Food consumption can be a source of health and well-being, providing good nutrition, pleasure, psychological comfort, and social goods for individuals, families, and communities. But food consumption patterns, agricultural practices, and other food system practices can also undermine health and well-being.
Public Health and Community Well-Being
One job of societies is to protect and promote human well-being, including importantly, human health. Food consumption patterns, agricultural practices, and other food system practices matter morally because they are simultaneously essential to the realization of health and well-being and a threat to them.
Food consumption can be a source of health and well-being, providing good nutrition, pleasure, psychological comfort, and social goods for individuals, families, and communities. Food is a locus of our social lives, and a way of expressing personal and group identities, including religious and cultural identities, and expressing personal values. But food consumption can also undermine health and well-being. Consumption of food contaminated with bacteria, viruses, parasites and chemical substances makes 10% of the global population ill each year, and kills an estimated 420,000 people.1 Food consumption patterns are also the main cause of the increasing rates of overweight and obesity in recent decades. These high rates of overweight and obesity have significant consequences for public health, increasing risk for diet-related disease and causing an estimated 4 million deaths worldwide in 2015.2 Significant rates of undernutrition exist alongside overnutrition: globally, 821 million people were undernourished in 2017, meaning they could not access enough food to meet dietary energy requirements.3 Thus, a most basic health-related concern with the food system is malnutrition in all its forms.
Some agricultural practices pose occupational health risks to farmers and farmworkers, such as health risks from exposure to pesticides.4 Agricultural practices can pose health risks to surrounding communities, or reduce their quality of life. For example, improper handling of manure on animal operations can lead to groundwater pollution and noxious smells that affect surrounding communities. Agricultural practices can also pose risks to the health of the public at large. For example, the routine use of antibiotics in animal agriculture spurs the creation of antibiotic-resistant bacteria, a significant threat to public health. At the same time, agriculture can be central to community identity and ways of life, and thus be essentially connected to a community’s well-being.
Health has clear ethical importance, given its value to individuals, families, communities, and societies. Health is a central dimension of individual well-being. Good health enables other valuable conditions of life: a life of normal length, without excessive pain and suffering, with gainful employment, family and caretaking relationships, and other meaningful pursuits. Some would argue that a certain level of health is essential to leading a good life; at the very least, health makes it much easier to pursue valuable opportunities and lead good lives. Health also has social value. Poor health has economic and social costs, such as lost productivity, health care costs, and the financial and personal costs of caretaking.
Given the personal and social value of health, some argue that for a society to be a just society, all people must have meaningful opportunities to be healthy.5 There is disagreement, however, about which opportunities to be healthy societies ought to provide, and about the ways in which societies are ethically required to support public health.6 Thus while there might be broad agreement that we owe it to each other to collectively protect public health, and we owe it to future generations of people to bequeath to them a society and natural world that can sustain their health, there will be disagreement about what more precisely this requires.
Because the value of health is so significant, food production practices that threaten health raise ethical concerns. It is not feasible, however, for production practices to be risk-free. Nor is this always ethically desirable, since there can be trade-offs between reducing health risks from production and other goals, such as profits for producers or wages for workers. Stakeholders may disagree about what are ethically acceptable levels of risk, given the trade-offs involved in reducing risk. Societies may differ in the trade-offs between health and other goods that are considered acceptable, as well as the level of risk to public health that is acceptable.
Nonetheless, some production-side practices exceed an acceptable level of risk to the health of workers, communities, and the public. Similarly, risks of foodborne illness that exceed certain thresholds are ethically unacceptable, though again, what counts as an acceptable level of risk will depend on the trade-offs and values particular to a society.
It is not only production practices, but also practices along the food value chain, that can affect public health and community well-being. For example, how foods are marketed affects what people consume and why they consume it. Various marketing practices raise ethical concerns because of how they affect consumer autonomy and public health and well-being. A general concern is that the food industry formulates and markets foods in ways that both diminish consumers’ health and undermine their autonomy — by formulating foods that are hard to resist even when consumers wish to eat less of them, by labeling foods in ways that are misleading or uninformative, and by marketing foods in ways that prompt overconsumption, such as packaging foods in large serving sizes. As food companies expand into new markets, newly introduced and heavily marketed packaged foods, processed foods, and convenience foods can displace other ways of cooking and eating, causing an increase in overweight, obesity and diet-related disease.7 At the same time, the wide consumption of these foods suggests that they have perceived value for consumers, health risks notwithstanding.
