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Chapter 6

Environmental Health

Explain the relationship between the environment and human health and disease.

Understand the key disciplines that inform nurses’ work in environmental health.

Apply the nursing process to the practice of environmental health.

Describe legislative and regulatory policies that have influenced the impact of the environment on health and disease patterns in communities.

Objectives (1 of 2)

Explain and compare the environmental health roles and skills for nurses practicing in public health, as well as those practicing in privacy settings.

Incorporate environmental principles into practice.

Objectives (2 of 2)

Physical

Chemical

Biological

Social

Psychosocial

An estimated 24% of the global burden of disease and 23% of all deaths can be attributed to environmental factors (World Health Organization [WHO])

Introduction to Environmental Health

Besides using these WHO factors, we can also divide and examine the environment from the perspective of the media in which environmental degradation takes place: air, water, soil, and food. And a third approach would be to divide environmental exposures into categories: biological, chemical, and radiological.

Herbicides

Pesticides

Other chemical carcinogens

Lead

Radiation

Environmental Carcinogens

Eliminate elevated lead blood levels in children.

Minimize risks posed by hazardous sites.

Reduce significant pesticide exposures.

Reduce the amount of toxic pollutants.

Reduce indoor allergen levels.

Decrease lead-based paint or related hazards.

Healthy People 2020 Objectives for Environmental Health

Nightingale: clean water and sanitation

Lillian Wald and Henry Street neighborhood

Environmental justice

Extrapolation studies

2001: Centers for Disease Control and Prevention (CDC) begins biomonitoring

Testing of human fluids and tissues for presence of potentially toxic chemicals

Historical Context of Environmental Health and Nursing

Poverty and race

Substandard housing

Hazardous plants and waste sites

Hazardous jobs

Poor nutrition

Less access to health care

Social Determinants of Health and Environmental Justice

The term environmental justice refers to the disproportionate environmental exposures that poor people and people of color experience in the United States and elsewhere, including lead paint dust exposure, the presence of pests (resulting in increased use of pesticides), and the use of supplemental heating sources that may cause dangerous carbon monoxide exposure. These combined circumstances multiply the risk for health disparities.

Toxicology

Epidemiology

Geographic information systems

Multidisciplinary approaches

Environmental Health Sciences

Sometimes called the study of poisons

Negative effects of chemicals

Pollutants have multiple routes into the body Epigenetics: hazardous changes to DNA

Individuals have unique responses

Chemical “families”

Toxicology

Most chemicals cross the placental barrier and can affect the fetus, just as most chemicals cross the blood-brain barrier. In addition to direct damage to cells, tissues, organs, and organ systems, there can be changes to the DNA from chemical exposures that can change gene expression which, in turn, can predict disease. This latter effect is the focus of a relatively new biological study, epigenetics.

Studies the strength of association between exposures and health effects

Uses

Occupational

Environmental

Epidemiologic triangle

Agent

Host

Environment

Epidemiology

Epidemiologic triangle is a simple model that belies the often complex relationships among agent, which may include chemical mixtures (i.e., more than one agent); host, which may refer to a community with people of multiple ages, genders, ethnicities, cultures, and disease states; and environment, which may include dynamic factors, such as air, water, soil, and food, as well as temperature, humidity, and wind.

Coding data

Relates it to a place on Earth (“mapping”)

GIS community-based maps

Educate communities and local policy makers

Provide graphic depictions of public health (PH) problems

Example

Hill and Butterfield’s model of environmental risks

Geographic Information Systems

For example: Nurse researcher Mona Choi used GIS to study the relationship between air pollution and emergency visits for cardiovascular and pulmonary diagnosis.

Multidisciplinary Approaches

Earth sciences that show how pollutants travel

Geologists

Meteorologists

Physicist

Chemists

Key public health (PH) professionals:

Food safety specialist

Sanitarians

Radiation specialists

Industrial hygienists

Earth sciences: Pollutants travel in air, water, and soil.

PH Professionals: We might also add a health educator and outreach worker to educate the family and encourage compliance with environmental health behaviors and clinical treatments. Finally, we may need to work with public health lawyers to address noncompliance.

