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Environment White Paper (PDF - 178KB)

Created on May 9, 2011

15 Submitted Comments on Environment

This white paper begins with a strong statement about the role of social factors and issues that require multilevel approaches and excellent discussion of methodological challenges and opportunities. I was dismayed to find that the description of NICHD left out the demographic work. The report addresses the influence individuals may have about the environment to which they are exposed and how they make choices that influence their exposure. It would be useful to understand what people know about environmental risks when they make those choices, and the extent to which they have choices. If the only affordable housing is near a toxic site, how do we interpret 'choice'? Having seen very poor families in India living on asbestos mines it is not clear that they had either much 'choice' or much information about risks. The report could have taken a step back to ask more questions about the social, economic and political environment that leads to increased risks for some. I applaud the balanced discussion of methods. It is not clear that it is only ethical considerations that keep social scientists from employing RCTs. RCTs are an excellent tool for asking some types of questions, but not all. The discussion of multidisciplinary teams is excellent. In addition to cross training, I would add that making available data sets that are of equal interest to different communities would provide concrete tools to bring teams together. If data provide sufficient social and economic data along with appropriate biological measures, teams will be formed to mine them.

Submitted by wendy Baldwin on May 12, 2011 at 4:14 PM

In their 2011 report, the WHO estimates that pneumonia and diarrheal diseases are the two biggest killers of children less than 5 years old, accounting for 18% and 15% of all deaths respectively in 2008. There were over 5.3 million deaths attributable to infectious diseases in children less than 15 years old in the world in 2008. Among these, there were a total of 418,000 deaths due to classic childhood infectious diseases, which include 195,000 deaths from pertussis, 148,000 deaths from measles, 68,000 deaths from tetanus, and 6,000 deaths from diphtheria. Additionally, there were over 777,000, 270,000, 97,000 and 39,000 deaths from malaria, HIV/AIDS, TB and other parasitic diseases, respectively, among children younger than 15 years. A further 1.6 million children less than 15 years died from respiratory infectious diseases and 1.3 million more died from diarrheal illness. As examples of the ongoing struggles with communicable diseases in children, we have made progress in some areas (i.e. HIV), but much more research is needed to combat these burgeoning epidemics at their current scale. For example, approximately one-half of all new HIV infections occur in young people under 25 years and only 38% of the 730,000 HIV-infected children under age 15 years who were in need of treatment were receiving therapy by 2008. After 30 years of HIV research, we still have no vaccine and have not found a cure. As another example, over the past decade, a median of 25% of children in the world younger than 5 years received treatment with an antimalarial medication yet bed nets and potentially toxic antimalarial drugs are the best we have to prevent this fatal disease. NICHD, as a lead sponsor of research for matters affecting children?s health and well-being, needs to take a strong lead in addressing urgent global infectious disease crises. In the next 10 years, the vision of improving the health of children, especially those affected by these illnesses must be at the forefront of our priorities.

Submitted by Bill Kapogiannis on May 16, 2011 at 6:15 PM

while HIV and vaccines are mentioned in several places, there does not appear anywhere in the plan targeted research opportunities for these foci. Please consider establishing HIV as its own category. Please consider vaccines as specifc agenda items and not subsumed in 'related areas'.

Submitted by Sharon Nachman on May 27, 2011 at 9:38 AM

Although the paper on environment starts out making reference to the social and psychological environment, these factors make no further appearances. Parental education and parenting practices impact the physical, emotional, and cognitive well-being of the child. As other commenters have noted, these factors also influence the "choices" about physical environment that parents can and do make.

Submitted by LouAnn Gerken on May 27, 2011 at 8:20 PM

I would strongly encourage NICHD to include schools and classrooms as critically important environments that impact children's development. Our twin research shows, for example, that teacher effectiveness impacts students' reading gains over and above genetics (Taylor et al., 2010, in Science). Schools and classrooms affect children's cognitive development as well as their social and emotional development. Moreover, schools are an integral part of communities and can effect changes in community health. At the same time, communities can have important influences on schools and how well they meet the health, academic, social, and emotional needs of children, especially children living in poverty. NICHD is strategically positioned to support important basic research in these important and interconnected areas.

