Moore On Health is presently enrolled at University of San Francisco – Population Health Leadership program. One of the requirements for course NURS 7007 Environmental and Occupational Health is to create blog entries disseminating information about environmental health. This course is designed to introduce the Population Health Leadership DNP scholar to a wide range of human health risks associated with the environment, including air, water, food, and product exposures. #NursePractitioners #EnvironmentalHealth #MooreOnHealth #USFCA

Week Nineteen | Sanitation – Basic Public Health

In Santa Barbara County there are at least two major water districts with each having treatment facilities.  For Montecito a portion of the treated water is not returned to the system for consumption but rather routed to the ocean.  Citizens in the community have questioned this practice and challenged local officials to construct plans where treated water can be recycled.  Statistics regarding the amount of untreated water suggest more than 500000 gallons could be reused if the infrastructure were updated to allow this water flow (https://www.independent.com/2018/10/13/montecito-water-war-erupts/).

Water treatment facilities are located across the county as this map shows (https://www.santabarbaraca.gov/gov/depts/pw/resources/system/cater/default.asp).  No single community is being singled out in terms of placement.

Previous blog entries have made mention of the scarcity of water in the county. As a result, water district has been more open to working together to address the supply crisis. The hope and expectation is that this collaboration will lead to long term success for the county and residents.

It’s impossible at times to comprehend 1.2-1.3 billion people living in a country that has the same land area as 2.2 Alaskans.  Said differently, the US is roughly 3 times larger than India in terms of land area (https://blogs.scientificamerican.com/observations/africa-is-way-bigger-than-you-think/). India is also the largest democracy in the world in terms of population.  Can the government that manages 1.3 billion people agree on policy/strategy or anything for that matter (https://en.wikipedia.org/wiki/India)?

Constructing a plan to solve India’s sanitation issue will require innovative thinking. On the one hand it’s accepted culturally.  On the other hand, there is a cost to bear.  Who pays this cost?

India has been successful in linking math and science dominance to world class engineers and programmers.  On the other hand, India has been successful in linking sanitation to health concerns or health cost.  The country doesn’t feel the collective pain of XX number of people using the streets as toilets.  Only then will India address the issue with the same energy and passion as attacking STEM related subjects.

Week Eighteen | Grow What You Eat 

You will not find any pesticides over here! Before reading and viewing all of the materials in this module, my family has made it a point to always eat organic.  In fact, since moving to California we’ve made it a point to grow all of our own vegetables. Interestingly, we can tell the difference between store bought veggies and the veggies grown in our organic garden.  Some of the immediate, noticeable differences are taste, color, crunch, impact on our bodies (i.e., digestive systems, cardio), etc. 

Even our pet chickens prefer our garden veggies vs. those purchased in a store. Now that we are aware of these differences, we are left asking how do the stores make the fruit look so appealing on the shelfs? What chemicals are local farmers using to increase their production?

Having said all of this, we became even more acutely aware of pesticides during our time in China where we lived for 4 years. That part of the world does not (or did not) have governmental bodies protecting the consumer from dangerous chemicals. Even though we were buying vegetables from only western stores, we washed the produce extensively while also preferring to buy organic. To be fair many vegetables in China are imported from places like Thailand and Australia, but we still took more care while living there. The video of the Indian farmers is exactly what comes to mind when one lives in China. 

In terms of public health there are two aspects that deserve some consideration: a) protecting the farmers and b) protecting the consumers.  Protecting the farmers of California seems to be happening in pockets. As I mentioned, we have seen farmers in masks and protective clothing in nearby counties long the 101 highway. In looking at farming videos on YouTube many farmers across the US use water-based, less harsh chemicals or dry chemicals that are naturally found in nature and/or are allowed by government agencies. Farmers are incentivized now more than ever to use chemicals that are sustainable because consumers and land conservationists are demanding action. Not following the rules means missing out on markets that need these goods.

Consumers are being protected in part by the labels that tell us where the goods are coming from. Some effort is still required by the consumer to research what the farming practices are for a given country or region. Consumers should not assume that a specific retailer is looking out for their best interest. In addition, organic farmer’s markets seem to be a more common occurrence – meaning farming locally. More education and awareness are required to ensure consumers take a more active role in understanding where goods are sourced. To be fair economic levels have something to do with what consumers are purchasing.  Each level of consumer needs the right level of knowledge so that proactive steps can be taken in order to promote positive health behaviors where pesticides are concerned.