WHO: “Climate change is a significant and emerging threat to public health, and changes the way we must look at protecting vulnerable populations.”

Nurses’ main roles

Mitigation: working at individual, community, institutional, and governmental level to ensure energy-conserving policies and practices

Response: public health nurses must be prepared for increased fire- and storm-related disasters

Climate Change (1 of 2)

There is still much to do to mitigate the steep upward slope now observed for temperatures, CO2 levels, and sea water levels. Working at the individual, community, institutional (school, hospital, and so on), and governmental level, there is much work to be done to ensure energy conserving policies and practices, rational transportation practices, and changes in our consumption patterns.

Regarding response preparation, public health nurses must lead the development of contingencies for long-term, high heat weather conditions, as well as increased storm activities (that include more severe storm patterns) and the associated disaster preparedness. Nurses should also be prepared for threats to food security from shifting weather patterns that may not support food production as usual. And nurses should be prepared for population migration away from low-lying, coastal regions creating a new type of refugee migration. The oil spill in the United States Gulf of Mexico will create an out-migration of people who can no longer support themselves with their traditional fishing industries. This type of mobilization will be typical if the projections for global warming are not reversed.

Climate Change (2 of 2)

Greenhouse gasses

Blanketing effect

Greenhouse effect

Risks can be categorized as follows:

Medium: air, water, soil, or food

Type: chemical, biological, or radiological

Setting: urban, rural, or suburban

Functional location: home, school, workplace, or community

Environmental Health Assessments

National Library of Medicine (NLM)

ToxTown

Household Products page

Environmental pages

Skin deep database

“Right to Know” is an American Nurses Association (ANA) environmental health principle that recommends access to all information necessary to make informed decisions to protect our health.

Information Sources

Note that, in both the NLM and the Safe Cosmetic databases, the information is predicated on what the manufacturers place on the label as ingredients.

The NLM’s website ToxTown (http://toxtown.nlm.nih.gov/) is one of the best places to start when developing environmental assessment skills.

Within ToxTown, there is a new Household Products page where you can research common products such as personal care products, cleaning products, pet care products, lawn care products, and others to see the potential health risks that may be associated with them.

Skin Deep database (http://www.ewg.org/skindeep) includes more than 73,000 products that can be searched by brand name and specific product descriptors. This database provides a ranking of the health risks.

Note the environmental aspects of the problem in every step of the process:

Assessment

Planning

Intervention

Evaluation

Applying the Nursing Process to Environmental Health

Assessment: Use your observational skills (e.g., windshield surveys); interview community members; ask your individual clients; and ask the families of your clients. Review Web-based data on existing exposures, such as air and water pollution monitoring data, drinking water testing, and contaminated soil. Relate the disease and the environmental factors in the diagnosis.

Planning: Look at community policy and laws as methods to facilitate the care needs for the client; include environmental health personnel in planning.

Intervention: Coordinate medical, nursing, and public health actions to meet the client’s needs. Ensure that the affected person or family is referred for appropriate clinical care.

Evaluation: Examine criteria that include the immediate and long-term responses of the client as well as the recidivism of the problem for the client.

Use of the “I PREPARE” mnemonic device

Investigate potential exposures

Present work

Residence

Environmental concerns

Past work

Activities

Referrals and resources

Educate

Individual Environmental Exposure History

I—Investigate Potential Exposures

Have you ever felt sick after coming in contact with a chemical, such as a pesticide or other substances? Do you have any symptoms that improve when you are away from your home or work?

P—Present Work

Are you exposed to solvents, dusts, fumes, radiation, loud noise, pesticides, other chemicals? Do you know where to find material safety data sheets for chemicals with which you work? Do you wear PPE? Are work clothes worn home? Do coworkers have similar health problems?

R—Residence

When was your residence built? What type of heating do you have? Have you recently remodeled your home? What chemicals are stored on your property? Where is the source of your drinking water?

E—Environmental Concerns

Are there environmental concerns in your neighborhood (e.g., air, water, soil)? What types of industries or farms are near your home? Do you live near a hazardous waste site or landfill?