Core Ethical Commitments
Health Risks from Consumption
Food consumption can be a source of health and well-being, providing good nutrition, pleasure, and social goods. But food consumption also poses health risks. Individual risk factors — allergies, food sensitivities, and conditions such as diabetes and high blood pressure — make consumption of specific foods risky or harmful for certain individuals. Some foods pose no risk to most consumers when consumed in moderation, but are presently widely consumed at unhealthy levels as part of dietary patterns inconsistent with optimal health — for example, calorie-dense, sugary, high sodium processed foods. These dietary patterns are prevalent at the population level in many countries, and are a primary contributor to overweight, obesity and diet-related illness globally. For many types of food products, we should expect disagreement about whether they pose an unacceptable risk to public health. However, there is more consensus about some food products, notably those that have minimal nutritional value but high levels of calories and sugar (e.g., sugary drinks), and foods with particular ingredients known to have harmful health effects (i.e., foods made with trans fat).
Some foods pose risks to consumers with specific allergies, diseases, or risk factors, but not to the public in general; marketing these foods is consistent with this commitment, as long as labeling clearly communicates the food’s risks to those consumers.
Consumption of contaminated food is a significant public health problem globally: consumption of food contaminated with bacteria, viruses, parasites and toxic chemical substances makes 10% of the global population ill each year, and kills an estimated 420,000 people.8 This matters ethically because of the value of health to individuals, their families, and their communities and societies.
Chemical food contamination may occur unintentionally following a technical failure (e.g. the presence of benzene in spring water), accidentally during processing or packaging (e.g. the introduction of dioxin into potato chips as a result of washing potatoes in contaminated water), or from environmental contamination (e.g. the bioaccumulation of methylmercury in fish). Additionally, there are also documented cases of intentional chemical contamination of food that has caused cause mild to severe toxicity reactions in consumers.9 Similarly, microbiological contamination may result from lack of adequate hygienic conditions in the food chain or neglect of hygienic practices from harvesting through processing. Additionally, inadequate facilities and insecure storage conditions, particularly in retail businesses and restaurants, can attract insects, rodents and other animals, resulting in contamination of food and, subsequently, infectious diseases in the consuming public.10
Contamination of any kind is largely an issue of inadequate control and compliance monitoring of the production-transport-retail chain.11 In other words, it is typically possible to reduce the risks of contamination through the use and monitoring of appropriate controls. What counts as an acceptable level of risk will depend on the trade-offs and values particular to a society, the willingness of the actor with the ability to implement a control to bear the extra costs, and the willingness of consumers to accept higher prices for safer food. Risk tolerance may vary across societies. At a minimum, attention must always be paid to handling food under hygienic conditions and to developing process controls designed to reduce the likelihood of contamination. Intentional and reckless introduction of chemical, microbial, and physical contaminants must always be avoided.
Food packaging can enhance food safety by keeping food fresh for longer. It can also enhance food safety by providing consumers information on food freshness, safe handling and storage, time and temperature controls, and production date. Enhancing food safety in these ways protects human health. Packaging that keeps food fresh for longer can also help to reduce food waste, which is an important goal for both human health and environmental reasons. Food packaging should also not contain components at levels that pose unacceptable risks to human health (for example, bisphenol A, cyclo-di-BADGE, phthalates in the lining in food cans or other disposable plastic containers). However, what counts as an unacceptable risk to human health, and what is the right balance between preserving freshness and minimizing health risks, may be different in different societies. When the food supply is less abundant, or more consumers struggle to afford adequate food, it is more important for packaging to maximize shelf life and reduce cost, even if this packaging does not minimize long-term health risks. For example, canned food has a longer shelf life and does not need to be kept cold during storage, making it a safe choice for regions and applications without reliable temperature control. Thus, canned foods may be preferable in some contexts to fresh and frozen food, even if this packaging does not minimize long-term health risk.
Food Fraud & Economic Adulteration
Economically motivated adulteration includes the padding, diluting, and substituting of a food product in ways that may or may not affect the safety of the product for the purpose of achieving an economic gain.12 This practice, commonly known as “food fraud,” not only harms consumers, but it also unfairly tarnishes the reputations of honest merchants and undermines faith in the institutions and regulatory bodies charged with ensuring quality and safety of the food supply.13 The phenomenon of food fraud is widespread.