If I was at a playground and knew of pesticides being used I would likely take the following actions:

1. Communicate to all of the parents at the playground to make sure they are aware of the hazards
2. Communicate on social media about the playground and the chemicals being used
3. Schedule a meeting with local officials to learn more about what the plans are for the playground and to learn what can be done to immediately remove the threat.
4. Look for longer term solutions involving placing placards on the property whenever pesticides are used or planned to be applied
5. If my practice was in the same neighborhood as the playground, then notices can be placed in my waiting area or common visiting rooms so that patients and visitors are more aware.
6. Whatever the communication is, I would love to have it translated into Spanish so that these folks are also aware of the dangers of pesticides.

My family lives in an area where crops are grown and roundup is used frequently to control weeds by farmers and landscapers. While my practice is focused primarily on SNF/LTC facilities, reviewing the effects of these pesticides was helpful for me. I partner closely with infectious disease and ER physicians as well as partnering with a medical director.  While I can identify the symptoms associated with these chemicals, it’s good to have other resources and experience to draw upon. #NoPesticides only #MooreOnHealth via #OrganicGardening techniques – #ItsALifeStyle and not a diet. 

Week Seventeen | Nutritional Health Check for the Homeless

Presently I manage patients at a long-term care / skilled nursing facility. Many of my skilled SNF patients are homeless. So, I true to educate and connect to the various non-profit resources within the community before they are medically cleared to be discharged to the homeless shelter.  

The homeless population are not positioned to be selective about the food they eat. At times they are uninformed about how a nutritional intact is important and directly related to their health and wellness. This population is usually dealing with  a variety of personal problems (e.g., mental illness, substance abuse) that hinders their efforts to get enough to eat. Since the mid-1980’s a tremendous expansion of homeless services, particularly food programs, with nutritionally adequate meals are now available at most shelters and at soup kitchens and other venues.

A standardized and validated tool: Malnutrition Universal Screening Tool (‘MUST’) is freely available to screen adults for malnutrition in the community and can be used by all care workers. ‘MUST’ is a five-step screening tool to identify adults who are malnourished, at risk of malnutrition (under nutrition), or obese (BAPEN). The ‘MUST’ tool can be accessed through the following link: http://www.bapen.org.uk/must_tool.html .

Resources:

https://www.qni.org.uk/wp-content/uploads/2016/09/nutrition_guidance.pdf

Lee, B. A., & Greif, M. J. (2008). Homelessness and hunger. Journal of health and social behavior, 49(1), 3–19. doi:10.1177/002214650804900102

Week Sixteen | Select More Sustainable Foods

As a Nurse Practitioner  (NP) I believe it is important to be a physical illustration of what I prescribe to our community at large – health and wellness. NPs are on the front lines of health care treating multiple patients with unique needs and can relate these professional experiences regarding how legislation can better support these patients. Promoting a healthier more sustainable eating lifestyle involves interventions consistent with primary prevention – aim to reduce the onset and/or incidence of disease. Thus, to help the community engage in making more sustainable food purchases we must educate them on way.

What makes food “sustainable”?

According to the Sustainable Agriculture Research and Education, sustainable food is considered as:

• produced by farmers and ranchers who care for the health of their animals and the land
• sourced locally and seasonally directly from family farms or farm cooperatives
• cooked from scratch to minimize processed ingredients
• good for the environment, the people who grow it, and the people who eat it

Why purchase sustainable food?

Sustainable food is considered to be more nutritious, tastes better and is good for the environment. Farmers that utilize the techniques promoting soil health through composting, mulching, cover cropping, crop rotation, and crop diversity eliminates the need for chemical pesticides, fertilizers, and herbicides.

For those that are who are red meat eater – did you know that 95% of US meat comes from Confined Animal Feeding Operations (CAFOs)? It is said the pigs in CAFO conditions eat a diet that is designed to be cheap and to fatten them up quickly. In addition they eat mostly grain and are routinely given growth hormones and antibiotics. Waste from these farms have the potential to carry pathogens, bacteria (often antibiotic resistant), and heavy metals that can be toxic when ingested. Researcher indicated that the numerous wastes produced by intensive swine production not only pose a significant challenge to effective environmental management but also are associated with decreased air quality in confinement houses, potentially transferable antimicrobial resistance patterns, and several infectious agents that can be pathogenic to humans (Fuentes & Suarez. 2018).

 Moore On Health believe in empowering the community at large to take better care of  themselves and the planet. We need to reduce our intake CAFOs meat – if not completely – and eat sustainable grass-fed animal products. Remember – you are what we eat.

