Disease-First: A New Paradigm for Environmental Health Science Research

By Wilson, Samuel H.; Schwartz, David A. | Environmental Health Perspectives, July 2006 | Go to article overview

Disease-First: A New Paradigm for Environmental Health Science Research


Wilson, Samuel H., Schwartz, David A., Environmental Health Perspectives


In recent years, many observers have advocated the adoption of a new paradigm in the environmental health sciences--a shift toward a sharper focus on understanding human disease and improving human health by integrating knowledge from environmental health research with that from the broad spectrum of medical research. We term this the "disease-first" approach. The first step in this approach is to prioritize specific common diseases according to the public health burden they pose. Next researchers will gather information on molecular changes that accompany the pathogenesis of each condition, including cellular and tissue changes that occur over time. We will then work to link these biological responses to environmental exposures including toxicants, metals, toxins, and lifestyle and dietary factors that eventually lead to disease. The fundamental goal of the NIEHS is to learn how this knowledge can be used to reduce morbidity and extend longevity. We believe the disease-first approach will allow our field to greatly reduce the burden of human disease.

The common diseases that account for the bulk of the public health burden of disease are chronic, disabling, and widely prevalent. Diseases such as asthma, obstructive lung diseases, and diabetes mellitus are leading causes of death in the United States and are increasing in incidence. These diseases are multifactorial and it is recognized that environmental exposures are a key risk factor in all of them, but large gaps exist in our ability to characterize the complex associations among environmental factors, genetic factors, and health outcomes. Gene-gene, gene-environment, and gene-vector-environment interactions all play important roles in any given condition. Thanks to advancing technologies in areas such as genomics, proteomics, and metabolomics, as well as in computational biology and bioinformatics, we now have the tools to redefine exposure-response relationships, develop quantitative models to support risk assessment, and reach more comprehensive understanding of the diverse and complex responses leading to pathogenesis. One of the key elements of the disease-first approach is to more fully leverage knowledge from these burgeoning technologies to vastly improve clinical outcomes.

The first priority of the disease-first approach is to more systematically track population health status in the United States, both temporally and spatially. Improved surveillance of health status can point to differences in exposures, which can be used as starting points for causality research. Although a comprehensive health status monitoring system does not yet exist, recent developments at the federal level suggest that it could soon be a reality [see Kyle et al., p. 980 this issue].

Such monitoring will allow for human body burden measurements of hazardous substances and xenobiotic metabolites. The disease-first approach will integrate this information with ongoing measurements from traditional environmental exposure assessments. …

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