Book Review

Critical Condition: Human Health and the Environment

N Engl J Med 1993; 329:1749-1750December 2, 1993

Article

Critical Condition: Human Health and the Environment
Edited by Eric Chivian, Michael McCally, Howard Hu, and Andrew Haines. 227 pp., illustrated. Cambridge, Mass., MIT Press, 1993. $15.95. ISBN: 0-262-53118-6

During the past 30 years, the public perception of the relations between the environment and health has changed considerably. There is a greater awareness that human beings are but one part of a complicated ecologic system that society can influence in many ways, both to our benefit and to our detriment. In response to this expanded awareness, major changes have taken place in both the public and private sectors. Legislation, such as the National Environmental Protection Act and the Clean Air and Clean Water Acts, has been passed, and organizations at every level of government have been created to promulgate and enforce regulations that concern environmental protection. The annual cost of complying with these regulations, according to the Environmental Protection Agency, is currently estimated to be $130 billion and is expected to rise from year to year (report EPA-230-12-90-084, December 1990). Most of these expenditures have been made to protect human health.

Reflecting widespread popular interest in the subject, the print and electronic media give considerable attention to environmental matters, but the coverage is frequently inaccurate and sensationalized. This is particularly true with respect to the effects on health of trace substances in air, water, and food. Patients sometimes ask their physicians for advice about such things as exposure to asbestos in schools or to radon in the home, reports of carcinogens in food, or the proposed siting of incinerators. Physicians need a balanced source of information about environmental matters, and this book was published to serve that purpose. The chapters deal with the contamination of air, water, and food; occupational health; radiation; the environmental effects of war; loss of stratospheric ozone; climatic change; species extinction; and the effects of unrestrained population growth. Of the 13 contributors, all but 2 are physicians. Regrettably, the book will not serve its intended purpose. There are many factual errors, and most of the chapters tend to be biased and sensationalized.

Examples of factual errors abound. The chapter on occupational health includes a four-page list of “sentinel health events” that contains several inaccuracies. Beryllium disease is incorrectly listed as a condition seen in nuclear-reactor workers. Ionizing radiation is listed as a cause of aplastic anemia, which it is not, whereas benzene, which is known to be causally related to aplastic anemia, is not included in the list. Although osteogenic sarcoma was a tragic consequence of the misuse of radium early in this century, radium was replaced 40 years ago by inexpensive and less hazardous substitutes. Radium should therefore not be included as a carcinogen of which contemporary physicians should be aware.

Citing an obscure reference, the authors state that up to 38 percent of all cancers in the United States result from carcinogens in the workplace. In 1981 the Congressional Office of Technological Assessment commissioned two British epidemiologists, Sir Richard Doll and Richard Peto, to study this question, and they reported that 4 percent was their best estimate (Journal of the National Cancer Institute 1981; 66:1193-1308). It is inexplicable that their research, by far the most authoritative and comprehensive to date, is not cited.

Reflecting the current bias in the popular attitude toward environmental influences on health, this book is mainly concerned with the effects of trace substances but fails to deal with more traditional matters of concern to public health officials. An investment in improved services at community health centers improves the quality of the environment and is likely to be far more beneficial than costly reductions in the amounts of trace substances in food, water, or air. Not that we should neglect the latter approach, but we must be careful not to go past the point of diminishing returns. Most of the $130 billion spent each year for environmental protection is intended to be beneficial to public health, but the benefits are marginal and not readily demonstrable in the national statistics on morbidity and mortality. Public health officials expect much greater returns on health investments. Think of what the effect might be on the 400,000 premature tobacco-related deaths that occur each year if even a small fraction of this money were spent on antismoking campaigns or on increasing the availability of health services for disadvantaged people.

Polls have shown repeatedly that there is overwhelming support for the expenditures associated with environmental protection, but the public is confused and badly misinformed by the conflicting statements that appear daily in the media. There is a need for a balanced presentation of the facts to assist physicians in dealing with their patients; this book falls far short of the mark.

Merril Eisenbud, Sc.D.
Duke University Medical Center, Durham, NC 27710

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