By David A. Kindig, MD, PhD
The population health model that underpins the County Health Rankings and this blog group the factors that drive health outcomes into four categories:
- Health Behaviors
- Clinical Care
- Social and Economic Factors
- Physical Environment
While we have discussed many aspects of the first three, we have (so far) focused little attention on the Physical Environment. This is partly justified; our model attributes only 10% of the total factor score to this area. But there is also the sense that environmental issues – which we all intrinsically recognize as affecting health and quality of life -- often seem a bit remote or beyond our control.
Much credit should be given to the journal Health Affairs and the Kresge Foundation for devoting much of the May 2011 issue to this topic. As Editor Susan Dentzer writes in her introduction, “our Nation’s approach to health and health care is so famously siloed that we have long neglected the obvious: the environment plays a role in nearly 85% of all disease.”
It is impossible for this brief post to do justice to the issue’s impressive set of articles. If you only have time to dip into one, I’d recommend Linda Birnbaum and Paul Jung’s “From Endocrine Disruptors to Nanomaterials: Advancing Our Understanding of Environmental Health to Protect Public Health.” The article begins by contrasting the classic view of environmental science (which focused primarily on how chemicals involved in air and water pollution can impact health) with the current scope of environmental policy and research (which broadly addresses pharmaceuticals, nutrition, physical activity, noise, light, stress, infections, and climate change). The authors note the increasing attention being given to the built environment and underscore the contribution of man-made surroundings such as roads and housing to health behaviors and overall health. They also call attention to the importance of environmental justice as it relates to fair and equitable treatment in the development and enforcement of environmental laws, regulations and policies.
Other noteworthy articles from the issue address:
- The environmental effects on genes and gene expression and their impact on chronic disease susceptibility (Olden and colleagues)
- The link between air pollution around schools to health and student performance (Mohai and colleagues)
- The cost ($77 billion) of environmental disease in children (Trasande and Liu)
- How Health Impact Assessments (HIA) can and are being used in urban planning and land use policies at all levels of government (Wernham)
Finally, Morell-Frosch and colleagues address the policy challenge of how to “evaluate and characterize the combined health effects of multiple environmental and social stressors on vulnerable populations.” In this article, the term ”environment” is used holistically, combining a more classic understanding of physical environment with social and economic factors. While I think the distinction made between these factors in our model is important, I also appreciate the authors’ assertion that critical interactions exist among them. In particular, they note that “extrinsic social vulnerability factors at the individual and community levels – such as race, sex, and socioeconomic status – may amplify the adverse effects of environmental hazards and contribute to health disparities.”
As we continue to work toward “health in all policies” approaches, we can’t afford to ignore the physical environment. I wouldn’t be surprised if future population health models give it greater emphasis, especially as our understanding of climate change and its interactions with other factor areas expands.
David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.
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