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The Role of the Environment in Health Outcomes

Joseph S. Alpert

Joseph S. Alpert, MD

Disparities in health outcomes in the United States and other high-income countries have been widely discussed in recent years.1, 2, 3, 4 Many reasons have been suggested for these disparities, including the income levels of individuals, their educational attainment and employment status, as well as a variety of neighborhood socioeconomic and environmental factors. During my many years of inpatient and outpatient attending, I have been convinced of the veracity of these observations. Many patients cared for at the inner-city university hospitals where I have worked have low income and educational levels and reside in areas that are rife with the threat of violence. These patients have limited access to stores selling healthy foods such as fresh fruits and vegetables, and they live in rural or urban zones often characterized by high levels of environmental pollution. Finally, the quality of the schools in these neighborhoods is often substandard.

Given this situation, it is not surprising that individuals living in communities exhibiting these negative qualities would find it difficult to follow the various lifestyle factors known from years of clinical and epidemiological investigation to increase longevity (eg, healthy diet, regular exercise, and freedom from air and environmental pollutants). Add to this picture the mental stress associated with living in neighborhoods with heightened levels of violence, and the result is an increased expression of many acute and chronic degenerative diseases, including a variety of cardiovascular illnesses and cancer. I have also noted that as a result of the high cost of quality dental care, there is a very high level of poor dental health in patients living in socioeconomically challenged neighborhoods. Poor oral hygiene increases levels of systemic inflammation and thereby increases the risk for both cardiovascular disease and cancer.

Despite the presence of community healthcare centers in socioeconomically depressed zones in the United States, health outcomes continue to be substantially reduced compared with results from more affluent sections of the same city.1 Patients often present with advanced expression of disease, which is difficult and expensive to control. Over the years, I have been convinced that, despite heroic efforts on the part of the doctors, nurses, and ancillary healthcare personnel in community health centers in areas of reduced socioeconomic and educational status, outcomes for a variety of illnesses are worse than in more privileged neighborhoods. I do not believe that the sole answer to improving health outcomes in these challenged zones is expanded numbers of community healthcare centers. Health outcomes will remain poor if the socioeconomic and educational aspects of these neighborhoods remain substandard. Therefore, I have some suggestions for approaches to improve the currently evident disparities in health in our country.

First, let me state that none of the interventions listed below are inexpensive. They will all require substantial levels of funding and intense community involvement. However, if the general level of health improves in these areas, then it is reasonable to assume that, with time, the overall health costs of these communities will decline. I also believe that police and fire control expenses will be reduced as the community environment mends. I view the situation as an example of “We can pay now or we can pay later” because, with these interventions, it is likely that individuals living in these neighborhoods will have a lessened likelihood of developing premature serious health conditions. Increased healthcare access alone will not improve the public health situation in these challenged neighborhoods.

The first intervention that I would suggest is to work with community leaders in these areas to develop short- and long-term strategic plans and funding for improving a number of physical and psychological aspects of these neighborhoods. For example, I would initiate a major program to better the physical characteristics of the schools in these depressed areas (many of which lack adequate heating and cooling systems and basic educational materials and equipment), I would start with modernized and efficient heating and cooling systems, better school furniture, and abundant teaching materials. Along with making physical improvements, I would markedly increase salaries for all faculty working at these schools. This would hopefully attract a new cadre of young, idealistic, and enthusiastic teachers. Additionally, I would augment school security with additional personnel and screening equipment similar to that used in our airports. And finally, I would markedly increase the level of discipline in the schools, perhaps even implementing a dress code for students and faculty. These interventions in the educational system of the community would not result in immediate improvement in employment or the overall quality of life in these distressed neighborhoods, but my hypothesis is that healthy lifestyles and employment opportunities in these communities will improve as the level and quality of the education available improves. Bettering educational settings will not result in an instant reduction in disease manifestation. I believe that this intervention is a long-term solution, and it will probably take some years before beneficial effects are observed.

Another important intervention would be to make substantial investments to improve housing and other infrastructure in these challenged communities. Such investments would include road and sidewalk repair; renovations to sewage, water, and power systems; removal of trash and environmental pollutants; and the rehabilitation of housing. Many of these communities suffer from industrial pollution left over from previous, less enlightened eras. The Environmental Protection Agency has been progressively rehabilitating and cleaning these sites, and this work must continue, with emphasis on distressed urban Superfund sites. The association between industrial pollution and human disease has long been recognized.5, 6

A variety of financial inducements could be offered to accelerate housing repairs and rehabilitation, but initially funding would have to come from public coffers. In addition, I would suggest that government leaders work with local community leaders and local and national business leaders to bring new stores and entertainment venues into these distressed communities in a manner similar to that done so successfully by Magic Johnson in Los Angeles, California.7 Particularly important would be to bring in supermarkets offering a wide variety of foods alongside encouragement for shoppers to make healthy food choices. I would hope that repairs to the infrastructure of these communities and the arrival of new businesses would result in increased employment for local residents, thereby elevating the economic resources of individuals living and working in these areas.

I know that all of this sounds Pollyanna in its scope. But as mentioned earlier, we can pay now or let our children and grandchildren pay later when the economic burden generated by increasing healthcare, crime, and fire control costs in these challenged zones results in an ever-increasing financial burden for our country.

As always, I am happy to hear responses to my suggestions from readers at

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-Joseph S. Alpert, MD

This article originally appeared in the October issue of The American Journal of Medicine.

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