Littered with Trash…

Nationally there are 2,632 landfills and 72 incinerators which handle much of the 250 million tons of trash produced in the United States each year. It is estimated that each of us generate nearly 4.4 pounds of garbage every day. Globally, the Organization of Economic Cooperation and Development calculates that 2.6 trillion pounds of trash are produced annually. In light of this most pressing problem, last week’s Supreme Court decision to sharply curtail the Environmental Protection Agency’s (EPA) authority to oversee power plants was particularly troublesome.

Obviously, the wellbeing of a given population is impacted by numerous factors. Most directly, the advances in therapeutics and medical technologies can have profound and almost immediate impacts. Improvements in general living conditions, including environmental, have a significant and perhaps less obvious influence on overall health. The promise of digital health innovation to inform, engage, activate users can also be quite dramatic, although may be limited when damaging environmental conditions persist. It is the confluence of all of these advances, supported by thoughtful responsive regulatory frameworks, that will lead to improved outcomes for all. Unfortunately, poor environmental conditions can overwhelm all of the other beneficial activities to improve health.

The EPA has been responsible for the implementation of the Clean Air Act for fifty years. This act to regulate fixed sources of air pollution reflected an emerging belief that public health was directly and profoundly impacted by environmental conditions, and that the infrastructure to manage issues such as waste was often sited in near or in disadvantaged communities, further exacerbating poor public health conditions. It is striking – and shameful – that 80% of the incinerators in this country are in “environmental justice communities;” that is, more than 25% of the residents as either low-income or minority. The Biden administration recently launched the “Justice40” initiative to ensure that at least 40% of the benefits of federal cleanup programs accrue to the disadvantaged communities.

To many observers, the east coast is often referred to as the “tailpipe of the country” given prevailing winds and the relative density of the waste handling infrastructure. Naturally, one would expect that air quality is particularly poor in urban areas and where heavy manufacturing industry is more prevalent. A recent University of Chicago study found that the difference between geographies with the best and worst air quality likely translates into 1.7 years of life expectancy. The researchers further concluded that 92% of Americans live in a region with either periodic or chronic unsafe air conditions, while the World Health Organization now estimates that 97.3% of the global population lives in unsafe zones. Ecoprog estimates that the amount of waste incinerated will increase by 48% between 2018 – 2028.

The distribution of landfills across the country looks eerily similar to the air quality map above. It is not surprising that the locations of landfills would be near/in major population centers given convenience and cost considerations. Undoubtedly decades ago at the time of original permitting, the dramatic public health risks were not properly weighted in that calculus. It is estimated today that the United States has approximately 62 years of remaining landfill capacity, suggesting that this situation will remain in place for some time. Landfills have been linked to the production of greenhouse gases and are known sources of dangerous toxins.

The framework for site permitting, zoning and tax policies for the waste handling industry arguably contribute to structural disadvantages and health inequities low-income and minority communities confront every day. And these issues become self-reinforcing as property values become more depressed with the increased presence of polluting industries, further exacerbating environmental health inequities. While slightly dated, the overall Environmental Quality Index by county (below) maps closely to the location of incinerators and landfills.

While not a direct overlay, the map of the life expectancy by county developed by the Centers for Disease Control and Prevention certainly correlates to many regions of the country when considering the public health impact of waste disposal. Climate change, a direct result of waste management, also indirectly effects life expectancy either with more intense, longer lasting heat waves, or flooding and droughts. Many disadvantaged communities are particularly vulnerable to extreme weather events and often lack robust public health infrastructure to respond appropriately. The World Health Organization recently determined that 250k more people will die globally each year between 2030 – 2050 simply as a result of climate change.

According to the Financial Times, approximately half of the world’s population lives in cities and while cities only occupy 2% of the land mass, they account for 70% of all waste produced and 80% of all energy consumed. A New York Times survey determined that 12% of the world’s population lives in “wealthy countries” yet produced over 50% of air pollution since the end of the Industrial Revolution. While the pollution issue is systemic and global, there are identifiable geographies that if remedied could have an outsized impact on overall wellbeing.

The investment community is broadly focused on two main vectors to address this issue: clean technology investments and a concerted effort to build social determinants of health (SDoH) companies. Pitchbook estimates that there are more than 1,000 clean technology companies which have raised $150 billion over the last decade. BloombergNEF identified $53.7 billion invested in clean technology start-ups just in 2021 with another $755 billion invested in major waste infrastructure projects such as energy storage, renewable energy, nuclear, electrified transportation, and sustainable materials. Pitchbook identified 369 clean tech investments year-to-date 2022. Much of this investment activity has been fostered by institutional interest in Environmental, Social and Governance (ESG) strategies, an often misunderstood segment of the investment landscape (although according to Morningstar, over $2.7 trillion is now held in ESG-focused funds). Yesterday, the European Central Bank announced that it would start to “tilt” its corporate bond holdings to companies that excel on climate matters.

The other vector that is focused on issues concerning public health involves the broader SDoH investment strategy, quite popular among healthcare venture capitalists now. A recent analysis in the Annals of Internal Medicine suggested effective SDoH management could reduce inpatient admissions by 11% and ER visits by 4%. According to Population Health Management, since 1985 more than 50 companies have raised $2.4 billion, which is now valued at $18.5 billion. Like ESG, SDoH is often misunderstood and is used as a catch-all for a basket of solutions that recognize one’s health is a function of a number of factors such as access to quality food, level of education, proximity to effective healthcare providers, etc. Oftentimes, these social determinants can be overwhelmed by poor environmental conditions.  

After the Great Depression more than 80 years ago, the federal government graded every neighborhood in several hundred cities to help inform real estate investment and subsidy decisions. This “redlining” legacy has contributed profoundly to structural disadvantages suffered by the most vulnerable – often the poor and minority – populations across the country. The relationship between these policies and the waste treatment infrastructure is clear and tragically will perpetuate many of these health inequities. A recent analysis by Deloitte concluded that disparate health outcomes will likely cost the U.S. healthcare system $1.0 trillion annually, tripling the costs today and consuming 12.5% of all healthcare spend.

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