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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary Summary* Throughout much of its history, the United States was predominantly a rural society. The need to provide sustenance resulted in many people settling in areas where food could be raised for their families. Over the past century, however, a quiet shift from a rural to an urban society occurred, such that by 1920, for the first time, more members of our society lived in urban regions than in rural ones. This was made possible by changing agricultural practices. No longer must individuals raise their own food, and the number of person-hours and acreage required to produce food has steadily been decreasing because of technological advances, according to Roundtable member James Merchant of the University of Iowa. The Institute of Medicine’s Roundtable on Environmental Health Science, Research, and Medicine held a regional workshop at the University of Iowa on November 29 and 30, 2004, to look at rural environmental health issues. Iowa, with its expanse of rural land area, growing agribusiness, aging population, and increasing immigrant population, provided an opportunity to explore environmental health in a region of the country that is not as densely populated. As many workshop participants agreed, the shifting agricultural practices as the country progresses from family operations to large-scale corporate farms will have impacts on environmental health. WHAT IS ENVIRONMENTAL HEALTH? According to the World Health Organization (WHO), environmental health is defined as “those aspects of human health, including quality of life, that are * The views expressed here do not necessarily reflect the views of the Institute of Medicine, the Roundtable, or its sponsors. This chapter was prepared by staff from the transcript of the meeting. The discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics.
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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary determined by interactions with physical, chemical, biological and social factors in the environment” (WHO, 1986). Thus, environmental health focuses on the quality of life and not simply on the absence of disease, and all the factors that contribute to environmental health, including the environment, are assessed when the environmental health of a population or region is evaluated. The definition of environmental health has evolved with research; therefore, the goals of environmental health should be to establish and maintain a healthy environment, to promote an environment that improves well-being both in function and in structure, and to allow the environment to be sustainable, said Roundtable member Donald Mattison of the National Institutes of Health. Rural America faces challenges such as poverty and isolation, limited access to health care, increasing prevalence of obesity, exposure to hazardous air and water pollutants, farm injuries, and a shrinking demographic. WHAT IS RURAL? Although the definition of “rural” is sometimes subjective, rural areas bring to mind small towns and sparsely populated areas. This definition may vary from one state to another, but in essence it refers to villages, cities, towns, or boroughs and excludes the rural portions of extended cities. According to the U.S. Census Bureau, rural is defined as not being urban, and urban, in turn, is any place incorporated with 2,500 or more individuals. In Iowa, “rural” is exemplified by grain bins, farmland adjacent to housing, small towns, and country roads, said Peter Thorne of the University of Iowa. The percentage of rural dwellers varies greatly by state. For example, Vermont has the highest proportion of rural residents—almost 62 percent—whereas California and Nevada each have less than 10 percent (U.S. Census Bureau, 2000a). However, the percentage for Nevada can be misleading because there are vast areas of open country in Nevada consisting of sagebrush and desert where no people live. In contrast, Iowa’s rural areas have a small town almost every 10 miles. Thus, the meaning of “rural” for Iowa and Nevada is very different, noted Sandra Charvat Burke of Iowa State University. The demographics of the populations in rural areas of the United States also differ. In Iowa, many counties have had and continue to have declining populations, but other nonmetropolitan areas in the western part of the country are growing rapidly. Burke noted that as the population increases, the health care demands in those areas differ from those in areas experiencing population declines. Families in rural areas often may not have access to health care because they are self-employed on their farms or in some other business that do not have a health plan provided by an employer. Other socioeconomic aspects, such as education, differentiate metropolitan and nonmetropolitan areas. Metropolitan areas tend to have more people who have completed high school. The difference is even higher in terms of the pro-