Submitted by Carol Connor on June 4, 2011 at 1:56 PM

The white paper fails to highlight the importance of infectious diseases in the research agenda of the NICHD. Through the IMPAACT, ATN and NISDI networks, the NICHD continues to playe an important role in the development of therapies for the prevention and treatment of HIV infection among children, youth, and women, including pregnant women. These programs include both domestic and international sites. Importantly, the NICHD has been the leader in defining the short and long-term complications of HIV infection and its therapies in children with perintal HIV through the PHACS protocols. Defining the safety of in utero exposure to antiretroviral therapy remains a critical objective of the PHACS project. These programs are an important part of the NICHD research agenda and should be emphasized in the future. Equally important are defining the short- and long-term outcomes of infections during pregnancy and childhood, including congenital infections, hepatitis B, hepatitis C, and HPV and exploring outcomes which include prematurity, infant mortality, and long-term disabilities.

Submitted by Russell Van Dyke on June 7, 2011 at 10:48 AM

The concepts of hormesis, radiation hormesis, and the hygiene hypothesis should be considered as fruitful areas of investigation. Hormesis dates back two millenia to the time of King Mithridates who regularly ingested small doses of poison to develop resistance to larger doses. Because of its association with homeopathy, the concept of hormesis has been derided but never disproved. The most convincing recent evidence that exposure to deleterious agents may maintain health comes from studies in Germany of children in rural and urban environments. Rural children were exposed to a much wider range of bacteria and fungi than urban children and were protected from asthma with an OR of 0.62 vs urban children. Exposures specifically to endotoxin, Listeria moncytogenes, bacillus species, corynebacterium species and eurotium fungus were inversely related to risk of asthma. [Ege M et al NEJM 2011: 364: 701; Braun-Fahrlander C et al, NEJM 2002: 347: 869]. Evidence for protective effects of radiation and other environmental toxins is less robust, although the concept has a certain appeal: to keep our detoxification mechanisms working well, e.g. CYP450 enzymes, DNA repair enzymes, we need repeated exposure to low doses of toxins or even low doses of ionizing radiation. Exploring such environmental challenges to our detoxification mechanisms and to our immune system may lead to interesting lines of basic research as well as to a better understanding of the origins of atopic and autoimmune disease, especially asthma and type 1 diabetes.

Submitted by Gilman Grave on June 8, 2011 at 12:56 PM

I hope that NICHD and all of the Institutes continue to see the importance of research related to HIV and other infectious diseases and the various co-morbidities associated with these diseases. Domestically and internationally infectious diseases are a major cause of morbidity and mortality for infants, children and women. A significant proportion of hospital admissions continue to have an infectious origin and bacterial resistance continues to be a major concern. Worldwide children and pregnant women continue to die from preventable diseases and access to care is a serious barrier. Although vaccines have helped eradicate many serious infectious diseases, almost daily we hear about an emerging or re-emerging infectious disease that often impacts children and pregnant women disproportionally. Clearly, research needs to continue on many levels in order to continue to gain strides in impacting the lives of children and women.

Submitted by Andrea Kovacs on June 8, 2011 at 9:06 PM

Congratulations on a strong vision paper that recognizes the many different dimensions of environment that affect health and development. This comment offers two suggestions. First, the white paper should strengthen its attention to the social environment. Even on page 8, where "non-chemical stressors" are acknowledged, the idea that social relationships are a key part of the human environment is strangely missing. Many of the external stressors that humans experience are social in origin - this is not surprising given that we are, above all else, social animals - and these social stressors have been clearly implicated in long-lasting effects on physiological pathways and later disease. The social environment is also centrally important in children's development. Given that appropriate expertise was available in the vision group, the lack of emphasis on this aspect of the environment may have simply been an oversight.
Second, the emphasis of the white paper rest largely on the effects of environmental influences on human biology. However, environmental effects on human behaviors likely have an even larger impact on health and development. These effects include both the structured incentives for behaviors in the economic and physical environment and the social and cultural influences that shape what individuals perceive as natural or appropriate behaviors under specific physical and economic conditions. These dynamic processes shape behaviors that are critically important to the NICHD - safe sex, marriage, smoking during pregnancy, diet, exercise, parental investments in children, care-seeking, and many more. There are many research opportunities for studying the production of these behaviors as a function of both developmental and experiential trajectories and specific environmental contexts. These are covered to some extent in the Behavior white paper, but the linkage to the interests expressed in the environment white paper should be made explicit.

Submitted by Christine Bachrach on June 9, 2011 at 2:35 PM

The American Occupational Therapy Association (AOTA) represents over 140,000 occupational therapy practitioners and students. As the national association representing occupational therapy, a profession dedicated to maximizing independence and function for people across the lifespan, AOTA appreciates this opportunity to submit comments to guide NICHD's vision for future research on the environment.