Adulteration of food can cause ill-health effects, for example when an alcoholic drink is diluted with methanol or edible vegetable oil is mixed with dioxin. In other cases, food adulteration has only negligible health risks but involves marketing a misbranded product of lower value as one of higher value or special provenance, for example selling sugar syrup with flavors and colors as genuine honey or selling lower grade olive oil as extra virgin olive oil.14 Often this kind of adulteration results in consumers getting a less nutrient-dense product than anticipated. Even when adulteration does not pose health risks, it can cause economic harm when consumers receive a less valuable product or one they prefer less. It can also offend the cultural sensibilities and violate the dietary commitments or norms of consumers, such as when horsemeat is surreptitiously substituted for beef in a place where the consumption of horse-derived products is taboo. Whatever the nature of the fraud, all forms of economically motivated adulteration erode consumer trust and confidence in the food supply.
While food fraud is already prohibited by law in many countries, including the United States, the ethical obligation under this commitment extends beyond mere compliance. Actors should also affirmatively seek and verify information about the provenance and composition of ingredients sufficient to guard against using or trading in economically adulterated, fraudulent food products.
Product Information and Marketing
This commitment requires that food labels provide accurate and complete information presented in a straight-forward, easy-to-understand manner. The commitment prohibits food labels that provide false or misleading information about products. Even when labels do not make outright false claims, they can still be confusing, and the language and images on labels can give consumers false impressions about the product. Lastly, even when labels are not misleading in any way, they can still fail to provide important information for consumers.
Labels that are misleading and that fail to provide important information undermine consumers’ ability to make informed food choices that protect their own interests and align with their values. We should expect disagreement about how much information, and of what kind, is required for the label to be informative. We should also expect disagreement about the boundaries between misleading and non-misleading language and imagery, particularly because the label of a food product is both regulated space and marketing terrain. Where tensions arise between these two purposes, efforts at consumer persuasion should be subordinated to the interests of transparency and informativeness.
If consumers are to make food choices that protect their own interests and align with their ethical values, they need to have an accurate understanding of important aspects of food products and their production processes. Thus an issue of overarching importance is for food marketing, including advertising, labeling, and other marketing activities, to provide consumers with key information presented in ways that are easily understandable by most of the consuming public.
There are dozens of certifications for food products capturing various aspects of production practices and of products themselves. Despite this plethora of certifications — or perhaps in part because of it — food marketing often does not provide information about ethically important aspects of products and their production processes. Food marketers should consistently present information in a way that maximizes the likelihood of consumers forming correct beliefs about important features of products and their production processes.
A variety of marketing practices are objected to as inappropriate, for a range of ethical reasons. Misleading marketing is seen to undermine consumer autonomy and can prevent consumers from making food choices that protect their health and other interests, or from making food choices that align with their values.
Food marketing targeting particular groups of consumers also raises concerns. In the United States, a pattern of targeting racial-ethnic minorities with more food marketing, particularly marketing of products with low nutritional value, is objected to as unfair, because it may exacerbate higher levels of overweight, obesity and diet-related illness in already disadvantaged populations. The marketing of unhealthy food towards children is also objected to, and seen as particularly inappropriate since children do not have the cognitive ability to understand marketing and interpret it correctly.
While we should expect disagreement about which forms of marketing are inappropriate and about the exact boundaries between appropriate and inappropriate marketing, food marketers should err on the side of avoiding marketing that may mislead consumers, and avoiding marketing aimed at children, especially when the marketed food does not make a meaningful contribution to nutrition or the marketing could increase intake of nutrients that could have a negative impact on child health.15
Animal Production and Waste Management
The use of antibiotics in livestock animals for non-therapeutic uses has contributed to the creation of antibiotic-resistant bacteria (“superbugs”), which are an increasingly serious global public health problem. When livestock are given low, subtherapeutic doses of antibiotics in order to promote growth and increase feed efficiency, this leads to the creation of antibiotic-resistant bacteria. These antibiotic-resistant bacteria are a significant public health concern: 2 million people become infected with antibiotic-resistant bacteria in the United States each year, and 23,000 people die.16
To minimize their contribution to this public health problem, animal production systems should not routinely use antibiotics at subtherapeutic levels. Antibiotics and antimicrobials should be used to treat disease at therapeutic levels for the time necessary to treat the animal. There may be a few exceptions to this general rule, for example use of antibiotics even in the absence of disease when an animal is being integrated into a herd.
