Pleasereadpriortoclass! HandoutforEnvironmentasaDeterminantofHealthsession Dr.LauraMcLeod September20,2010 Whatisenvironmentalhealth? 1. effectsofenvironmentonhumanhealth,nothealthofecosystem,thoughtheseare interrelated. 2. apublichealthdiscipline,carriedoutbypublichealthinspectorsalsocalledenvironmental healthofficers 3. amedicalfieldofpracticenotaRoyalCollegeSpecialtyyet,butengagedinbyOccupational MedicineandCommunityMedicinespecialistsandfamilyphysicians. Whatistheimpactoftheenvironmentonhealth? TheCanadianInstituteforAdvancedResearchin2001estimatedthatthephysicalenvironmentwas responsibleforabout10%ofhealthstatusinCanada.Incountrieswithpoorsanitationandhygiene, thispercentageismuchhigher.(Sewagesystemsreducediarrheaincidenceby3060%.

Itsimportanttorecognizethatthedeterminantsofhealthseldomactinisolation,butareinterrelated. socioeconomicstatusaffectsyourphysicalenvironment.e.g.wealthyneighbourhoodsarent builtnexttoindustrialareas. educationaffectsyourknowledgeofhazardsintheenvironmentandhowtoavoidthem. personalhealthpracticesareinfluencedbytheenvironmentyoulivein: healthyeatingisstronglyinfluencedbythesupplyofsafe,nutritiousfoodsvs.unsafe foodsorjunkfoods.Somestudieshaveshownincreasedobesityinneighbourhoods withmoreaccesstofastfoodrestaurantsthantosupermarkets.Exposuretofoodborne infectiousdiseaseswillbemuchhigherwhentherearefewsafefoodstochoosefrom. Activelivingishighlyinfluencedbyurbanplanning,availabilityofparks,bikepaths,and safestreets.Atrendinurbanplanning,NewUrbanism(AndresDuanyandcolleagues) looksatneighbourhooddesignandhowitaffectsactivityaswellassocialinteraction. Squareblockneighbourhoods(likethosebuiltbeforethe1960s)areeasierfor pedestrianstonavigatethanneighbourhoodsbuiltwiththecurvingstreetsofmost

modernsuburbs.Peoplelivinginmodernsuburbsaremorelikelytodriveevenshort distancesthanpeopleingridneighbourhoods. Smokingpatternsarestronglyinfluencedbypublicpoliciesbanningsmokinginpublic places.Smokefreebuildingshavedramaticallybetterairqualitythanthoseinwhich smokingispermitted. Healthychilddevelopmentisstronglyinfluencedbyexposuretoeitherinfectionsorchemical pollutants,especiallythosethathaveneurotoxiceffects.Childrenaremorevulnerableto pollutantsthanadults,foravarietyofreasons.Theyexploretheworldwiththeirmouthsas infants,soingestmore;theyplayinthesoilsoingestmoresoilcontaminants;theyhavemore rapidrespiratoryratessoinhalemoreairpollutantsfortheirmass;theyaresmall,sothesame doseisagreaterdose/kg;andtheirorgansarestilldeveloping,somorevulnerabletodamage, particularlytheirbrains.

biologyandgenetics:Certaindiseasessuchasasthmamakesomepeoplemorevulnerableto pollutantsthanothers.Aswell,biologicalprocessesofagingmaketheelderlymorevulnerable tosomeenvironmentalthreats,particularlyheat.Thereisdevelopinginterestinthegene environmentinteraction.Thenewscienceofepigenomicswhichlooksathowspecific chemicalsmodifyDNAtoturnspecificgenesonoroff,ishelpingustoseeexactlyhow environmentalexposurescanaffecthealth,butalsowhypeoplecanreactdifferentlytoa commonexposure.Ithinkthatthegeneenvironmentinteractionwillbeagrowingfieldof medicineinthefuture.

Frameworkforlookingatenvironmentalexposures: WeusewhatiscalledaRiskassessmentframework.WellgointothisinmoredetailinthePrevention Unitlecture,butatthispointwewilllookatthefirststep,HazardAssessment. Whatisahazard?anythingthatcouldcauseharm. Howarehazardscategorized? Biologicalhazardsmicroorganismsorallergansthatcanharm,i.e.pathogens,notcommensals Chemicalhazards Physicalhazardsusuallyatransferofenergy - kinetice.g.energychangesfrommovementtostoppingwhenhittingthefloorafter trippingisatransferofkineticenergyfromthefalltothetissuesinjuredbytheimpact. - ergonomicrepetitivestrainsonmusclesandtendons - radiationUV,ionizing Psychologicalhazardsaresometimesincludedaswell,dependingontheissue. Itisextremelyimportantinenvironmentalhealthtorememberthatthesimplepresenceofahazard doesntmeanharmwilloccur.Butitisoftenassumedbypatientsandthegeneralpublicthatthe presenceofahazardmeansadversehealthimpacts.Wewilllookintothisinmoredetailintherisk assessmentframeworkinNovember. Whatdoestheenvironmentconsistof?

thenaturalenvironment:air,water,soil,biomass(everylivingorganism) thebuiltenvironment:whichincludescommunicationandtransportationsystemsaswellashomes, offices,schools,hospitalsandotherbuildings. Forhumanhealthpurposes,biomassisusuallyconsideredtobemicroorganisms,food,us,oritis ignored. Wastes:whicharepartlybiomassandpartlybuilt Theglobalenvironmentincludessuchcomplexmultisystemissuesasclimate,warandsolarradiation.