P—Past Work

What are your past work experiences? What job did you have for the longest period of time? Have you ever been in the military, worked on a farm, or done volunteer or seasonal work?

A—Activities

What activities and hobbies do you and your family pursue? Do you burn, solder, or melt any products? Do you garden, fish, or hunt? Do you eat what you catch or grow? Do you use pesticides? Do you engage in any alternative healing or cultural practices?

R—Referrals and Resources

Environmental Protection Agency (www.epa.gov), National Library of Medicine—Toxnet Programs (www.nlm.nih.gov), Agency for Toxic Substances and Disease Registry (www.atsdr.cdc.gov), Association of Occupational and Environmental Clinics (www.aoec.org). Occupational Safety and Health Administration (www.osha.gov), EnviRN website (www.enviRN.umaryland.edu), Local Health Department, Environmental Agency, Poison Control Center

E—Educate (a checklist)

Are materials available to educate the client? Are alternatives available to minimize the risk of exposure? Have prevention strategies been discussed? What is the plan for follow-up?

What does the first letter “E” found in the “I PREPARE” mnemonic device stand for?

Exposure factors

Educational needs

Environmental concerns

Evidence-based practice

Quick Recall (1 of 2)

Answer is C.

Environmental concerns

Quick Recall (2 of 2)

“I PREPARE” mnemonic device

Investigate potential exposures

Present work

Residence

Environmental concerns

Past work

Activities

Referrals and resources

Educate

How’d You Do?

Windshield survey

“Nature-deficit disorder”

Positive environmental factors

Features that can positively contribute to a community’s health

Green space, bike paths, walkable communities

Community-Wide Environmental Health Assessment Tools

A windshield survey is a helpful first step in understanding the potential environmental health risks in a community.

Urban communities: Note proximity to factories, dump sites, major transportation routes, and other sources of pollution.

Rural communities: Note if and when there are aerial and other types of pesticide and herbicide spraying; if people rely on wood-burning stoves; if there are industrial-type agricultural practices and/or contaminated waterways.

Nature-deficit disorder was coined by author Richard Louv in his book Last Child in the Woods to describe what happens to young people who become disconnected from their natural world. Louv links this lack of nature to some of the most disturbing childhood trends, such as the rises in obesity, attention disorders, and depression.

Air

Sources of pollution

Point sources (identifiable—for example, smokestacks)

Non-point sources (mobile—for example, cars and trucks)

Clean Air Act

Indoor air quality (IAQ)

Water

Consumer Confidence Reports (CCRs)

Sources of pollution

Waste from industry, pharmaceuticals

Storm runoff, erosion, especially due to loss of 80% of the world’s forests leading to massive erosion

Environmental Exposure by Media (1 of 2)

Superfund sites: highly contaminated sites, with associated health threats that are designated by the EPA

Brownfield sites: land that has been used previously and which is now slated for redevelopment

Land and soil

Contaminated land designations

Superfund site

Highly contaminated

Threat designated by the Environmental Protection Agency (EPA)

Brownfield site

Previously used

Now slated for redevelopment

Food

Pathogenic causes: Escherichia coli, Salmonella; pesticides; genetically modified organisms (GMOs)

Environmental causes: pesticides, antibiotics in animals

Environmental Exposure by Media (2 of 2)

Superfund sites: highly contaminated sites, with associated health threats that are designated by the EPA

Brownfield sites: land that has been used previously and which is now slated for redevelopment

Air Pollution

Several environmental statutes give the public the right to know about the hazardous chemicals in the environment.

Health professionals and community members can easily access key information by zip code regarding major sources of pollution that are being emitted into the air or water in their community.

Consumer Confidence Reports

Hazard Communication Standard

Material safety data sheet (MSDS)

Right to Know

The EPA has an “Envirofacts” section on its website that provides several sources of exposure data by zip code.

When a water supplier provides drinking water to a community, the supplier, in contrast to individual wells, must test the water and report the results to its customers in the form of a consumer confidence report. Nurses should review the consumer confidence reports, sometimes referred to as right to know reports, to determine what pollutants have been found in the drinking water.