Along with antibiotic resistance, antifungal resistance is also on the rise, and is a concern for both public health and food security. Fungi can infect animals (including humans) and plants. Anti-fungal drugs are used against fungal infections in humans and in animals, and fungicides are used in plant agriculture. Fungi that are resistant to existing antifungal drugs are on the rise. Fungi resistant to multiple drugs and anti-fungal chemicals are causing infections in humans and plants (including food-producing crops), respectively, worldwide. Experts have recommended better stewardship of existing anti-fungal drugs and of fungicides, and more use of non-chemical means of controlling fungi in plant agriculture.17
Along with the routine use of antimicrobials, other practices in animal agriculture can contribute to the creation and spread of novel pathogens. Housing and feeding conditions can allow the incubation of novel viral strains (such as novel influenza), as well as other diseases (such as Mad Cow Disease). Confinement facility workers and veterinarians can spread pathogens, enabled by inadequate surveillance and biosecurity protocols, or inadequate enforcement of protocols (for example, workers not always wearing recommended protective gear when working in facilities). Inadequate manure management practices can also encourage the spread of pathogens by air and water.
To minimize the risk of spreading pathogens, recommended management practices should be assiduously followed and compliance monitoring protocols should be implemented. Additionally, all workers who handle or come into contact with manure should be trained on and rewarded for the consistent use of recommended management practices. Finally, producers should periodically review technical assistance resources to determine whether more effective management practices have been developed over time.
Confinement animal operations involve the concentration of animals, and thus animal manure, in relatively small spaces. Large quantities of manure can create health and quality of life problems for surrounding communities. When inadequately treated, large quantities of manure can cause runoff and contaminate groundwater, potentially affecting both drinking water and surface water (e.g. lakes, streams). This runoff can contain antibiotics, hormones, pesticides, heavy metals, fecal bacteria and pathogens. Air emissions from animal operations can also contain pathogens and pollutants, posing health risks to nearby communities. Noxious odors from confinement operations can also be a significant quality of life issue for surrounding communities and can prompt burdensome lifestyle changes.
To minimize these negative effects, recommended waste handling practices should be assiduously followed and compliance monitoring protocols should be implemented. Additionally, all workers who handle wastes should be trained on and rewarded for the consistent use of recommended management practices. Finally, producers should periodically review technical assistance resources to determine whether more effective management practices have been developed over time.
Excess Food, Waste and Disposal
An estimated one third of food that is produced is never eaten.18 This commitment requires that across the food chain, from farm to consumer, production, packaging, labeling, and marketing practices should deter rather than promote food waste. The ethical justification for reducing food waste is multifold. Reducing food waste will help to ensure that we have enough food as the world’s population and food demand increase in coming decades. Though estimates vary significantly, food demand could increase 60-70% by 2050.19,20 Reducing food waste will also reduce the environmental impact of agriculture. By reducing the amount of food wasted, we reduce the amount of food that needs to be grown, and thus reduce the resources used and the greenhouse gases emitted in connection with meeting human food needs. By reducing the amount of food that goes uneaten, we may also reduce the amount of food that ends up in landfills; this is an important environmental goal, since food in landfills produces methane, a potent greenhouse gas.
Food waste occurs all along the food supply chain: at the consumer level (e.g.,, when consumers throw out spoiled or uneaten food), at the retail level (e.g., when a grocer throws out bananas that have gone brown), and earlier along the supply chain. One way of reducing food waste early in the supply chain is to fully utilize food inputs, for example through careful preparation and trim practices or by finding markets and productive uses for excess ingredients and inedible residues.
In the United States and many other highly developed countries, the largest amount of food waste occurs at the retail and consumer level. Consumer food waste is driven by many factors, including, for example, oversized portions, overly ambitious purchasing, time-pressure, diminished food preparation skills, frequent eating out, lack of knowledge about proper food storage, or lack of confidence in assessing food freshness. While some of these factors must be mitigated by consumers, upstream actors can support reductions in household and consumer level food waste through a range of responsible strategies, such as including information about proper storage and handling on food labels, using consistent date labeling schemes that clearly distinguish safety and freshness timelines, making use of packaging that is readily resealable or that provides a sensory signal of deterioration, offering options for different portion sizes at reasonable price points, and disfavoring bulk promotions that stimulate over-buying.