AIR Mosthazardsinairarechemicalhazards,pollutantscausedbycombustionoffuels,byindustry,firesor vehicles:CO,CO2,NO,hydrocarbons,andparticulates. Carbonmonoxidebindstohemoglobinformingcarboxyhemoglobin,andisfatalathigherlevels, usuallyinconfinedspaceslikeahome,garage,trailer,ratherthaninthebroaderenvironment.At lowerlevels,headachesandfatiguearecommon. Carbondioxideathighlevelscancauserespiratoryirritation,headache,irritability,butismore importantasagreenhousegaslinkedtoglobalwarming. T henitrogenoxidesareimportantcomponentsofphotochemicalsmog(thatbrownbandyou sometimesseeonthehorizoneastofCalgaryondaysofweatherinversions).NOisproducedby combustion,andNO2isasecondarypollutant,usuallyformedbyoxidationofNObysunlight,butcan alsobeaprimarypollutantfrompowerplantsorgasstoves.NO2combineswithhydrocarbonsinthe presenceofUVlighttoformO3,ozone.BothNO2andO3arerespiratoryirritants,andNO2cancause increasedrespiratorybacterialinfections.Animalstudieshaveshownitcanalsoincreaselungcancer metastases,thoughitisnotcarcinogenic.

NasasatellitephotoofNO2levels.Mostlyelevatedwhereyouwouldexpect,basedonhigherindustrial areasoftheworld.(redishighest)NotethewhitishareainAlberta! Hydrocarbonsinairpollutionaremanydifferentchemicals.Manypolycyclicaromatichydrocarbons (PAH)areproducedfromdieselfuelcombustion,andarecarcinogenic.Formaldehydeisproduced fromthecombustionofalcoholfueladditives,andisbothanirritantandanasalcarcinogen.Thereare manyothers,varyingwiththefueltypes,andmanyarecarcinogenic. Particulatesarethetinyflecksofmatterintheairmadeupofdustsandcarbonmoleculesthatcan adsorbhydrocarbonsoracidsontothem.Intherecentforestfiresmokeepisode,extremelyelevated particulateswerethereasonfortheairqualityadvisorytellingpeoplewithlungdiseasestostay indoors.Theyareinhaledintotherespiratorytractdifferentdistancesdependingontheirsize. ParticulateMattergreaterthan10micronstendstolandinthenasopharynxwhereitcanbeclearedby themucussystem.Thesmallcategoriesofparticulates,PM10andPM2.5,canbeinhaleddeeplyinto thealveolaeofthelungs,wheretheytriggerirritanteffectsbutalsoduetohydrocarbontransport, depositcarcinogens.

Theabovecombustionbyproductsarecommoninwoodburning,cigarettesmokeandautomobile emissions.Whenlookingatindustrialemissions,alloftheaboveareproduced,butalsoSulphur Dioxide.Sulphuriscommonincoal,socountrieswherecoalisusedforindustryorheating(Chinaisa biguserofcoal,aswasBritainuntilrecenttimes)havemuchhigherSO2levels.SO2isanacidaerosol, andatriggerofbronchoconstrictionandcomponentofacidrain.

Photochemicalsmog. InLondonin1952therewasanairinversionthatelevatedlevelsofSO2andparticulatesby310times, hospitalbedswereovercapacity,andmanypeoplediedfromrespiratoryandcardiaccauses.This episode,knownastheLondonFog,wasatriggerforrecognitionofthehealtheffectsofairpollution. InAlberta,SO2isprimarilyproducedbyflaringofsourgas,butthisflaringhasdecreasedby70%since the1970s.SourgasdrillingisabigindustryinAlberta.Thegasiscalledsourbecauseitcontains HydrogenSulphide,H2S,whichcanbeinstantlyfatalinlargeamountsandcausesirritanteffectsand nauseainsmallerdoses.Excessgasoranemergencyreleaseofgasisburned,whichproducesSO2, whichisarespiratoryirritant,butnotfataltomostpeople.

Sourgasflare GroundlevelOzone,alsocalledtroposphericozone(differentfromstratosphericozonediscussedlater) isanothersecondarypollutant,becauseitisntproducedimmediatelybycombustionbutfromthe reactionreferredtoabove,ofNO2andUVlightandHydrocarbons.GroundlevelOzoneisarespiratory irritant,andhastheinterestingeffectoftriggeringareflexinthelungsofasthmaticsthatblocksdeep inhalation.Nonasthmaticsexercisingwhileexposedtoozonewillhaverespiratorysymptomsranging fromnoseandthroatirritation,tocough,wheezeandchestpain,andothernonrespiratory symptomslikeheadacheandfatigue.InAlberta,themajorcitieshaveregularexceedancesofthe thresholdforozonesoarerequiredbyAlbertaEnvironmenttodevelopozonemanagementplans.