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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary portions of people with a college education. Higher levels of education and higher rates of high school completion, in turn, correlate with a lower prevalence of poverty, less unemployment, and greater access to health care. Nonmetropolitan areas tend to have a higher proportion of people older than 65 years of age. One of the reasons for this disparity is that nonmetropolitan areas have had more outmigration of youth, said Burke. Nonmetropolitan areas tend to have less ethnic diversity and smaller minority populations—that is, any race other than white—than metropolitan areas, although in this regard there are major differences among nonmetropolitan areas. Rural Mosaic in America In Iowa, as in much of the Midwest, African Americans live mostly in metropolitan areas. Historically, Hispanics did not settle in the Midwest. In the central region of the United States, many counties had populations that were less than 1 percent Hispanic as recently as 1990. By 2000, however, the change in some areas was dramatic, largely because of opportunities for employment in food-processing industries, said John-Paul Chaisson-Cardenas of the Iowa Division of Latino Affairs. Almost all Iowa counties had growth in the Latino population between 1990 and 2000. As a result, a culture and a language different from those of the predominantly white population are becoming part of Iowa and will influence Iowa’s future development, said Chaisson-Cardenas. With the growth in the Latino population comes a subpopulation with limited proficiency in English. Latinos are disproportionately affected in many areas of health; 50 percent of Iowa’s Latinos do not have health insurance, and they are much more likely than other groups to become diabetic (Iowa Commission, 2004). Young Latino women tend not to receive the prenatal care that they need. The result is an environment in which the institutions created to serve other people are not responding adequately to the growth of the new population, noted Chaisson-Cardenas. One significant reason for the unresponsiveness of the health care system to the needs of Latinos is a lack of “cultural competence,” defined as the ability of a professional to be effective with a client who is of a cultural background different from his or her own, said Chaisson-Cardenas. HEALTH AND THE RURAL ENVIRONMENT Significant differences exist between rural and urban populations and their health care delivery systems. When actions at the local rural community health level are planned or information on national policy decisions with implications for rural health is sought, it is important to understand the unique characteristics of rural communities, their environments, and the conditions under which health
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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary care is delivered to rural populations. This means the consideration of factors as varied as population density, the remoteness of a community from large urban areas, the characteristics of the local workforce—and, even more specifically, the characteristics of the rural health care workforce—and the cultural norms of the region, all of which influence health and health problems that rural communities face, said Mary Wakefield of the University of North Dakota. Mental health is a facet of health that undergirds the vitality of all rural life, noted Cecilia Arnold of the Ligutti Rural Community Support Program. The problems associated with mental health in rural areas have many facets. The percentage of working poor in rural areas is higher than that in urban areas, and, in general, rural areas have more poverty. Services like law enforcement, emergency medical services, domestic violence shelters, and mental health services have diminished in rural areas, whereas social problems, such as the scourge of methamphetamine use, have taken hold. The culture of rural states such as Iowa tends to be one of self-sufficiency, traditional values, and patriarchal social structures, noted Arnold. Rural residents represent several generations who embrace these and other cultural characteristics with varying levels of intensity. The population of Iowa is now more diverse as a result of the immigration and migration of people from many cultures, who face discrimination along with the challenges of assimilation. All these facets of rural life point to the challenges that can distress individuals, families, and communities and act as a catalyst to mental health problems, noted Arnold. Farming Practices and Rural Health Today’s agricultural farming practices are under a lot of scrutiny, and World Trade Organization negotiations that will have major implications for U.S. agricultural production and production policy on cotton, sugar, and possibly rice are under way. Therefore, systems that minimize ecological impacts and that transition agricultural practice to a new phase that features more renewable energy transformations must be the target of agroecologists and agricultural scientists, said Ricardo Salvador of Iowa State University. Some agricultural production practices have direct health effects, said Mark Ritchie of the Institute of Agricultural and Trade Policy. For example, an estimated 70 percent of antibiotics are used for nontherapeutic purposes in intensive livestock production; therefore, the risk of contracting an antibiotic-resistant infection could increase for somebody working in an intensive hog-rearing barn. Other farming practices have more indirect effects on health, noted Ritchie, but they affect the environment—the air, the water, and the soil. Furthermore, production practices can affect food quality and have other effects brought about by processing and consumption. For example, workers in meatpacking plants can be infected with tuberculosis as a result of contact with animals.