When food does not get consumed, it should be handled in ways that enable efficient nutrient cycling (for example, composting or anaerobically digesting this food rather than sending it to landfills).
This commitment concerns negative health effects of production and distribution practices for humans and animals. Some agricultural practices affect the health of farmers, workers,and surrounding communities quite directly, as when exposure to pesticides poses health risks for workers, farmers, or surrounding communities, or contamination of water or air by agricultural run-off or particulate poses health risks for surrounding communities. Other threats to health are indirect, such as when livestock waste creates foul conditions and impairs air quality, causing residents of the surrounding areas to shelter inside their homes and preventing them from accessing health benefits and enjoying outdoor activity. Similar effects are observed around major distribution hubs, where the volume of truck traffic causes high concentrations of pollutants to persist in the environment and has been causally linked to respiratory and other diseases.21
Actions that should be taken in accord with this commitment vary based on the source of health-impairing conditions and the actor seeking to make positive change. Actors seeking to make progress on this commitment should investigate and identify the negative health externalities of their production, processing, or distribution activities and identify options for reducing or offsetting these impacts.
While this commitment focuses on negative health effects generally, CEC #33 highlights one kind of negative health effect from animal production: Waste products from animal production are handled in ways that minimize the likelihood that the health and well-being of adjacent communities will be affected.
Access to Nutritionally and Culturally Important Foods
The globalization of the food system — including increased crop production for a global market in many countries, and increased imports of foods — has brought new opportunities and new threats to food access, to food security, and to culturally significant food practices.
Crop production can displace existing agricultural practices or forms of food provisioning, as when commodity crops displace diversified production and foraging by small farmers. People can be displaced from the land that they were using for food production and provisioning by the acquisition and consolidation of agricultural land by large players. This can threaten livelihoods, including the livelihoods of small farmers and subsistence farmers, and threaten their food security and health. The creation of export markets for foods can increase the local price of the food, as happened with quinoa in the Andes, potentially reducing food security and nutrition. Conversely, the creation of export markets also has the potential to improve livelihoods, food security, and nutrition, depending on the circumstances.
Advances in food processing have enabled distribution of processed foods into more corners of the globe than ever before. These foods are distributed and marketed in ways that can displace local foods and food practices, including traditional foods and culinary practices. This displacement can have negative nutritional and health effects, as when dietary patterns shift to include more high sugar, high sodium, calorie-dense food, and rates of overweight, obesity and diet-related illness increase. The displacement of traditional and local food practices can also diminish access to culturally-important foods and participation in culturally-important food practices, which might matter ethically whether or not it worsens public health.
We should expect disagreement about the best way to characterize the cultural impact of this displacement. When should this displacement be seen as a kind of cultural loss of ethical concern, and when is it a form of cultural change that is neutral or even positive? While the answers to these questions are necessarily context-dependent, affected groups must be given voice and an opportunity to express their individual and collective preferences in any discussions about changing food cultures.
In addition to their production practices, companies engage in other practices that can improve public health and the well-being of workers, producers and communities or, alternatively, undermine them. These practices include participation in voluntary agreements to make their product lines healthier, for example by reducing the sodium or calorie content of their product lines. They also include voluntary agreements about the marketing of food, such as agreements about limits on food marketing to children. Relevant corporate practices also include investment in public health efforts in communities, as well as workplace practices and benefits to improve the health and well-being of workers. Companies can also support public health by supporting public health efforts; conversely, they can undermine public health by lobbying against these efforts, either publicly or behind the scenes.
We should expect disagreement about which corporate practices should be recognized as meaningful efforts to improve public health and well-being. For example, in the United States, companies have entered into voluntary agreements to make their product lines healthier or to limit how they market their products, but these agreements fall far short of what industry has a responsibility to do, according to some public health experts and ethicists.
We should expect disagreement about whether companies should be recognized and rewarded for participation in standards and programs that make incremental progress yet don’t change the basic fact that the food industry profits from marketing products that are consumed in ways that undermine public health. At a minimum, food industry actors should limit efforts to exert undue or disproportionate influence on public governance efforts to improve public health and the well-being of workers, producers, and communities.