Otherhazardsinair: Asbestoswasusedininsulationuntilthemid20thcentury,soolderbuildingscancontainasbestos, usuallyasinsulationofpipes.Manyhavebeenremediated,soyoucantjudgeitspresencesimplyby theageofthebuilding.Asbestosisntairborneunlessitisdisturbed,somainlybecomesaproblem whenolderbuildingsarebeingrenovated.Ifasbestosfibresareinhaled,theyareahighriskfactorfor asbestosis(whitelung)andthedevelopmentofmesothelioma,ahighlymalignantcancerofthepleura, andlungcancer.(Smokingmagnifiesthisriskoflungcancerfromasbestos,soisnotjustanadditive risk.) Lead:leadusedtobeacommonadditiveingasoline,sowasanairpollutantanddepositedonsoils nearmajorroadways.Childrenlivingnearmajorroadsoftenhadelevatedleadlevels.Sinceleadhas beenbannedingasolineinCanada,leadlevelsinthepopulationhavefallensignificantly.Itwas commoninpaintsuntilthemid20thcentury.Itisreleasedfromthepaintwhenthepaintisdisturbed, suchaswhensandingthepaintedsurface.(Infantsandyoungchildrencouldalsoingestleadfrom gnawingonpaintedsurfacessuchascribrailings.)Inthe1980sleaddustwasidentifiedonwindow miniblinds.Elevatedleadlevelscauseneuropsychologicaleffects,includinglearningdifficulties. Volatileorganiccompounds(VOCs):thisgroupofchemicalsincludebenzene,chloroform,methanol, formaldehydeandhundredsofothers.Indoors,theyemanatefrompaints,drycleaningresidueson clothing,upholsteredfurnitureandcarpetglues. Theycancauserespiratoryirritation,headachesandathighlevelsneurologicaleffects.(Theseare usuallyseeninoccupationalexposures.) Newbuildingshavethehighestlevelsandovertime(about6months)theydiminish;tospeedtheoff gassingoftheVOCs,buildingsaresometimesbakedoff,whereinthetemperatureisraisedandthe ventilationmaximizedtocleartheVOCsmorerapidly. Allergens:pollen,animaldander,mouldsporesandinsectfeces(primarilydustmiteandcockroach) willtriggerallergicreactionsinsensitivepeople.Humidityincreasesbothdustmitesandmould. Mouldisoftenfoundinbuildingswithwaterdamage,fromfloodsorleakingpipesorroofs.Itshealth effectsarecontroversial,withclearevidenceofallergyinsusceptibleindividuals,andriskofinfection inimmunecompromisedpeopleandsomeothers.Thecontroversialeffectsaretheneurotoxicones frommycotoxinsfromcertainblackmoulds.TheCollegeofEnvironmentalandOccupationalMedicine saysthesemycotoxinsareheavypeptidesandnoteasilyairborne,soareonlyarisktopersons disturbingthemduringmouldremediation.Howevertherearemanypeoplewhobelievetheycan becomeillfromthepresenceofthesemouldsinabuilding,andmanybuildingshavebeendestroyed becauseofmould.

Physicalhazardsthattravelthroughtheairincludeheatandcold,airpressure,soundandradiation. Thesehavetheobviouseffectsassociatedwiththosehazards,butIwontdiscussthemindetail. Radiationcanbenonionizing(visiblelight,UVlight,lasers,andelectromagneticfields)orionizing(the kindthatisusedinXrays,radiationtherapyandnuclearweapons.)Ionizingradiationathighlevels causesskinburns,bonemarrowsuppression,radiationsicknessanddeath.UVeffectsarediscussed belowintheozoneholesection.Healtheffectsofelectromagneticfieldsareanongoingcontroversy, firstwithpublicconcernsthatchildrenlivingnearhighvoltagepowerlineshadanincreasedriskof leukemiaandlymphoma,forwhichnoclearevidencehasshownarelationship.Morerecentlycell phonesandbraintumourshasbeenapublicconcern,andmostrecentlywirelessnetworks,withsome schoolsineasternCanadabanningwirelessintheschools.Forbothofthesetherehasbeennostrong evidenceeither. HealtheffectsofAirPollution:

Irritanteffects:conjunctivitis,rhinitis,asthma. Cancer:nasopharyngeal,lung,mesothelioma. Infections:theinflammatorychangestriggeredbyairpollutionhavebeenshowntodecreasethe immuneresponseandphysicaldefenses(ciliaryclearance)toinfections,soincreasetheincidenceof otitismedia,bronchitisandpneumonia.SomenewepidemiologicalresearchattheUofC(Dr.Gil Kaplaan)hasshownarelationshipbetweenairpollutionandappendicitis,andheisnowlookingat inflammatoryboweldiseaseandairpollution.Itappearsthattheimmunechangesinducedbyair pollutantsarenotrestrictedtotherespiratorytract. Neurotoxicity:fromCO,heavymetalsandVOCs.Headache,learningdifficulties,andmoresevere neurotoxicityifhigherlevelsthaninnormalairconcentrations.ThereisanincreasedrateofSudden InfantDeathSyndromeininfantsexposedtoindoortobaccosmoke. Reproductivetoxicity:increasedriskoflowbirthweightinfantsinmotherswhosmoke.Thereis controversyaboutwhetherairpollutioncontributestomiscarriageinhumansandanimals.(Thisis

particularlyanissuewithsourgasemissions,wherestudieshavebeenconflictingastowhetherthere isanincreaseinlossofcalvespriortobirthorinthefirstyearoflife.) Cardiotoxicity:someairpollutants(CO,Particulates,Sulphuroxides)havebeenshowntoexacerbate symptomsinthosewithunderlyingheartdisease,socancauseincreasedangina. Death:fromcancer,cardiopulmonarycauses,orneurotoxicity. TheBurdenofAirPollution: Deaths ERvisits Cost Alberta2008 173 8638 $600million Canada2008 21,000 30,000 $8billion Canada2031 39,000 (N/A) $18billion

