declines• Chronic diseases become increasingly

prevalent

Age of Receding PandemicsAge of Receding PandemicsReduction of infectious diseases leads to Reduction of infectious diseases leads to

demographic transitiondemographic transition

Public Health Benefits FromWater Treatment in US

• Between 1900-1940– Mortality from diarrheal disease decreases from 140 20 per 100,000– Child mortality rates decrease from 130 60 per 1000 live births – Life expectancy at birth increased by 16 years– Cholera and typhoid fever virtually eliminated

• Cost-benefit analysis conducted by Cutler & Miller, 2005– 1:23 cost-benefit ratio – Every life saved cost $500* resulting in $11,500 gain– A 1% reduction in annual deaths corresponds to a social rate of return of $160

billion annually

* 2002 US$

Age of Man-made DiseasesChronic diseases are the principal causes

of illness, hospitalization and death inIndustrial nations

Increases in Neurological Disabilities

In Children:• ADHD, Autism, Mental Retardation• Affect 3-8% of all children

In Elderly:• Alzheimer’s • 3% ages 65 to 74• 50% ages 85+

Photograph by Peter Essick, Chemicals Within Us, National Geographic Oct 2006

Photograph by Peter Essick, Chemicals Within Us, National Geographic Oct 2006

Asthma Epidemic

NEJM 2006; 355, 2226

Age-Adjusted Testicular Cancer IncidenceAges 20-49, All Races

SEER Data, NCI

Evidence for Environmentally-Related Cancer

• Radiation• Radon• Arsenic• Aflatoxin• Solvents, especially benzene• Pesticide exposure

Most Chemicals Have Not Been Adequately Tested for Toxicity

• 80,000+ chemicals in commerce

• 2,863 produced or imported in quantities of 1 million pounds or more per year (HPV)

• No basic toxicity information is publicly available for about half of HPV chemicals

• Information on developmental toxicity is publicly available for fewer than 20% of HPV chemicals

EPA: Chemical Hazard Data Availability Study, 1998

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Change to Modern Environment• Sprawl•Traffic•Sedentary life style•Changing diet

Environment is a powerful determinant of health and disease

Attributable risk of morbidity and mortality associated with modifiable environmental factors:

24% of the disease burden1

23% of all deaths 2

Among children aged 0–14 as much as 36% of deaths 2

1 defined as healthy life years lost 2 defined as premature mortality

Source: WHO

Environmental risk factors and related diseases

Environmental Risk Factor Related diseases

Outdoor air pollution Respiratory infections, cardiopulmonary diseases, lung cancer

Indoor air pollution (solid fuel use) COPD, lower respiratory infections, lung cancer

Lead Mild mental retardation, cardiovascular disease

Water, sanitation, hygiene Diarrheal disease, trachoma, schistosomiasis, ascariasis, trichuriasis, hookworm

Climate change Diarrheal disease, malaria, unintentional injury, protein-energy malnutrition

Occupational factors (injuries, noise, carcinogens, airborne particulates, ergonomic stressors)

Unintentional injuries, hearing loss, cancers, asthma, COPD, low back pain

Comparative Risk Assessment, WHO 2002

DeathDeathor or

DisabilityDisabilityDiseaseDiseaseIndividualIndividual

The Clinical ApproachThe Clinical ApproachCare for the individual patientCare for the individual patient

Dade Moeller Environmental Health

DeathDeathor or

DisabilityDisabilityDiseaseDiseasePopulationPopulation

The Public Health ApproachThe Public Health ApproachCare for the communityCare for the community


DeathDeathor or

DisabilityDisabilityDiseaseDiseasePopulationPopulation

EnvironmentEnvironment

The Environmental Health ApproachThe Environmental Health Approach


Prevention Paradox"A preventive measure which brings much benefit to the population [yet] offers little to each participating individual" ... and thus there is poor motivation for the subject. ... In mass prevention each individual has usually only a small expectation of benefit, and this small benefit can easily be outweighed by a small risk’.

- Geoffrey Rose

Core ConceptsCore Concepts

All public health graduates should have an understanding of:

• Chemical, physical and biological nature of the environment

• Interactions of people with their living and working environment

• Concepts of exposure to potentially harmful environmental hazards

• Tools for assessing the risk posed by hazards

• Consequences of exposure in terms of toxicology and health effects

Date Topic

Mon, March 30Introduction to Environmental Health (Kile)

Weds, Apr 1Introduction to Hazard Identification, Evaluation and Control (Kile)

Mon, Apr 6Case 1: Can popcorn make you sick?Guest: Greg Wagner

Weds, Apr 8Case 2: Hazardous waste in Ashland, MAGuest: Suzanne Condon

Mon, Apr 13Introduction to Environmental Epidemiology (Dockery)

Weds, Apr 15Case 3: Ecological study of asthma in CyprusGuest: Diane Gold

Mon, Apr 20Killer Fog: Acute episodes of air pollution and mortality (Dockery)

Weds, Apr 22Case 4: Clean skies: regulating particulate matter in the USGuest: Frank Speizer

Mon, Apr 27Introduction to Risk Assessment (Kile)

Weds, Apr 29Case 5: Coal Power: What is the public health burden?Guest: Jonathon Levy

Mon, May 4Case 6: Phthalates: Should they be allowed in children’s toys?Guest: Russ Hauser

Weds, May 6Case 7: Arsenic in drinking water in the US Guest: Ronnie Levin

Mon, May 11Introduction to toxicology (Kile)

Weds, May 13Case 8: Lead: Should CDC lower the blood lead action level?Guest: David Bellinger

Mon, May 18Case 9: Does Bisphenol A pose a human health risk?Guest: Karin Michaels

Weds, May 20Presentations & Paper Due

Grade Assessment:Class participation – 25%Environmental Opinion Papers (4) – 25%Group research paper – 25%Group poster presentation – 25%

All material posted on website:http://isites.harvard.edu/icb/icb.do?keyword=k37679&pageid=icb.page163101

Principles of Environmental Health (EH202) Spring 2009 Molly Kile, ScD Doug Dockery, ScD .

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