PREVENTtVE

MEDICINE

5,

1-3 (1976)

EDITORIAL

The Future of Environmental

Medicine’

THEODORE CARPER U. S. Department of Health, Education and Welfare Washington, D. C. 20201

It is customary, and in my opinion a bit glib, to use an occasion like this to toss off fine-sounding phrases about the frontiers of medical research and new breakthroughs in scientific knowledge. While all of that has a nice ring to it, it casts the field of environmental medicine in what I think is an inappropriate mold-or, in any case, it overlooks the fact that environmental medicine is one of the most ancient taproots of the art and science of health. Hippocrates counseled his students to study the Airs, Wu?ers and Places in which their patients lived, and his admonition is as important today as it was 2,500 years ago. In fact, I think the whole field of environmental medicine is taking on immensely increased importance for two reasons: First, it is abundantly clear that the major disease problems facing the United States and the other advanced nations of the world are, to one degree or another, caused, mediated, or aggravated by environmental factors. And second, I think it is equally clear that preventive, rather than curative, medicine offers the more promising approach to solution of most of these disease problems. Obviously, I don’t want to suggest that future advances in diagnosis and therapy will be of little consequence. Far from it. But it seems to me that as we learn more and more about the health implications of environmental contaminants, of behavioral and occupational patterns, and of genetic factors, we are forced to conclude that efforts aimed at prevention must occupy a very much larger place in health planning and in the delivery of health services than they have in the past. As some of you may know, we are now into the second generation of a planning process for the Public Health Service that attempts to identify the major issues in health and to determine how the Federal health program can most effectively address those issues in partnership with other levels of government, the private sector and, indeed, all the elements of the pluralistic American health enterprise. Some of you may have seen the basic planning document, the Forward Plan for Health, so-called because it attempts to take a 5-year look into the future of health issues and what will be required to face up to them. I mention this planning effort because one of its major themes is, I think, highly L Adapted from an address given at the dedication of New Research Facilities, New York University Medical Center Institute of Environmental Medicine, Sterling Forest, New York, September 22. 1975.

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germane to this dedication and the work of this Institute. The theme is prevention, and the attitude with which we in the Public Health Service approach this subject is that, despite some major knowledge gaps, enough is known about the links between numerous diseases and their antecedents to justify a special emphasis in primary preventive action now. The word primary is significant here. In our planning, we have followed a concept, certainly not of our own invention, that views prevention as a triumvirate in which primary prevention focuses on etiologic agents, secondary prevention focuses on early detection and treatment to cure or control the course of disease, and tertiary prevention involves efforts to ameliorate the seriousness or consequences of disease. By this scheme, secondary and tertiary prevention overlap what we usualIy think of as curative medicine, that is, the diagnosis and treatment of the sick. And, as all of us are acutely aware, providing care for sick people is an enormously expensive enterprise; it cost the American people well over $100 billion last year, and it is sure to cost a good deal more this year and next. Thus, as I have said, our planning theme in the area of prevention concerns primary prevention, which is intervening in the process of etiology. As such, it is concerned not with specific disease entities or groups of entities--cancer, heart disease, mental illness, and so forth-but rather with environmental and societal factors that do or may contribute to illness, for example, smoking. There is strong evidence that smoking-related diseases include cancer of the lung, lip, larynx, oral cavity, esophagus, bladder and other urinary organs; chronic bronchitis and emphysema; arteriosclerotic heart disease, including coronary artery disease; and certain noncoronary cardiovascular diseases. In view of the fact that this devastating indictment includes several of the leading causes of death in the United States and the world, a primary prevention effort directed at smoking could certainly be expected to have a major impact on health. Other examples are no less arresting. The use of alcohol by some 100 million Americans leads to these consequences: nine million people in this country are alcoholics or alcohol abusers: alcohol plays a role in half of all highway accident fatalities, half of all homicides, and one-third of all suicides. The societal cost of work absence, health and welfare services, and property damage resulting from the consumption of alcohol has been estimated at more than $15 billion a year. I could elaborate on other areas that are obviously ripe for primary prevention efforts: inadequate or excessive food consumption, motor vehicle accidents, environmental pollution, physical inactivity, occupational hazards, product safety, genetic factors, societal and psychological stress, and infectious diseases. In every one of these areas, our fund of knowledge, while by no means complete or satisfactory, is sufficient to permit significant progress through primary prevention. How to mount effective programs and how to assign responsibilities among public and private interests are knotty problems, to say the least. Even more difficult is figuring out what kind of efforts are feasible, and who should pay for them. But I think there can be little argument with the fundamental premise that prevention, specifically primary prevention, must occupy a much larger place in a national health strategy for the years to come.

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Although there are many opportunities to apply what we already know in the area of primary prevention, far too much of our present knowledge is limited to rather broad generalizations. The application of this kind of knowledge to primary preventive measures is of necessity rather diffuse and very often takes the form of puerile admonitions-“Don’t smoke,” “Drive carefully,” “Read the label,” “Get plenty of exercise,” and so forth. All of this is good advice, not to be scorned. But it scarcely represents the highest imaginable achievement of environmental medicine or primary preventive health practices. If the use of tobacco and alcohol cannot be eliminated from our culture-and I rather think they can’t-then what can research offer that will give society something to choose other than prohibition (which won’t work) or pious advice (which seems to have little effect)? Similarly, if modem technology involves the introduction of hundreds and thousands of potentially toxic materials into the environment-the workplace, the home, the city, indeed the whole biosphere-then is it not absolutely necessary that we develop the scientific information that will enable society at the very least to comprehend the hazards involved and, one would hope, to control or eliminate them? I can and will, here and in the Forward Plan and in other public places, advocate a greater concern, more attention, and a greater share of national resources for environmental research of a comparable nature even if it means we must curtail some of our enthusiasm for other important health research programs. It is society that must make such choices, in ignorance or in wisdom. The business of dealing with environmental insults cannot and should not be left to medicine or science. The decisions that will have to be made will require judgments that go far beyond the province or the expertise of medicine and the biomedical sciences. They will call for the sober insights of economists and anthropologists, of educators and philosophers, of statesmen and of ordinary citizens, each of whom will look to the work of this laboratory and others for at least a part of what they need to know. Environmental medicine surely is one of the wellsprings of the health sciences. I am confident that it will, in the years to come, have an increasingly large and beneficial impact on the health and wellbeing of the entire human population.

Editorial: The future of environmental medicine.

PREVENTtVE MEDICINE 5, 1-3 (1976) EDITORIAL The Future of Environmental Medicine’ THEODORE CARPER U. S. Department of Health, Education and Wel...
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