CMAJSept23,2008/www.cma.ca Clearlyareductioninairpollutioncouldleadtosignificanthealthsystemsavings,aswellaslossoflife. Globally,theburdenofairpollutionismuchgreater.Industryislessregulatedindevelopingcountries, whatregulationsexistareoftennotenforced,andthecountrieseconomiesoftencantaffordtolimit industrialactivity.TheBrownAsianSmogcloudisapermanentsmogcloud3kmthickoverlyingparts ofChinaandSEAsia,andkillingthousandsandadverselyaffectingthehealthofmillionsofpeople. (RememberwhentheOlympicstookplaceinBeijingandthegovernmentshutdowntheindustriesfor thedurationofthegames?)Similarsmallercloudsexistelsewhereintheworld. Indoorairpollutionismuchhigherinplaceswherepeoplecookinsidewithoutchimneys.Smoky indooraircontributestorespiratoryinfectionsthatkill4millionayear (WorldBankfigure),mostlychildrenunder5yrs.

Particulatelevelsabove50100micrograms/m3cancauseseriouslungdiseaseandriskofcancer; insidehomesinNepalandPapuaNewGuinealevelsof10,000havebeenrecorded.

WATER Waterisusuallycategorizedasdrinkingwaterorrecreationalwater.Hazardsinwaterareusually ingested,butcanalsohavedermaleffects,likecontactdermatitisfromirritantchemicalsinwater. Schistosomiasisisaparasiticinfectionthatentersthebodythroughskinexposuretofreshwater infestedwiththemicroscopiclarvae.Thediscussionbelowwillfocusoningestedhazards. Drinkingwater: Waterforconsumptioncanbefromasurfacesourceoragroundwatersource.Belowisaschematicof asurfacewatersystem.

Surfacewatersarealwayscontaminated,tovaryingdegrees,fromrainwaterrunofffromtheland surface,ordirectlyfromanimalsorbirdsdefecatinginthewater,orfromhumansewagepipedinto thewaterbody.Groundwaterisusuallypurer,butitcanbecontaminatedfromleakywells,or excessivesepticfieldpercolation,orchemicalcontamination. Walkerton,OntariohadaninfamouscrisisofE.coliO157:H7contaminationofwellwaterwithsurface manure,causingmanypeopletobecomeilland7todiefromhemolyticuremicsyndrome(kidney damagefromtheinfection).ThetownofBraggCreekwestofCalgaryisonapermanentboilwater advisoryduetobacterialcontaminationofgroundwaterfromsepticfields.LargeareasofAlberta havegroundwaternexttocoalseams,andmethanefromcoalcontaminatesthewater.Peopleliving intheseareascanlighttheirwateronfire!Currentindustrialactivitydrillingforcoalbedmethaneisa potentialrisktoincreasesuchcontamination.(Therearenohealtheffectsfromthemethaneasitoff gasesatroomairpressure,butitisanexplosiverisk.Aswell,othertracehydrocarbonsfromthecoal poseapotentialriskfromingestion.)

RecreationalWater: Recreationalwatercanbenatural,suchaslakesandoceans,orconstructed,includingswimmingpools, hottubs,waterslidesandwaterparks.Naturalrecreationalwatersarevulnerabletosewageand chemicalcontaminationfromagriculture,industry,andsepticsystems.Poolsandotherwaterfacilities arevulnerabletofecalorganismcontamination,whetherfromachildsfecesororganismsontheskin ofbatherswhodontwashthoroughlybeforeenteringthepool.Hottubscancauseaskininfection, Pseudomonasfolliculitis(fromabacteriathatcanliveinhottemperatures),ifnotproperlydisinfected. Halogenssuchaschlorine(orbromineinsomepoolsandhottubs)areusuallyusedtomaintainproper disinfectionofdrinkingorrecreationalwater.Ultravioletlightissometimesused,asisozonation,and reverseosmosisinsmallprivatesystems.Therecanbecarcinogenicchemicals(trihalomethanes) producedfromtheinteractionofhalogenswithorganiccompounds,buttherisktradeoffofmass epidemicsofwaterbornediseasesoutweighthepotentialriskofthesechemicals.Toreducetherisk, organicmaterialsareremovedasmuchaspossibleinwatertreatmentplantspriortochlorination.For urbansystems,chlorinationispreferabletoUVorotherdisinfectionsystems,becausearesiduallevel canbemaintainedtoprotectwaterthroughoutthedistributionsystem.

Insufficientwaterisalsoahealthrisk,aswaterisneededtosurvive.Washinginwaterisimportantfor preventingskinandeyeinfections.Inmanydevelopingcountries,watersupplyismoreimportantthan waterpurity. Hazardsinwater: WaterbornediseasesincludehepatitisA,cholera(Vibriocholerae),typhoid,(Salmonellatyphi), variousE.coliinfections(pathogenic,toxigenic,hemorrhagicetc)GiardiasisandCryptosporidiosis.The lasttwoaretheonlymajorcausesofillnessincountrieswithgoodwatertreatment.Thesporesof theseprotozoans,GiardiaandCryptosporidia,areresistanttochlorineandotherdisinfectants.People withhealthyimmunesystemsrarelybecomeinfectedfromthefewsporestheymayingest,but immunecompromisedpersonsshouldbetoldtodrinkfilteredorboiledwater.Thatsaid,therehave beenoccasionaloutbreaksofCryptoinvolvingtenstohundredsofthousandsofpeople.Locally, Giardiaiscommonlyknownasbeaverfeverasitisacommondiseaseinhikersdrinkinguntreated

surfacewater.Itisalsocommoninreturningtravelers,whooftenpresentwithchronicdiarrheaand gas. (Mostwaterborneinfectionscanalsobetransmittedpersontoperson,orviafood.)