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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary Initiatives for Improving Rural Health As mentioned above, air and water quality have improved in rural America, but changes are still needed. Agriculture is a regulated industry now, and farmers are recognizing that they need incentives that will pay for good environmental practices in the future. Alliant Energy incentives were discussed at the workshop as one of the examples of cost-effective conservation measures. The company offers a performance contracting initiative to its customers in Iowa and financial incentives for its larger industrial customers to put energy-saving and energy efficiency devices in place. These incentives are paid for by using the savings from reductions in energy use. Electric utilities, regulators, legislators, and customers must continue to show initiative to improve air quality in the future, said Erroll Davis, chief executive officer of Alliant Energy. Rural community health can be strengthened with a strong commitment to a new energy economy based on renewable energy and energy efficiency, said Michael Noble of Minnesotans for Energy-Efficient Economy. The Nebraska Environmental Partnerships (NEP) Program provides environmental health assistance to small communities (those with populations greater than 1,000) that are thought to be out of compliance with state or federal health regulations. The program was created to manage the health concerns that have emerged as a result of complex environmental regulations, limited financial resources, an aging infrastructure, an aging population, and decreasing populations in rural communities. This program works with the towns as a nonregulatory program in a regulatory manner but using a community-based team process that assists local governments with assessing and solving local public health and environmental challenges, and the towns know and respect that, said Jackie Stumpff of NEP. The team helps small communities work through environmental health problems by providing resources and technical assistance, at the request and convenience of local leaders. The Agricultural Health Study (AHS) was designed to study a wide range of health effects of agricultural exposures in farmers and their families. It is a collaborative venture between the National Cancer Institute, the National Institute of Environmental Health Sciences, the U.S. Environmental Protection Agency, and the National Institute of Occupational Safety and Health (National Institute of Environmental Health Sciences, National Cancer Institute, U.S. Environmental Protection Agency, 1993). The exposures studied by AHS include those to pesticides, animals, diesel, and solvents. The health effects considered by the study include cancer, respiratory health, reproductive outcomes, and neurological disease. In the future, AHS plans to analyze data on specific chemicals and cancer, Parkinson’s disease, respiratory disease, rheumatoid arthritis, and the overall rate of mortality among the members of the cohort over time, said Jane Hoppin of the National Institute of Environmental Health Sciences.
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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary 2002 Farm Bill The 2002 Farm Bill covers some environmental health aspects. Senator Tom Harkin of Iowa, who had a brief tenure as chair of the Senate Agriculture Committee, introduced various new ideas and programs into the bill. Eileen Huntoon of Senator Harkin’s office provided the Roundtable with an overview of Senator Harkin’s contribution to the 2002 Farm Bill. Aside from funding existing programs, his vision was to add new value-added rural development programs and, for the first time ever, to have renewable energy be part of the Farm Bill. The new Farm Bill included an expansion of land and water conservation programs, said Huntoon. Other grant programs added to the Farm Bill focused on biological product-based energy: ethanol, biodiesel, biomass research and development, and biorefinery development. The Farm Bill is evaluating whether second-generation biorefineries that would produce ethanol biodiesel should be financed. Despite all the efforts and dreams that went into the Farm Bill, some major challenges remain, said Huntoon. Some of the farm programs were not funded, some were reduced, and some were eliminated. Nevertheless, some solid ideas for development of the next Farm Bill, which will be legislated in 2007, have been laid out. Huntoon pointed out that a strong constituency of individuals from rural areas for rural development and policy issues does not exist. There is no broad collaboration among groups from rural areas, and there is a need to develop such a strong rural constituency of many groups and communities working together. NATURAL ENVIRONMENT IN RURAL AMERICA Agriculture provides an economic base for Iowa residents, but at the same time it also has significant environmental impacts. People once had a good connection to their land, and in rural America they still do, but the land and the water are changing, said Jerald Schnoor of the University of Iowa. When driving around the middle of the United States and looking at farms, one would think that they do not appear much different from they way they did 40 or 60 years ago. Although changes are not obvious by looking at the countryside, U.S. agriculture has undergone a dramatic transformation over the past century-and-a-half, said Neil Harl of Iowa State University. The change started quite early after settlement, beginning in about 1850. When the land was tilled for farming, it became vulnerable to soil and water erosion. In addition, natural habitat has been destroyed to make way for agricultural development. In fact, Iowa is the most ecologically altered state in the entire union: since 1850 it has lost 99 percent of its prairies, 95 percent of its wetlands have been drained, and 75 percent of its forests have been cut (Iowa Natural Heritage Foundation, 2002). Since 1935 there has been an unbroken succession of reductions in the number of farms in the United States and increas-
