Las entrevistas personales

Over the past decade, the environment has emerged as a major concern in health care. Water quality, for example, has become a health issue in some parts of the United States and is a critical health issue in developing nations throughout Asia and elsewhere.

Environmental threats to health are growing on a global scale, despite significant progress in some areas. Both outdoor and indoor air pollution contribute to respiratory diseases. Even in the richest nations, poor areas often bear heavy burdens of pollution

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and toxic-waste exposure. Deforestation and habitat destruction in the tropics are major factors in the emergence of new diseases. Depletion of the stratospheric ozone layer is causing a rise in the incidence of skin cancers worldwide, but especially in parts of the Southern Hemisphere.

Michael Lerner, as noted, urges a global dialogue on industrialization’s environmental impacts. As a wide-ranging example of these impacts, Lerner points to endocrine- disrupting chemicals,16 which are implicated in hypospadias,17 testicular cancer,

reported declines in male sperm counts in industrial nations, endometriosis and learning and behavior disorders in children.18

Global warming threatens to bring tropical diseases into northern latitudes and may cause more weather extremes, with storms and flooding leading to injuries and other health problems. Global warming is also likely to enlarge the “hot zones” which produce new strains of disease. Meanwhile, worsening problems of soil erosion, water scarcity and over-fishing could undermine the nutritional status of hundreds of millions of people in the decades ahead. Environmental problems can also contribute to economic

problems and outbreaks of conflict, which in turn pose threats to health.

As health increasingly becomes the focus of health care, health care providers whether conventional, complementary or alternativeultimately will see their work judged in relation to these broader issues. Many will seek to discover and invent ways in which they can make a contribution, through their patients and beyond, to

environmental issues.

Poverty

Poverty increasingly is being recognized as the largest risk factor for ill health in the United States. Poor living conditions, high-stress environments, poor nutrition and limited access to preventive health care all increase the risk of disease. For example, the health status of residents in parts of Washington, DC, is as poor as that in Haiti, with an overall life expectancy akin to that of the former Soviet republic of Turkmenistan— due primarily to negative social, economic and environmental health stresses like those mentioned above. Furthermore, infant mortality among poorer populations in cities like Washington, DC, is far higher than in most developing countries.19 _{The health care}

system, in seeking outcomes, ultimately will need to confront both these disparities and the poverty that is a major cause of them.

Medicaid combines federal and state funds to subsidize health care costs for the poor (along with disabled people and those in nursing homes who are not private-pay patients). Over recent decades most primary health care for the poor has come from physicians who accept Medicaid, as well as from community clinics staffed by public health workers and emergency rooms. Overuse of expensive emergency rooms, rising costs, few prevention programs and poor health outcomes for Medicaid recipients have led many states to move their Medicaid populations into managed care systems.

Some health care delivery systems are also working to provide poor communities with working models that improve health. For example, three HMOs in the Minneapolis region have joined to open a clinic in the local school of a poor region of the city, where they cover most of the students and their families as Medicaid recipients. Some of these experiments in providing care for the poor also provide access to CAAs. One

outstanding example is the King County Natural Medicine Clinic in Kent, Washington, where poor and uninsured people can receive integrated conventional and CAA services. (See Appendix C for details.)

As the poor are moved into systems of integrated care driven by outcomes, these systems are more likely to target poverty as an overarching source of ill health. Traditionally, CAAs have been excluded from Medicaid coverage. Now their practitioners need to become aware of syndromes like poverty and consider contributions they could make to alleviating them.

One approach, suggested by futurist Leland Kaiser, who is coaching a number of health care systems around the country, is for managed care systems to give 10% of their net income to the community for health promotion efforts, including efforts to reduce

poverty. And public health leaders, often with the participation and sometimes with the funding of their local health care providers, have created “healthy community” programs around the country to demonstrate that better health can be achieved in populations beset by poverty. (See “Population Health and the Healthy Cities/ Communities Movement,” below.)

Violence

Both homicide and suicide have increased in recent decades, making violence a significant cause of early death and disability. The link between economic status and violence is strong: poor populations are more likely to have higher rates of homicide, while wealthier groups have higher rates of suicide.20

The rise in violence has leveled off in the mid-1990s, however. Some experts consider this phenomenon temporary and forecast new increases in youth violence and a wave of “superpredators.” Alternatively violence could moderate as political attention turns to society’s failure to support at-risk children. This awareness has begun to move

resources back toward youth. Violence prevention programs, in particular, have demonstrated that both homicide and suicide rates can be lowered in at-risk populations; these programs are likely to expand over the coming years. Likewise, KiddieCare-Child Health Insurance Programs, federally and state-funded programs to provide health care coverage for poor or uninsured children, are growing in certain states. The states may expand funding of these programs or develop their own new programs.

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