Giardia Cryptosporidium Chemicalhazardsinwater: Naturallyoccurring:arsenic,fluoride(inexcessiveamounts,wellabovewhatisusedinfluoridation.) ArsenichasbeenabigprobleminBangaldeshafterwellswereprovided.EveninAlbertawehavesome communitieswitharsenicinthewater. Agriculturalrunoff:nitratesinwellwaterfromfertilizercancausemethemoglobinemiaininfants. Pesticidescanbeanothercontaminant(seeFoods). Industrialwastewater:heavymetals(moreafoodchainissuethanwateringestion),andpersistant organiccompoundssuchasdioxins(commonfrompulpmills)andfurans. Leachatesfromlandfills:heavymetalsandhydrocarbons. Pharmaceuticals,especiallyfemalehormones,fromcontraceptivesandmenopausalreplacement therapy.Effectsonfish,andpossiblyhumans.?decreasingspermcounts,possiblecarcinogens. Distributionsystem:oldwaterpipesweremadeoflead,andmorerecentonesmayhavehadlead solder.(newerpipesareplasticorcopper).

 PhotosofresidentsofavillageinMexicowithhighleadandarsenicinthewater.Notetheleadlines inthegums.(PhotoscourtesyofDr.DavidBethune,hydrogeologist,whoworkedinthecommunity.) HAZARDSINSOIL

Soilpollutantsusuallyaffecthumanhealththroughcontaminationoffoods.However,therearesome soilpollutantsthataffecthealthdirectly. Biologicalhazards: Parasiticdiseasessuchashookworm,orcutaneouslarvamigransarepickedupfromeggsorlarvaein thesoil.Inthecaseofhookwormtheeggsareingestedoffhandsthatcontactedsoilwhereeggswere depositedinhumanfeces;withlarvamigransthelarvacontacttheskindirectlyfrombarefeetwalking onsandcontaminatedwithanimalfeces.

 Hookworm(scanningEM) Cutaneouslarvamigrans Thehookwormlatchesontotheintestinalwallandcausesanemia.Larvamigransisjustanirritating selflimitingdisease,butoneyouarelikelytoseeinreturningtravellersfrombeachholidays. Bacterialinfectionsfromsoil: Clostridialinfectionsfromthesoilcancausebothgasgangrene(Clostridiumperfringens)andtetanus (Clostridiumtetanii).Botharecausedbybacteriainfectingasoilcontaminatedwound.Ingas gangrene,theoutcomeisoftenamputationoftheinfectedbodypart,ordeath,andintetanus,itis usuallydeath,ifnotpreventedbyimmunizationortetanustoxoid.Tetanuscausesspasmodic contractionofmuscles,dominatedbythestrongermusclegroup,soarmflexionandbackandneck extension.Deathoccursfromrespiratoryfailure.Itiscommonininfantsincountriesofpoorsanitation andlowimmunizationrates,wheretheportalofentryistheumbilicalcordstump.

GasGangrene

Tetanus

Radiationhazardsinsoil: Radonisacommonhazardinmanypartsoftheworld.InAlbertathereisnotmuchradon,butthereis inSaskatchewan.Itisradiationfromthebedrockthroughsoils,anditcanriskpenetratebasementsof housesthroughvariousentrypoints(seediagram).Radoniscarcinogenic,particularlyforlungcancer.

NaturalResourcesCanada Chemicalsinsoil: Industrialcontaminants:Aspreviouslymentioned,leadcancontaminatesoils,bothbyroadwayswhere leadedgasolineisstillused,andfromindustrialcontamination.Otherheavymetalslikecadmiumand mercurycanbefoundinindustrialsites. Pesticides:Manydifferentpesticidesarespreadonsoiltokillweeds,fungiorinsects.Theyaremost commoninagriculturalareas,butthecosmeticuseofpesticidesforweedcontrolinlawnsandpublic parksisgettingincreasingattention.Pesticidescanhavemanydifferenthealtheffects,dependingon thetypeofchemicalandhowitisabsorbed,whetherinhalationofvapours,ingestiononfoods,or throughskincontact. Someinsecticidesarecholinesteraseinhibitors,andcauseneurologicalsymptomsrangingfromblurred visionandheadachetoneuropathy.Otherpesticidescancausefetaltoxicity,teratogenicity,irritantor photodermatitis,cataractsandimmunesystemdamage.Somesourcessaypesticidescantrigger asthmaandlymphomasmaybelinkedtopesticides.Moreresearchislikelyneeded.Thosemostatrisk frompesticidesarethosewithoccupationalexposures,particularlyinpoorercountrieswherethe storageandadministrationofpesticidesispoorlyregulated.Ihavemetoccupationalmedicine specialistsandintegratedpestmanagementspecialistswhohaverepeatedlyfoundopenbarrelsof pesticidesstoredunderbedsinhomes.