1 World Health Organization, “WHO Estimates of the Global Burden of Foodborne Diseases: Foodborne Disease Burden Epidemiology Reference Group 2007-2015” (Geneva: World Health Organization, 2015).
2 GBD 2015 Obesity Collaborators, “Health Effects of Overweight and Obesity in 195 Countries over 25 Years,” The New England Journal of Medicine 377, no. 1 (July 2017): 13-27.
3 Food and Agriculture Organization of the United Nations et al., The State of Food Security and Nutrition in the World: Building Resilience for Peace and Food Security (Rome: FAO, 2017).
4 Corinna Hawkes and Marie Ruel, “The Links between Agriculture and Health: An Intersectoral Opportunity to Improve the Health and Livelihoods of the Poor,” Bulletin of the World Health Organization 84, no. 12 (December 2006): 984-90.
5 Madison Powers and Ruth Faden, Social Justice: The Moral Foundations of Public Health and Health Policy (Oxford; New York: Oxford University Press, 2006).
6 James Wilson, “Health Inequities,” in Public Health Ethics: Key Concepts and Issues in Policy and Practice, ed. Angus Dawson (Cambridge University Press, 2011).
7 Andrew Jacobs and Matt Richtel, “How Big Business Got Brazil Hooked on Junk Food,” The New York Times, September 16, 2017, https://www.nytimes.com/interactive/2017/09/16/health/brazil-obesity-nestle.html.
8 World Health Organization, “WHO Estimates of the Global Burden of Foodborne Diseases: Foodborne Disease Burden Epidemiology Reference Group 2007-2015” (Geneva: World Health Organization, January 2016), https://apps.who.int/iris/bitstream/handle/10665/199350/9789241565165_eng.pdf;jsessionid=33958F0425FF68CB9D401DEBB6100E5E?sequence=1.
9 Bridget M. Kuehn, “Melamine Scandals Highlight Hazards of Increasingly Globalized Food Chain,” JAMA 301, no. 5 (February 2009): 473-475.
10 Herman B.W.M. Koëter, “Food Safety,” 2016, http://www.bioethicsinstitute.org/wp-content/uploads/2016/11/Food-Safety.pdf.
11 Koëter, “Food Safety.”
12 “Renée Johnson, “Food Fraud and ‘Economically Motivated Adulteration’ of Food and Food Ingredients,” CRS Report R-43358, Congressional Research Service, 2014, http://www.fredsakademiet.dk/ORDBOG/lord/food_fraud.pdf.
13 Michael Roberts and Whitney Turk, “The Pursuit of Food Authenticity: Recommended Legal and Policy Strategies to Eradicate Economically Motivated Adulteration (Food Fraud),” 2017, https://doi.org/10.2139/ssrn.2947347.
14 Roberts and Turk, “The Pursuit.”
15 Federal Trade Commission et al., Interagency Working Group on Food Marketed to Children — Preliminary Proposed Nutrition Principles to Guide Industry Self-Regulatory Efforts — Request for Comments, 2011, https://www.ftc.gov/sites/default/files/documents/public_events/food-marketed-children-forum-interagency-working-group-proposal/110428foodmarketproposedguide.pdf.
16 Centers for Disease Control and Prevention, “Antibiotic / Antimicrobial Resistance (AR / AMR),” accessed July 9, 2019, https://www.cdc.gov/drugresistance/index.html.
17 Matthew C. Fisher et al., “Worldwide Emergence of Resistance to Antifungal Drugs Challenges Human Health and Food Security,” Science 360, no. 6390 (May 2018): 739-42.
18 Food and Agricultural Organisation, “Food Wastage Footprint: Full-Cost Accounting” (Rome: FAO, 2014), http://www.fao.org/3/a-i3991e.pdf.
19 Food and Agricultural Organisation, “How to feed the world in 2050,” (Rome: High-Level Expert Forum; FAO, 2009).
20 Nikos Alexandratos and Jelle Bruinsma, “World Agriculture towards 2030/2050: The 2012 Revision,” ESA Working Paper (Rome, 2012), doi:10.1016/S0264-8377(03)00047-4.
21 George D. Thurston, Ariel Spira-Cohen, and Lung Chi Chen, “South Bronx Environmental Health Policy Study (SBEHPS): Final Report of NYU School of Medicine Research” New York University School of Medicine, 2007, https://static01.nyt.com/packages/pdf/nyregion/20081002_SOM.pdf.