AOTA commends NICHD for considering environment broadly. Although the paper mentioned people with disabilities early in the paper, in the context of negative effects of the environment, surprisingly little was said about how the environment could improve the health and functional performance of individuals with disabilities. The authors of the paper cite that NICHD's focus includes reproductive health, pregnancy, and child health but neglect to cite another important part of NICHD's mission, to "ensure the health, productivity, independence, and well-being of all people through optimal rehabilitation".

The International Classification of Functioning, Disability, and Health (ICF) Model may be useful to guide future research (World Health Organization, 2002) about the interplay between environment and health and performance of individuals. According to the ICF Model, we need a method of classifying environmental factors in order to analyze the impact of social and physical environments on functional performance.

In occupational therapy, we view environment as a variable, which can be either a positive or negative influence on performance and health. Therapeutic interventions by occupational therapy practitioners include environmental modifications, which include the elimination of environmental barriers or the creation of environmental facilitators. Much research is needed to guide rehabilitation providers regarding which environmental interventions (e.g., assistive technology, adaptive equipment) should be used for individuals with disabilities. We need to investigate the effectiveness of tailored home modification programs, community programs using universal design principles (e.g., accessible parks, playgrounds, and transportation), and workplace modifications to improve the productivity and independence of individuals with disabilities.


World Health Organization. (2002). Towards a Common Language for Functioning, Disability, and Health, from

Submitted by Susan Lin, ScD, OTR/L on June 9, 2011 at 9:40 PM

Although there is considerable emphasis on the prenatal period in this white paper, there is very little discussion of on the early post-natal period. It is made clear that "rapid development continues after birth" but does not define the important post-natal periods for considerations. However, breastfeeding is a well defined and preferred method of infant feeding during the first year of life when both growth and maturation are very rapid. There are several critical environmental issues that impinge the health and well-being of the infant related to milk and breastfeeding. First, many environmental toxins are readily transferred from the blood to breast milk in quantities that are not generally present in cow's milk. Indeed a mother with long term exposure to fat soluble toxins like DDT, PCB and dioxins accumulates and stores these compounds in her adipose tissues from which they are mobilized and secreted into her milk. It is critical to define populations where breastmilk toxins may alter the developmental course of the infant. Second, therapeutic drugs are often transferred to breastmilk where they may have enduring effects on infant development and behavior. While our knowledge about transfer of drugs into breastmilk is increasing, we often do not understand the extent to which these agents alter infant growth and development. Third, the least understood problem is that some drugs, and we do not know which ones, have the potential to alter the secretion of breast milk. This problem is particularly acute in developing countries with high rates of HIV infection in pregnant and lactating women. It is fortunately becoming common to give anti-retroviral drugs to infected pregnant and breast-feeding women, both to prolong their lives and to prevent infection of the infant. In many of these populations formula is not an option both because of its expense and because clean water is not available to make it up. There is an urgent need to understand the effect of these and other drugs on the secretion of breast milk.

Submitted by Margaret Neville on June 9, 2011 at 10:47 PM

Despite its broader introduction and promising background statement, this paper lays out a very narrow view of the environment, one focused on negative exposures. Unlike the Development Origins vision paper, the Environment vision paper does not incorporate anything resembling a balance between positive and negative perspectives on studying states of health and environment. Without a balance between positive and negative factors and exposures, we lose the opportunities to identify positive factors which lead to both personal and community resilience. Just conveying to the public (and policymakers) what they should avoid, provides no guidance about policies and practices which should be supported and adopted. Environment includes more than toxic exposure and infectious agents - the physical, technological, social, cultural, communication, economic, and policy environments need to be incorporated into opportunities and vision.
One example of a positive functional approach to environmental factors is the whole area related to inclusive fitness/wellness. What environmental factors need to be in place for people throughout the lifecourse, including people with disabilities, to be able to participate in wellness activities which improve/maintain their health and wellness? And at the very least, do no harm - so things which may be beneficial at one developmental stage, do not become harmful at a different stage in life. While other agencies may look at issues like the design of accessible fitness equipment, inclusive for all, NICHD could be looking at developmentally appropriate indicators for things like overuse and underuse for people with disabilities in varying environments (physical, built, economic, cultural, etc.) Opportunities should be explored within the framework of the WHO-ICF (referred to in other's comment above) where function and participation are appropriate measures of environmental influence. The environment can either interfere with, or promote and enhance prevention of both primary and secondary disabilities. The environment can support a culture of health and wellness throughout the lifecourse -- but only if we develop methods and take advantage of opportunities for understanding the full range of environmental interactions, not just the negative exposures and threats, but also the resilience building mechanisms, using appropriate measures.