HAZARDSINFOODS:

Microbial: Themostcommonfoodbornhazardismicrobialcontamination. Thesemicrobescancontaminatefoodanywhereonthefarmtoforkpath,fromirrigation(Iwaspart ofaninvestigativeteamthatlinkedaCalgaryrestaurantoutbreakofShigellatoparsleyfarmedinBaja Californiawheretheirrigationwaterwascontaminated),fecalcontaminationoffields(animalor human)ormeat,harvesting,transporting,storage,displayingforsale,transporthome,storage, preparationandcooking.Inrichercountries,refrigerationoffoodisstandard,butnotinpoorer countries. Bacteriagrowwellinthetemperaturerangeof4o60oC.Buffetfoodsareoftenleftforlongperiods atroomtemperature,iftherestaurantdoesntprovidegoodhotandcoldtables.Crosscontamination offoodswithrawmeatjuicesisacommonsourceoffoodinfectioninthehome.

Anicemodelofhowfecaloralcontaminationcanoccur.ThanksagaintoDr.DavidBethune.

 Consequenceofmanyfoodborneillnesses! Commonfoodborneinfectionsare: E.coliO157:H7(socalledhamburgerdisease,butcommononmanymeats.Grindingdistributesthe bacteriathroughoutthemeat,whereasasteakwilljusthavebacteriaonthesurfacesoitseasiertokill theorganismswithcooking) SalmonellaandCampylobacter(bothcommononpoultry,aswellasothermeats) Listeria(delimeats,softcheeses)whichisahigherriskinfectiontopregnantwomen,andpersonsover 60 Staphylococci:thebacteriaproduceatoxinwhichcausesnauseaandvomitingandabdominalpain,but notusuallydiarrhea.Becauseitisatoxin,symptomoccurrenceisrapidafteringestion,withinafew hours,comparedtodaysneededforsufficientnumbersofbacteriatoreproduceandcauseillnessin otherinfections. HepatitisA,theviraloneofthegroup(ofteninshellfishthatgrewinsewagecontaminatedseawater). Priondiseasesareaspecialcaseoffoodborneillnesses.BovineSpongiformEncephalopathy(BSE)is thebestknown.Inthe1980sand90s,prionsinthebrainandspinalcordofcattleweretransmitted whenanimalfeedcontainedanimalparts.Meatfrominfectedcattletheningestedbyhumansledto humandisease,whichpresentsasarapiddementiaandlossofcoordination.Cattlearenolongerfed animalprotein,andtheslaughteringprocessnowminimizesanycontaminationofmeatwithspinal cordorbrain,sohumancasesarenolongeroccuringindevelopedcountries.

Chemicalhazardsinfood: Manychemicalsarefoundinfood,frompesticides,toantibioticsandhormonesgiventoanimals,to foodadditives.Somefoodsrequiremorepesticidestogetthemtomarketlookingappealingto consumers,andothersless.(Youcancheckoutlistsoftheseonthewebifyouareconcerned.mostof thetimewashingyourfruitsandvegetables,especiallywithsoap,willremovemostoftheresidue). Thehealtheffectsofmostofthesearepoorlyunderstood.Antibioticsinanimalscontributeto antibioticresistantorganismsinhumans.HealthCanadahassaidthatthefoodinCanadianstores containssuchsmallamountsofthesechemicalsthatthereisnocauseforconcern. Naturallyoccurringtoxins:manyfoodscontainnaturallycarcinogenicchemicals.Thisisarealsurprise. Broccoliisone.Butthegoodnutrientsinthefoodsoutweighanypotentialharmfromthem,sothereis noreasontogiveupeatingvegetables. Onetypeofnaturaltoxinhowevershouldbeavoided:aflatoxinsaremycotoxinsproducedby Aspergillisspeciesonfoodssuchaspeanuts,grains,andoils,inwarmhumidconditions.These aflatoxinsarelinkedtoprimarylivercancers,especiallyincombinationwithHepatitisB. Bioaccumulatedcontaminants:theseareheavymetalsorpersistantorganiccompoundslikePCBs,that persistinfat,andareaccumulatedupthefoodchain.Manypersistentorganiccompoundsarepresent inbreastmilk.Largecarnivorousfishareamajorsourceofbioaccumulatedchemicals,sincewedont eatmanycarnivorousmammals.Mercuryisaneurotoxin,particularlytodevelopingnervoussystems.

OneofmanychildrenexposedtomercuryinuteroinMinamataJapan,inthe1950swhenindustrial effluentcontaminatedthefisheatenbypregnantwomen.Thereweremanychildrenwithmental handicapsandneurologicaldamage. WASTES Wastesarejustgroupingsoforganismsandchemicalsthathavebeendiscussedaboveinwaterand soil,butitisimportanttoconsiderthembecauseaddressingtheminvolvesknowinghowtheyare disposedof.

Biomasswastes:sewage,decayinganimalsandplants

SewageenteringthemediterraneanoffMalta. Solidwastes:plastic,metal,glassetc.

dumpingofhouseholdwastes Hazardouswastes:radioactive,chemical,biomedical

Chemicalwastesareoftenstoredinbarrelsthaterodeovertime,releasingtheircontents.Radioactive wastehastobestoredsafelyalmostforever.Biomedicalwasteisusuallyincineratedtokillany pathogens.Therehavebeencommunitiesadverselyaffectedbychemicalwastes,suchastheLove Canal,theSydneyTarPonds,andmanyRioGrandecommunities.