Hazard Communication Standard: this standard requires employers (including hospitals) to maintain a list of all of the hazardous chemicals that are used on-site.

Process to determine the probability of a health threat associated with an exposure

Four phases

Assess toxicology and epidemiologic data.

Has the chemical been released?

How much and by which route of entry of the chemical?

Risk assessment process

Subject to interpretation

Risk Assessment

Four phases

Determining whether a chemical is known to be associated with negative health effects (in animals or humans)

Determining whether the chemical has been released into the environment: into the air, water, soil, or food

Estimating how much and by which route of entry the chemical might enter the human body

Characterizing the risk assessment process and taking into account all three of the previous steps

Social determinants contribute to risk levels.

Economic factors: lower income clients are at increased risk for health problems

Live in substandard housing

Live in close proximity to pollution sources

Employed in more dangerous occupations

Have less access to healthy food options

Life cycle factors

Very young and very old are more vulnerable

EPA report: “Growing Smarter/Living Healthier: A Guide to Smart Growth and Active Aging”

Vulnerable Populations

Children’s bodies operate differently than adults, putting them at potentially increased risk for toxic exposure.

Increased respiratory rate translates to a proportionately greater exposure to air pollutants.

Immature blood-brain barrier

Kidneys less effective at filtering undesirable chemicals

Children’s Environmental Health

Increasingly difficult to prove specific hypotheses regarding the relationship of exposure to a singular chemical and disease outcome in humans

A “precautionary approach” advised when animal research and other indicators demonstrate a possible toxic relationship between a chemical and health effect

The Precautionary Principle

The American Nurses Association (ANA) has adopted the precautionary principle as the basic tenet on which to guide its environmental advocacy work.

Apply basic principles of disease prevention.

Prevention is a core goal in PHN.

Every nurse’s role in risk reduction

Shift to e-records to avoid paper

Recycle

Promote minimal packaging and green wrappers

Go fragrance free

Turn off equipment not used

Report dysfunctional plumbing

Promote local sustainable foods (organic)

Start a Green Team

Create community

Environmental Health Risk Reduction

Every nurse’s role in environmental risk reduction:

Shift to electronic records, thus avoiding the use of paper. When paper is a must, use products that are made from recycled ingredients.

Recycle: paper, glass, cans, plastic, small batteries, blue wrap, electronic equipment

Work with suppliers to get products with minimum packaging and the safest ingredients possible— “environmentally preferable purchasing”

Promote the use of green cleaners.

Go fragrance free—using fragrance-free products in the hospital and creating a policy that requires employees to use fragrance-free personal care products (shampoos, creams, etc.)

Turn off lights, computers, patient monitoring equipment when rooms not used

Report leaky sinks, toilets, and other plumbing sources.

Promote the purchase of local, sustainably grown foods (with a preference for organic, no use of GMOs, no use of unnecessary antibiotics, and no pesticides).

Start a hospital/clinic/health department garden.

Start a Green Team, or join the existing one in your institution.

Create community while doing these activities and build relationships—it makes the whole process more meaningful and fun!

Industrial hygienists: public health specialists

Workplace exposure to hazards that contribute to health risks

Hazards: physical, chemical, and biological

Hierarchy of controls

Three Rs to reduce environmental pollution

Reduce

Reuse

Recycle

Industrial Hygiene Hierarchy of Controls

Industrial hygiene hierarchy of controls

Eliminate unnecessary toxic chemicals.

Substitute less hazardous or non-hazardous substances (e.g., using water-based vs. solvent-based products).

Isolate the hazardous chemicals from human exposure (e.g., use closed systems).

Apply engineering controls (e.g., ventilation systems, including exhausts hoods).

Reduce the exposures through administrative controls (e.g., rotating employees in areas with high exposures).

Use personal protective equipment (e.g., gloves, respirators, protective clothing).

Risk communication includes all the principles of good communication in general.

It is a combination of the following:

The right information

To the right people

At the right time

Risk Communication

Risk communication includes all the principles of good communication in general. It is a combination of the following:

The right information: Accurate, relevant, in a language that audiences can understand. A good risk assessment is essential information for shaping the message.

