Letters to the Editor  |   June 2012
Environmental Reform Needed to Decrease Costs of Health Care
Author Affiliations
  • Sarunas Sliesoraitis, DO, PharmD
    Winston Salem, North Carolina
Article Information
Cardiovascular Disorders / Obstetrics and Gynecology / Preventive Medicine / Professional Issues / Pulmonary Disorders
Letters to the Editor   |   June 2012
Environmental Reform Needed to Decrease Costs of Health Care
The Journal of the American Osteopathic Association, June 2012, Vol. 112, 326-383. doi:
The Journal of the American Osteopathic Association, June 2012, Vol. 112, 326-383. doi:
To the Editor: 
Another presidential election is here, and the candidates are busy discussing the future of our country. One of the topics of discussion is health care, including the need to decrease costs. The direct costs of health care are known and seem to be steadily rising. Among factors often cited as being associated with the high costs are innovations in medicine (eg, new medical technology, new medications), the increasing elderly population, and the underserved poor population. However, the association between environmental pollution and health care costs has not been thoroughly assessed. 
Water and air pollution have major impacts on our health. Although the US Environmental Protection Agency (EPA) continues efforts to limit exposure to pollutants, the health risks of pollutants remain high. Because air pollutants are most concentrated in the inner cities, I propose that they are a clinically significant problem for underserved populations. The effects of these pollutants could explain increased respiratory problems, poor cardiovascular outcomes, and more aggressive cancers among inner-city populations.1-6 The most effective ways to contain air pollution include the use of water and air filters at the sources (eg, automobiles, manufacturing and agricultural facilities). Rather than investing money in environmental monitoring of individual chemicals, the government would do better—in terms of both health benefits and saving money—to require effective filters for these sources. 
Given our current economic woes, every effort must be made to limit federal government spending—but without compromising the health of the US population. During the past decade, investment has increased on primary prevention and health maintenance in the United States, reflecting the recognition that such spending saves money on a long-term basis. 
In certain other countries, environmental influences on health care expenditures—which may not appear to be as investment worthy as primary prevention or health maintenance—are being examined.7,8 In a recent study by Haucke and Bruckner,8 the annual costs of environmental health disturbances in Germany were found to be 15 billion to 62 billion euros. These costs accounted for 4% to 15% of total health care expenditures in Germany, equivalent to 0.75% to 2% of that nation's gross domestic product.2 However, that study addressed only some of the known pollutants and their effects on known diseases, grossly underestimating the true effects of pollution on health. 
There are likely many harmful environmental pollutants that remain unknown. Studies investigating such elusive pollutants and their possible effects on health are needed. The United States, which has long been a champion in innovation, should take the lead in such research. 
Americans are exposed to several air pollutants every day, including ozone, particulate matter, nitrogen dioxide, sulfur dioxide, and volatile organic compounds. The effects of these substances on health are considered additive and, at times, synergistic in causing diseases, including cardiopulmonary diseases and cancers.9 Studying these chemicals individually may underestimate their actual impact on health. Thus, their effects should be evaluated in combination in future studies.9 
An estimated 800,000 premature deaths occur worldwide each year as a result of particulate matter pollution, according to the World Health Organization.10 This particulate matter exposure is linked to respiratory and cerebrovascular morbidity, as well as premature mortality.10 In the 1990s, amendments to the Clean Air Act provided new requirements for industry regarding particulates and other air pollutants.11 
In 1989, industry reports estimated that more than 2.7 billion pounds of toxic air pollutants were produced each year in the United States, accounting for at least 300 to 1500 cancer-related fatalities annually.11 Industry reports at that time listed more than 300 chemical compounds as potentially toxic or carcinogenic, and another 16 compounds were added to the list in 2010.11 As I previously suggested, the chemicals in particulate matter are more concentrated in inner cities as a result of high levels of vehicular traffic and the location of many industrial facilities. Recent studies have found that rates of premature births and asthma are higher, and cancer outcomes are worse, in inner cities than in other communities.1-6 Pollution likely plays a substantial role in health discrepancies between inner-city and suburban populations. Studies on health outcomes of environmental pollution are difficult to conduct because there are a multitude of chemical pollutants, some of which may have synergistic effects in causing diseases at concentrations lower than that mandated by the EPA. In addition, the duration of exposure needed to cause disease may be difficult to assess for many chemicals. Although further studies are necessary to focus on environmental causes of health problems, waiting for these studies should not delay reforms to improve the quality of our water and air. 
The worldwide health effects of air pollution are substantial, but so are the health effects of water pollution. In China, more than 190 million people become ill and more than 60,000 die each year as a result of water pollution.12 The government of China is planning to spend billions of dollars in attempts to clean up only a small portion of its contaminated waters.12 In the United States, more than 19.5 million illnesses per year have been attributed to water-borne pathogens.13 Several chemical compounds in water are associated with multiple human diseases, from elevated cholesterol levels to various cancers.14 
A cost-benefit analysis regarding public health and government regulation via the Safe Drinking Water Act was described by Raucher.15 In the study,15 potential estimated health risks per population were compared with costs needed to contain and monitor pollutants. Raucher15 concluded that if the cost of intervention is less than the anticipated benefits for a population, the chemical should be regulated at higher levels or not at all. However, the limitations of such a conservative regulatory approach include a lack of consideration of the concentrating effects of chemicals in the food chain, of the cumulative exposure to chemicals over several years, and of the health effects on more susceptible populations (eg, infants, pregnant women). Furthermore, most chemical compounds and other pollutants in water cannot be properly monitored or assessed at the present time because of inadequate knowledge regarding potentially harmful effects or high costs of implementing monitoring programs. 
Meanwhile, US oil corporations are attempting to gain access to drilling in the Arctic Ocean.16 An oil spill—including the release of such toxic compounds as benzene, toluene, ethylbenzene, and xylene—could be as devastating for Arctic communities and ecosystems as was the sinking of the Deepwater Horizon oil rig on Atlantic Ocean ecosystems in 2011. Another major problem with drilling in the Arctic is that there is no proven method of effectively cleaning up oil spills.16 Chemical pollution from the drill rigs, as well as particulate matter in associated air pollution, could threaten the health of the native populations and ecosystems of Alaska.16 Congressional efforts to permit oil drilling in the Arctic are among several ongoing legislative moves with high pollution potential. 
The health effects of pollution are real for millions of people worldwide, including in the United States. Pollution also affects the cost of health care in the United States. The presidential candidates seem to be well aware of the need for change in US energy policy, and both support increased efforts for such energy alternates as fuel cells in cars, solar power, and wind turbines. Until such alternatives become more widespread, there is an urgent need to develop air and water filters to decrease the industrial release of carcinogens and other harmful chemicals, and to develop other safer practices and controls for pollutants. The EPA needs increased funding to provide us with the protection we deserve. More widespread filter installation and advances in muffler design for automobiles could further benefit public health as we wait for more health-friendly cars to be developed. 
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