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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary es in the average size of farms. In 1900, the average size of a farm was 118 acres. This average increased to 156 acres by 1925, 282 acres in 1969, and 352 acres at present (USDA, KASS, 2003). Water and Air Quality In Iowa, seven tons of soil is lost per acre, and each acre yields about 150 bushels of corn, said Jerald Schnoor of the University of Iowa (NRC, 1986). Consequently, for every pound of corn produced, the land loses approximately two pounds of topsoil sediment and farmers are actually “exporting” two pounds of soil annually for every pound of corn harvested. On the basis of this calculation, Iowa has lost approximately half of its topsoil since presettlement times. These extensive changes in land cover and land use cause changes in water quality through runoff, asserted Schnoor. Increasing nitrate concentrations in the Iowa River, which feeds into the Mississippi River, mirror the applications of nitrogen to Iowa farmland. Nitrogen flows from the Mississippi River to the Gulf of Mexico, and currents pull the nutrients west from the mouth of the river, causing hypoxia—low oxygen conditions, or less than 2 milligrams of nutrients per liter—along the U.S. coast in the Gulf of Mexico, said Schnoor. These conditions affect the shrimping industry and the livelihoods of people who make use of the water and the coastal margins in Louisiana and the Gulf Coast. Rural residents are also affected by water quality because they are drinking water from their own wells, which are not subject to the Safe Drinking Water Act, noted Schnoor. Shallow groundwater wells less than 50 feet deep are commonly contaminated with pesticides, nutrients, industrial chemicals, and various volatile organic carbon compounds (USGS, NAWQA, 2005). Among other chemicals that have an effect on people who live in rural areas are polybrominated diphenyl ethers, which accumulate in breast milk; polychlorinated biphenyls (PCBs); and mercury. PCBs and mercury are neurobehavioral agents that especially affect unborn and young children. Air quality has generally improved in rural America because of the Clean Air Act, noted Schnoor, but challenges remain, such as occupational exposures to dust, windblown soil, ammonia, pesticides (especially those from animal feeding operations), endotoxins, mycotoxins, animal dander, and hydrogen sulfite. THE BUILT ENVIRONMENT AND HEALTH IN RURAL AREAS Urban encroachment in rural areas creates health problems and issues such as health care access issues, air pollution, water pollution, water availability, and other concerns, said Bernard Goldstein of the University of Pittsburgh. Other health problems due to urban sprawl include heat islands, global climate change, noise, a lack of availability of healthy food choices, public health workforce
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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary issues, and safety issues such as crime and traffic. When a green area is replaced by asphalt, a bigger heat island results in changes in local temperatures and ecosystems. Heat island and temperature changes also affect the rural areas that are near the suburbs, noted Goldstein. Attempts to try to understand the impact of urban sprawl on the public health workforce are beginning. The workforce is decreasing and the resources are diminishing at a time when the public health system is encountering some of its greatest challenges, said Goldstein. Furthermore, a large turnover of the public health workforce is anticipated because of retirement. The impact is different in different areas, but often the public health workforce in the rapidly growing suburban areas has less expertise because the budget for the public health infrastructure cannot keep up with the growth, noted Goldstein. Iowa has housing issues both in rural areas and in the inner cities of urban areas. One of the distinguishing features of Iowa’s housing, particularly compared with the housing features of its neighbors, is the age of its housing. Although age is not the only thing that describes housing, it is a surrogate for many of the problems associated with housing, said Rita Gergely of the Iowa Department of Public Health. Abandoned housing can become an environmental health and safety issue when, for instance, children play near houses that are in imminent danger of collapse. Abandoned buildings in remote rural areas are perfect places for methamphetamine labs, said Gergely. Also, people are often concerned that abandoned houses are a reservoir for rodents and insects that can travel to nearby homes, particularly in urban areas. Environmental health issues in the context of occupied housing include lead poisoning in children, carbon monoxide, fire and electrical hazards, water damage and mold, private wastewater treatment systems, the lack of rental housing codes, and improper sanitary conditions. Water damage and mold in homes result from flooding, leaking roofs and windows, plumbing problems, excess humidity in bathrooms and kitchens, and wet basements. These are more likely to be found in older and poorly maintained homes, noted Gergely, and can cause health problems in susceptible people. The awareness that these conditions can lead to the growth of mold, which can be a significant environmental health issue, is increasing. As in the rest of the United States, obesity is a growing health concern in Iowa. The state has the 17th highest rate of adult obesity in the nation (23.9 percent) and the 10th highest rate of overweight among low-income children ages 2 to 5 years (13.6 percent) (Trust for America’s Health, 2005). The built environment, such as residential areas, the grounds, and sidewalks, has a direct impact on obesity, because the physical environment either encourages or discourages people to exercise, noted John Lowe of the University of Iowa. There is no funding within the communities to fix the sidewalks that are deteriorating in most counties in Iowa. Socioeconomic factors, such as personal or household income, material deprivation, unemployment, a lifetime history of poverty, asset
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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary ownership, and the receipt of welfare, affect one’s physical activity as well, said Lowe. The Roundtable addressed rural environmental health issues in an interactive way, with those attending the discussions participating in a free exchange of views on how to rebuild the unity of health and the environment in rural America. Although the Roundtable defines environmental health in broad terms, not all aspects of environmental health could be discussed in their entirety during the limited time of the meeting. This workshop summary captures the presentations and discussions by the speakers and participants, who identified areas in which additional research was needed, the processes by which changes could occur, and the gaps in our knowledge.
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Representative terms from entire chapter: