The quality of nutrition and the contaminants in food affect consumers most directly, but the entire agricultural system has numerous indirect impacts as well. Dominant forms of agricultural practices are often enormously destructive, causing soil erosion; desertification; salinization; soil, water, and air pollution; habitat loss; diminished biodiversity and soil fertility; genetic contamination; and social and economic disruption. These are very real public health concerns in the dynamic, richly interconnected, whole biotic communities where people live.

Food Production and Distribution in the U.S.
In recent decades in the U.S., with some geographical variations, food agriculture has seen declining numbers of midsized farms; increasing concentration of large, industrial, vertically-integrated agricultural systems producing for large commodity markets (e.g., corn, soybeans, sugar, pork, beef); and some increase in small producers for differentiated markets (Kirschenmann 2005).

“What we eat is a major determinant of death and disease. The health care sector has an obvious interest and responsibility and it could be among the leaders in promoting healthy food and healthy agriculture.”

Many food products are designed to meet the needs of today's industrial agricultural system, with efficiency, durability, and marketability as drivers. Consequently, the nutritional quality of food often suffers, while the enormous environmental and social impacts of how it is produced are largely accepted as the cost of doing business in this way.

Nutritional Quality of Food
Despite significant advances in the nutritional sciences, many people do not eat a healthy diet. The composition of food and the nature of the American diet are in large part a result of food production, distribution, and marketing interests, which are overwhelmingly based on products for large commodity markets. Highly processed food that is calorie rich and nutritionally poor is promoted, especially to children (Nestle 2006).

Many food analysts and health professionals note with concern the prevalence of obesity, diabetes, heart disease, foodborne illnesses, some kinds of cancer and birth defects, dementia, and other health conditions that are linked to what we eat as well as the food production and distribution system more generally. These diseases cause suffering, are increasingly expensive to treat, and are obvious targets for preventive measures.

Confined animal feedlots are just one example of the relationship between food production systems and nutrition. Beef cattle that are largely raised on corn in a feedlot and routinely treated with antibiotics and hormones reach marketable size more quickly than pastured animals. But the fat composition of the meat of the corn-fed animals contains a much higher ratio of omega-6 to omega-3 fatty acids than grass-fed counterparts (Wood 1999). Industrial poultry production has had a similar impact on chicken. Today’s typical diet in the U.S. has a far higher ratio of omega-6s:omega-3s than fifty to a hundred years ago, directly contributing to cancer, heart disease, arthritis, obesity, cognitive decline, and, in all likelihood, numerous other diseases (Allport 2006).

Antibiotic Use
Industrial agricultural systems that produce poultry, swine, beef, and farmed fish routinely use large amounts of antibiotics as growth promoters rather than as pharmaceutical agents to treat identified disease. More antibiotics are used in agricultural production than in clinical medicine. The routine use of antibiotics as growth promoters in animal husbandry contributes substantially to antibiotic resistance in bacteria that are human pathogens (Wegener 2003).

Pesticide Use
The annual use of hundreds of millions of pounds of insecticides, herbicides, and fungicides in food production directly leads to significant populationwide, farmworker, and farm-community exposures, often exceeding established “safety” limits. It increases risk of some malignancies, neurodegenerative diseases, asthma, and birth defects (Ontario College of Family Physicians 2004).

Foodborne Infectious Illnesses
Foodborne infectious agents are estimated to cause seventy-six million illnesses, 325,000 hospitalizations, and 5,200 deaths in the United States each year. Known pathogens account for an estimated fourteen million illnesses, 60,000 hospitalizations, and 1,800 deaths annually (CDC). In addition to bacterial and viral vectors, bovine spongiform encephalopathy (“mad cow” disease) is a growing concern in the U.S. Its spread depends on feeding practices in which animals that may end up in the food supply are fed animal products contaminated with the prion responsible for the disease. These practices are undergoing extensive modification following the identification of an infected animal in Washington in 2003.

Environmental Health Considerations
Confined animal feedlot operations (CAFOs) and other large industrial farms are point sources for runoff of growth promoters such as arsenic, hormones, and antibiotics into local surface waters, and in some cases into ground water (USGS 2003). Studies of runoff from CAFOs show that hormones are present in surface waters at concentrations that are sufficient to alter fish reproduction and development (Soto 2004, Orlando 2004). Organic arsenic, used as a growth promoter in swine and chicken production, not only contaminates the meat with arsenic at levels of concern (Lasky 2004) but also is discharged into the environment when animal manure is spread onto the land. Once in soil or sediments, organic arsenic is converted to its more toxic inorganic form, making it water-soluble and allowing it to seep into surface and groundwater ultimately used for drinking (Gabarino 2003). Because of a dense concentration of animals in a relatively small space, CAFOs are also a source of noxious airborne emissions from manure lagoons that make people sick.

Pesticide runoff and air emissions from agricultural operations contaminate waterways, rainwater, and air (USGS 1999). Drinking water in the Midwest is contaminated with atrazine during seasons of herbicide use (U.S. EPA), and air monitoring in California shows that pesticide drift from spraying operations exposes farm communities to unsafe levels (Pesticide Action Network, 2006). Wildlife studies in the field and in the laboratory show adverse impacts at current levels of exposure.

A Role for the Health Care System
Hospitals and health care systems can play an important leadership role in addressing each of these concerns. Hospitals routinely feed patients, staff, visitors, and the general public, affording a perfect opportunity to directly influence health and disease risk as well as to model dietary patterns to others. This is reminiscent of the important role that hospitals played in the 1980s with the adoption of no-smoking policies as a demonstration of an important public health intervention. By adopting food procurement policies that show an understanding that the quality of nutrition and food production systems matter, health care institutions also recognize the inextricable links between individual, public, and ecosystem health, or what might be collectively called “ecological health.”

An ethical dimension to this under-standing also places medical ethics within an expanded framework of bioethics. Any viable system of ethics must preserve the ecosystems from which it arises and that sustain it (Elliott 1997, Pierce 2004). That is, the rules of ethics must conform to the rules of nature. Bioethics and medical ethics need to seek a more unified ecological moral framework. The health care system has a particular responsibility to address today’s ecological realities because of its mission, its opportunities, and the size of its ecological footprint. A reformulated bioethic and medical ethic will see beneficence, nonmalfeasance, and justice not only through the eyes of the patient and health care provider, but also from the perspective of the entire community and the natural environment.

Proposed Goals for Health Care Institutions

• Adopt food procurement policies that provide nutritionally improved food for patients, staff, visitors, and the general public.
• Adopt food procurement policies that support food production systems that are ecologically sound, economically viable, socially responsible, and morally feasible.
• Adopt food procurement policies that reflect an ecological understanding of the dependence of human health on healthy ecosystems and that help promote sustainable agricultural practices.

• Health promotion and disease reduction
• Reduced use of nontherapeutic antibiotics in food production with decreased risk of antibiotic-resistant organisms
• Reduced pesticide use; reduced pesticide exposures to farmworkers, communities, consumers, and wildlife
• Reduced ecological impacts of food production
• Improved social and economic conditions in food-producing communities
• Improved hospital-community relations