Resources:

https://www.nrcs.usda.gov/wps/portal/nrcs/main/national/plantsanimals/livestock/afo/

https://www.sierraclub.org/sierra/2017-2-march-april/feature/cafo-industrys-impact-environment-and-public-health

Ramos A, Fuentes A and Carvajal-Suarez M (2018) Self-Reported Occupational Injuries and Perceived Occupational Health Problems among Latino Immigrant Swine Confinement Workers in Missouri, Journal of Environmental and Public Health, 10.1155/2018/8710901, 2018, (1-8), Online publication date: 19-Jun-2018

Week Fifteen | Do you know where your water comes from?

Did you know that private wells are not regulated under the Safe Drinking Water Act and well owners are not required, except in some jurisdictions, to test their water.

Your drinking water comes from natural sources that are either groundwater or surface water. Groundwater comes from rain and snow that seeps into the ground. The water gets stored in open spaces and pores or in layers of sand and gravel known as aquifers. We use water wells or springs to harvest this groundwater. Most people in the U.S. who live in large cities and towns get their water from a public water supply. If you have a public water supply, a local government agency or private industry delivers water to your home.

Not only do we need to be aware of how chemicals impact our water supply – what about weather conditions? Recently, a Boil Water Advisory for areas in the Santa Barbara county. The advisory was the result of incurred damages to surrounding infrastructures secondary to heavy rainfall and mudflows that took place on January 9, 2018. Due to the extent of damages at individual service connections and to the system amassive effort to repair and disinfect its distribution system was made following the storm damage from the deadly floods and mudslides. Customers in certain areas where advised to boil or otherwise disinfect their tap water before using it for drinking or cooking, or use bottled water.

It is said that, “monitoring water quality provides empirical evidence to support decision making on health and environmental issues,” Donna N. Myers. In the United States, an emphasis is placed on monitoring for compliance with the Clean Water Act and Safe Drinking Water Act, which are administered by the U.S. Environmental Protection Agency (EPA). It has become very challenging to monitor water because of the large number of chemicals used in our everyday lives and in commerce that can make their way into our waters. Current methods of chemical analysis and knowledge of chemical toxicity are available for only a few thousand of the more than 80,000 chemical compounds estimated by EPA to be in commercial use in the United States. Here is a list EPA’s National Primary Drinking Water Regulations 

Here is a video that explains how water is processed.  – Know You Water

An example of why we need to monitor water quality is the case of corrosive water, one of the underlying causes of lead in drinking water in Flint, Michigan, Washington, D.C.

Click on the EWG images, enter your zip code and learn where your tap water comes.

Resources:

https://water.usgs.gov/owq/WhyMonitorWaterQuality.pdf

https://www.epa.gov/assessing­and­managing­chemicals­under­ tsca/how­epa­assesses­chemical­safety

https://www.congress.gov/bill/114th­congress/senate­bill/697/all­ info#summary

https://www.usgs.gov/news/chemicals­elk­river­spill­lingered­longer­ traveled­farther

https://www.usgs.gov/news/new­study­shows­high­potential­ground­ water­be­corrosive­half­us­states­0

Week Fourteen|Environmental Health – H2O

The Central Coast region of California relies on a number of water sources to supply residents, industry and agriculture.  These sources include water from reservoirs (man-made), desalination plants, rainwater, ground water and surface water (lakes, rivers, etc). A chart below shows the exact breakdown of the sources of water (http://www.montecitowater.com/quarterly-water-supply-update.htm?u=0119) for a community in Santa Barbara county. For this part of the state most of the water discussion centers less on water quality and more on water supply. The water districts play a significant role in controlling water supply.  There are a number of NGOs in the area with perhaps the most involved being the Montecito Association (https://www.montecitoassociation.org).

As the chart above shows, ground water makes up 12 to 15% of the required water supply. Ground Water supply has been limited by the number of permits issued in the county.

Managing ground water has become the job of many guardians in the community including those in local government.  There is an extensive well permit process in place for anyone who wants to use ground water as a source of water for their property (https://countyofsb.org/uploadedFiles/phd/PROGRAMS/EHS/Water%20Well%20Application%20Packet.pdf). Much of this process has to do with monitoring and controlling the supply of water sources given its scarcity.

In many respects everyone in this community is a water guardian.  Becoming a ground water guardian will mean understanding the permitting process, required equipment and the fees involved while working with local land owners to determine how best to comply the procedure. Local reaction to the new process has been mixed (https://lompocrecord.com/news/local/new-wells-will-require-discretionary-permit-in-santa-barbara-county/article_049720b4-9ecd-52c0-b67b-b39263dfdc17.html) but all seem to agree that there are likely some scenarios where new wells make sense.