Submitted by Alexandra Enders on June 10, 2011 at 1:09 PM

What is the environment? The paper does not fully include the social and psychological components in its definition of the environment. Specifically, there is no clear description of a) what constitutes "social", b) how it may be operationalized and measured, or c) why/when it may be important. Toxic exposure is emphasized at the expense of social risk/supportive factors. The words "norm", "normative", or "culture" do not appear in this document. There is no discussion of the social and psychological aspects of discrimination. A lot of research exists on specific measures of the social environment (psychometric properties, various outcomes affected by the environment) and none of them (e.g., collective efficacy, social cohesion, contextual stressor scales) are discussed.
How to operationalize the environment? Most of the environmental factors are proximate (and biological) risk factors. Few comments are made about the role of the broad social environment as a fundamental cause. The contours of the environment are not clarified, so it's hard to know how broad social contexts were considered. As examples, the words "school" or "neighborhood" are not mentioned.
Why does the environment matter? The paper does not address how the "environment" may limit or enable certain exposures. The report addresses the influence individuals may have about their environmental exposure and how they make choices that influence their exposure. We need more information about what people know regarding environmental risks when making those choices, and the extent to which they have choices. The report should encourage more questions about the social, economic and political environment that can increase individual risk.
In closing, we want to comment on the need for not only cross training, but also increased investment in multi-disciplinary data sets containing social, economic, and biological data to encourage the formation of diverse research teams.

Submitted by David Lam on June 10, 2011 at 1:59 PM

1)Linkage of components in mixtures (i.e., air, water, soil, etc.) to toxicity (as evidenced by actual health outcomes or surrogates of health outcomes). This would include uptake of the pollutant via multiple exposure routes and the effect of the route on the type and magnitude of the health outcome.
2)Identification of susceptibility, including sensitive time periods in utero or in development, and the factors that might make the periods more sensitive or susceptible.
3)Extrapolation of exposure, effects, and susceptibility in nonhuman animal models to the human population.
4)Measurement of exposures and outcomes - developing biomarkers and cost-effective tests for measuring them.
5)Examination of the window of exposure, long-term, and trans-generational effects - multiple factors and their possible synergism in affecting human health.
6)Consideration of a wide range of doses of environmental exposures to include low levels and their interactions with other chemicals, i.e. it's critically important to understand the potential health effects of many environmental exposures, each of which likely occur at low doses.
7)Development and use of animal, in vitro, and in silico models (both existing and new) to generate hypotheses regarding environmental effects on human health.
8)Examination of the role of individuals and their own environmental exposure.
9)Methods and resources for studying the effects of environmental change on human health.
10)Development of multi-component biorepositories and registers with standardized data collections that encompass the transgenerational lifespan. The scientific community should have open access.
11)Development and population of databases and the means to share data across disciplines and organizations is critical to understanding the effects of chemicals over the lifespan and multiple generations.

Submitted by Martha Guest on June 10, 2011 at 5:20 PM

Scientific Opportunities: Measuring exposures and Outcomes- We would like to suggest that in addition to examining the direct effect of exposure to environmental toxins and chemicals, it would be useful to continue to examine the indirect effects of nutrition, exercise and environmental stress on the long term health of individuals.

Submitted by Dr. Llewellyn Cornelius- Society for Social Work and Research
Scientific Opportunities: The time dimension: long term and trans-generational impact -We believe that it is important for NICHD to support the funding of studies which focus on collecting longitudinal intergenerational data. We also believe that some attention needs to be paid to the development of methodological techniques that will further assist research in controlling for historical/event factors that may bias interpretations of long term outcomes.
Scientific Opportunities: How do individuals and societies chose and shape their environment/ How Can these choices be effected? It is hoped that NICHD will support the development of studies that use data which controls for the relationship between communities/neighborhoods and individuals/families. We anticipate that data which captures this dynamic will assist us in gauging the impact of the individual on the environment.
Scientific Opportunities: What Interventions are effective at mitigating environmental effects? How to make sure they are implemented. We are supportive of research endeavors the focus on the development of culturally responsive partnerships that use the CBPR framework to guide the implementation studies and the adoption of the interventions by the local community.

Submitted by Llewelyn Cornelius on June 10, 2011 at 9:07 PM

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Last Reviewed: 06/04/2012