To the right people: Those affected and those who are worried but may not be affected. Information on the community is essential: geographic boundaries, who lives there (i.e., demographics), how they obtain information (e.g., flyers, newspapers, radio, television, word of mouth), where they congregate (e.g., school, church, community center), and who within the community can help plan the communication.

At the right time: For timely action or to allay fear.

Federal agencies for environmental health regulation

Environmental Protection Agency (EPA), Food and Drug Administration (FDA), Department of Agriculture

United States Department of Health and Human Services (USDHHS)

The National Institute for Environmental Sciences (NIEHS), The National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC) (including the National Center for Environmental Health (NCEH))

Important steps and concepts

Permitting

Environmental standards

Compliance

Monitoring

Governmental Environmental Protection

An important step in the process of controlling pollution is permitting, a process by which the government places limits on the amount of pollution emitted into the air or water. A permit is a legally binding document.

Environmental standards may describe a permitted level of emissions, a maximum contaminant level (MCL), an action level for environmental cleanup, or a risk-based calculation; environmental standards are required to address health risks. It is the responsibility of potential polluters to operate within the regulations and standards. Compliance and enforcement are the next building blocks in controlling pollution. Compliance refers to the processes for ensuring that permit/standard/regulatory requirements are met. Clean up or remediation of environmental damage is another control step. Public information and involvement processes, such as citizen advisory panels or community forums, are integral to the development of standards, ongoing monitoring, and remediation.

Nurses can guide and drive policy.

1 in every 100 Americans is a registered nurse!

Nurses have a responsibility to be informed and take action in the best interest of public.

Nurses can serve as resources for state and federal legislators and staff.

Nurses also work as advocates for environmental justice and rights of others.

2008—Alliance of Nurses for Healthy Environments

Created to coalesce nurses and nursing organizations around relevant issues

Policy and Advocacy

Certain environmental health risks disproportionately affect poor people and people of color in the United States.

1993: Environmental Justice Act was passed

1994: Executive Order 12898, “Federal Actions to Address Environmental Justice in Minority Populations”

Environmental Justice and Environmental Health Disparities

If you are a poor person of color,

More likely to live near a hazardous waste site or an incinerator

More likely to have children who are lead poisoned

More likely to have children with asthma

Methylmercury exposure

Persistent Bioaccumulative toxins (PBTs)

Chemicals that do not decompose

Also referred to as persistent organic pollutants (POPs)

Dioxin

Pollutant created by health care industry

Created by incineration of chlorine

Health care without harm

ANA was a founding member of this campaign.

Environmental Health Threats From the Health Care Industry

Mercury:

Mercury thermometers and sphygmomanometers

Hospitals that use incinerators to dispose of waste

Synthetic chemicals

Persistent bioaccumulative toxins (PBTs) or persistent organic pollutants (POPs)

These are chemicals that do not break down in air, water, or soil, or in the plant, animal, and human bodies to which they may be passed.

An international campaign called Health Care Without Harm is working to reduce and eliminate mercury and polyvinyl chloride (PVC) plastic in the health care industry, as well as the elimination of incineration of medical waste. The American Nurses Association (ANA) was a founder of the Health Care Without Harm campaign, and nurses have taken many leadership roles in the activities in the United States and around the world. The Health Care Without Harm website (http://www.noharm.org) and the ANA’s website (http://www.nursingworld.org/rnnoharm/) provide outstanding information and resources about pollution prevention in the health care sector.

National Library of Medicine’s ToxTown

EPA (www.epa.gov)

Environmental epidemiology unit or toxicology unit of the state health department

Association of Occupational and Environmental Clinics (www.aoec.org)

Pediatric Environmental Health Specialty Units (10 of these in the United States)

Poison control centers

Agricultural extension offices

Referral Resources

Community involvement/public participation

Individual and population risk assessment

Risk communication

Epidemiologic investigations

Policy development

Roles for Nurses in Environmental Health

As nurses learn more about the environment, opportunities for integration into their practice, education programs, research, advocacy, and policy work will become evident and will evolve. Opportunities abound for those pioneering spirits within the nursing profession who are dedicated to creating healthier environments for their clients and communities.