Hazardsfromanimals:

PhysicalTrauma(bites) ChemicalVenoms(wasps,bees,jellyfish) Biological Insectvectorbornediseases:malaria,Japaneseencephalitis,dengue,WestNilefever,yellowfeverare allmosquitoborne;Lymedisease,tickborneencephalitis,andRockyMountainspottedfeveraretick borne;plagueandtyphusarefleaborne.LymediseasehasnotbeenaprobleminAlberta,althoughit hasbeenpresentinsoutheasternB.C.foranumberofyears.However,inthelastfewyears,several ticksofoneofthespecies(Ixodes)whichcancarrytheLymediseaseorganismhavebeenfoundtobe infectedinAlberta,sowewilllikelystartseeingcases.

Zoonoticdiseases: Rabiesisavirusthatattacksthecentralnervoussystem,andisalmostuniversallyfatalbythetimeitis diagnosed.Itistransmittedinsalivaofamammalatthetimeofabiteorscratch.Itisverycommonin developingcountries,mostlycarriedbydogsandmonkeys,butfewcasesoccurinCanada,dueto variouspreventiveprograms.InAlberta,themostcommonlyidentifiedrabidanimalsarebats,and occasionallycatsanddogs.Verysmallmammalssuchasrodentsandsquirrelsarerarelytransmitters ofrabies.

Hantavirusisavirusdiseaseofrodents,particularlydeermice,whichisexcretedintheurineandfeces ofthemice,theninhaledwhenaerosolizedduringcleaningofdroppings.Itcausesasevereacute respiratorydistresssyndromewhichcanbefatal.InAlbertaweusuallyhaveacoupleofcasesayear, usuallyinspringwhenpeoplecleanupoutdoorsorinsheds.Duetoaclusterofcasesonareservein CentralAltaafewyearsago,HealthCanadadidanepidemiologicstudyofmiceincentralAlta,and foundmanymicewereinfected,especiallyinoldbarnsandotherabandonedbuildings,wherethey cameincontactwithothermice,onandoffreserve. EntericinfectionssuchasSalmonellacanbetransmittedfromhouseholdpetstotheirowners.Turtles andreptilesarecommoncarriersofSalmonella,anddogsandcatsfedrawmeatsareofteninfected. Fungalinfectionslikeringwormcanbespreadfrompetstoowners.BirdscancarryPsittacosis,alung infection. Plagueisaveryrarediseasenow,afterallthecarnageitcausedinthemiddleages,butstilloccurs occasionallyinthesouthwesternUS,VietnamandIndia.itisarodentinfection,transmittedtohumans byfleas. EmergingZoonoses:

Ashumanspushdevelopmentfartherintoforestedareas,theycomeintocontactinlargernumbers withanimaldiseases.SARS,Ebola,SimianBvirus,andLymediseaseareallattributedtothisincreased contactwithanimaldiseases.EvenHIV,althoughnolongeremerging,isthoughttohaveoriginated withcontactwithprimateblood.

THEBUILTENVIRONMENT:

Asmentionedabove,thebuiltenvironmentincludeseverythingbuiltbyhumans,sobuildings,roads, phones,computers,toys,clothing,furniture,etc. Mostofthehazardsinthebuiltenvironmenthavebeendiscussedabove,exceptphysicalhazards causingtrauma. Idliketopayparticularattentiontoacommonissuereferredtoassickbuildingsyndrome.Thisisa misnomer,sincethebuildingisntsick;itsthepeopleinitwhofeelill.Modernbuildingsarebuiltvery tightlytomeettheneedforenergyefficiency,butasaresultareoftennotventilatedwell.Aswe discussedinthechemicalairpollutants,manybuildingmaterialsgiveoffVOCs.Aswell,peoples personalbehavioursindoorscontributetopoorairquality;smokingindoorswascommonuntilrecent years,andstilloccursinmanyprivatebuildings.Perfumesandotherscentedbodyproductsrelease VOCs.EvenbreathingindoorsreleasesCO2,whichifitreacheshigherconcentrationscancause headachesandirritability. HVAC(Heating,ventilationandairconditioning)systemsinbuildingsneedtobedesignedand operatedproperly,totakeinairfromarelativelycleansource,appropriatelyhumidifyit,andexchange itfrequentlyenoughtomeettheneedsforfreshairforthenumberofpeopleinside.Somebuildings havetheirairintakesnexttothetruckloadingdocks,oronabusystreet,ornexttotheairexhaust! Peoplecomplainingofheadaches,eye,noseandthroatirritationandcoughsinofficebuildingsthat improvedwhentheywenthomeusedtobedismissedasmasspsychologicalphenomena,orpeople whohatedtheirjobs,butinmorerecentyearsithasbeenrealizedthatbuildingaircanbecausing theirsymptoms.Indoorairqualitycanbemeasuredandifinadequatecanbeimprovedinmostcases. AsomewhatrelatedissueisthatofMultipleChemicalSensitivity,iepeoplewhoreportbeingmadeill byamuchlargerrangeofsubstancesthanareknowntoirritateallergicpeople.Again,thishasbeen attributedtopsychologicalproblemsbymostphysiciansandscientists,butothersfeelthatitisatrue hypersensitivity.

GLOBALENVIRONMENTALISSUES: Ozonedepletion:

NASAGFSC2006. Thissectionisreferringtostratosphericozone(good),notgroundlevelozone(bad). ThelayerofozoneinthestratosphereprotectstheearthfromtheUVradiationofthesun.Chemical catalystssuchasChlorofluorocarbons(fromindustry,refrigerationandairconditioning,andaerosol cans)combinewithozoneinthepresenceofcoldtemperatures,andcreateoxygenandaholeinthe ozonelayer,mostpronouncedoverthepoles.EventhoughtheCFCsarentbeingproducedanymore, theyhaveahalflifeof75yearsormore,sotheireffectsareexpectedtocontinue.HealtheffectsofUV radiationincludesunburn,skincancer,retinaldamageandcataracts.Thereissomeevidenceof decreasedimmuneresponseaswell.ThesearegoingtobemostpronouncedinsouthernChileand Argentina,AustraliaandNewZealand.EffectsinCanadasnortharentlikelytobeasgreat,sincethe northernpoleozoneholeissmallerthanthatofthesouthernpole. GlobalWarmingandClimateChange: Althoughthereisstillsomedebate,particularlyintheenergysector,abouttheexistanceofglobal warming,theglobalmeantemperatureisatitshighestsincetemperatureswererecorded.Regardless ofthecause,thiswillhaveincreasingimpactsonhealthifitcontinuestorise.

GreerAetal.ClimatechangeandinfectiousdiseasesinNorthAmerica:theroadahead.CMAJMar11,2008

Youareundoubtedlyaware(ifnotfromAlGoresfilmAnInconvenientTruth,fromnumerousbooks andmediaarticles)oftheenvironmentaleffectsofglobalwarmingandclimatechange.Risingsea levelswouldfloodlowlyingfoodproducingareasliketheNiledeltaandBangladesh,displacing millionsofpeopleandlimitingfoodsupplies.(Thiskindofimpactissimilartowhatweareseeingnow inPakistanfromsevereinlandflooding.)Heatcouldcausedroughts,desertificationofnowarable land,cropfailures(likeweareseeingnowinCanada,RussiaandtheUkraine),andlossofforeststo firesandinsects(likeweareseeinginBCwiththeforestfiresandpinebeetledevastation).Airquality candecreaseduetoincreaseddust,photochemicalsmog,andfiresmoke.Insectvectorswillmove fromcurrenttropicalareasintonewareasasthoseheatup.Climatechangecanbringstorms,flash floods,soilerosionandlandslides.Massmigrationsofpeoplewouldbelikelyduetofamineorlossof homes,climaterefugees.

Thehealtheffectsofglobalwarminginclude: increasedrespiratoryandcardiovasculardiseasefrompoorerairquality malnutritionandfaminefromdecreasedfoodproduction increasedvectorborneandwaterborneinfections(floodscontaminatewatersupplies) increasedinjuriesinfloodsandstorms increaseddeathsfromheatstress(butlessfromcold!onegoodthingaboutglobalwarming.) mentalhealthstressors EGProjectedmovementofLymediseasevector:

GreerAetal.ClimatechangeandinfectiousdiseasesinNorthAmerica:theroadahead.CMAJMar11,2008.

Muchofwhatwewillbeabletodoaboutglobalwarmingisalreadyintherangeofaccommodation tochangesratherthanbeingabletoreverseorslowthewarming.Emergencypreparednessand disasterplanninginAlbertaincludessuchnaturaldisastersasfloodsandtornados.Asfuture physicians,youneedtobeawareoftheseglobaltrendstobeabletoshapehealthpolicy,service deliveryetctomeettheneeds.Canadamaybeinafortunateposition(otherthanthedroughtprone areasoftheprairiesandthefires)withincreasedfoodproductioncapacityinthenorth,andgreater waterresourcesthanmostoftherestoftheworld,sowilllikelybeatargetofincreasingmigration morethanoffamine.Migrationmovesmicroorganismsintonewgeographies.Beingculturally competentandbeingawareofthepsychologicaltraumaofdisplacedpersonswillbeincreasingly importantskills. Backtotheenvironment! Finalglobalissue:war Warcreatesspecificenvironmentalhealthhazardsfromtrauma,andthepotentialforchemical, biologicalandnuclearwarfare.Inwar,thenaturalenvironmentisusuallydestroyed,sofood production,waterandfuelsuppliesaredisrupted.Massmigrationsofpeopleoccur,fleeingtosafety. Refugeecampsrequirespecifichealthplanningandservicedelivery. InCanadawearenotimmunetoconflictsinotherpartsoftheworld,andparticularlyterroristacts,so wehaveplanstodealwithchemical,biologicalandnuclearexposures.In2001thereweresome isolatedusesofanthraxasaweapon,butwidespreadpanicandimitatorsmailingbenignwhite powdersrequiredemergencyresponses.Thethreatofsmallpoxishighonthelistofbiologicalweapon concerns,sincetherearefewpeoplewithnaturalorvaccineimmunityanymore,sinceitwas eradicatedinthe1970s(exceptforafewlaboratories). SUMMARY: Theenvironmentismadeupofthenatural(air,water,soil)andbuiltenvironments.Hazardsexist whichmaybebiological,chemical,orphysical.Healtheffectsofexposurestothesehazardsaremany, rangingfromdevelopmentalandreproductivetoxicity,organtoxicitysuchaslung,brain,liveror kidney,toinfectionsandcancers. Childrenaremorevulnerabletoenvironmentalexposuresthanadults. Environmentalissuesarenotonlylocalexposurestohazards,butalsoglobaltrendsthatimpactthe environmentandtherebyhumanhealth.