Week Thirteen|Radon, Carbon Monoxide and VOCs Awareness

Health care providers should be aware  educate the patients on the harmful effects radon exposure, carbon monoxide poisoning and volatile organic chemicals.

 Radon Awareness

Did you know that the 2^ndleading cause of lung cancer is exposure to radon? However, smoking causes more lung cancer deaths. If you smoke and your home has high radon levels, your risk of lung cancer is especially high.

 Radon is a radioactive gas. It comes from the natural decay of uranium that is found in nearly all soils. It typically moves up through the ground to the air above and into your home through cracks and other holes in the foundation. Your home traps radon inside, where it can build up.

Any home may have a radon problem. This means new and old homes, well- sealed and drafty homes, and homes with or without basements. Radon from soil gas is the main cause of radon problems. Sometimes radon enters the home through well water. Nearly 1 out of every 15 homes in the U.S. is estimated to have elevated radon levels. Elevated levels of radon gas have been found in homes in your state. Contact your state radon office (http://www.epa.gov/radon/find-information-about-local-radon-zones-and-radon-programs) for general information about radon in your area.

The average indoor radon level is estimated to be about 1.3 pCi/L, and about 0.4 pCi/L of radon is normally found in the outside air. Where Can I Get a Radon Test Kit?

 Carbon Monoxide (CO) Poisoning Awareness

The symptoms and signs of carbon monoxide poisoning are variable and nonspecific. The most common symptoms of CO poisoning are headache, dizziness, weakness, nausea, vomiting, chest pain, and altered mental status. The key to confirming the diagnosis is measuring the patient’s carboxyhemoglobin (COHgb) level. COHgb levels can be tested either in whole blood or pulse oximeter.

The symptoms and signs of carbon monoxide poisoning are variable and nonspecific. The most common symptoms of CO poisoning are headache, dizziness, weakness, nausea, vomiting, chest pain, and altered mental status. The key to confirming the diagnosis is measuring the patient’s carboxyhemoglobin (COHgb) level. COHgb levels can be tested either in whole blood or pulse oximeter.

It is important to know how much time has elapsed since the patient has left the toxic environment, because that will impact the COHgb level. If the patient has been breathing normal room air for several hours, COHgb testing may be less useful.

 According to the CDC – Guidance for Management of Confirmed or Suspected CO Poisoning

• Administer 100% oxygen until the patient is symptom-free, usually about 4-5 hours. Serial neurologic exams should be performed to assess progress, and to detect the signs of developing cerebral edema.
• Consider hyperbaric oxygen therapy (HBO) therapy when the patient has a COHgb level of more than 25- 30%, there is evidence of cardiac involvement, severe acidosis, transient or prolonged unconsciousness, neurological impairment, abnormal neuropsychiatric testing, or the patient is ≥36 years in age. HBO is also administered at lower COHgb (<25%) levels if suggested by clinical condition and/history of exposure.
• Hyperbaric oxygen is the treatment of choice for pregnant women, even if they are less severely poisoned. Hyperbaric oxygen is safe to administer and international consensus favors it as part of a more aggressive role in treating pregnant women.

According to the CDC – Directrices clínicas para la intoxicación por monóxido de carbono (CO) después de un desastre

El monóxido de carbono (CO) es un gas inodoro, incoloro y tóxico que puede causar enfermedad y muerte repentinas si se encuentra en una concentración lo suficientemente alta en el aire del ambiente. Cuando se producen cortes de electricidad durante emergencias —como huracanes o tormentas invernales—, el uso de fuentes alternativas de combustibles o electricidad para calentar, enfriar o cocinar puede producir una acumulación de CO en la casa, el garaje o la casa rodante para acampar, e intoxicar a las personas y a los animales que estén adentro. Los generadores, parrillas, estufas (cocinas) de campamento y otros aparatos que funcionan con gasolina, gas propano, gas natural o carbón nunca se deben usar dentro de la casa, el sótano, el garaje, una casa rodante para acampar, y ni siquiera afuera cerca de una ventana abierta o de una unidad de aire acondicionado instalada en una ventana.

Volatile Organic Compounds’ (VOCs) Impact on Indoor Air Quality

There are three VOCs that can be commonly found in homes such as: paint thinners, cleaning supplies, and glue contained in carpets (https://foobot.io/guides/list-of-common-volatile-organic-compounds.php). Most of these examples are petroleum based so ethanol, butanol and alcohol are the most common chemicals. The key to first be aware that these hazards are present in the households.  With this knowledge these hazards can be avoided by buying organic, by storing the products in a well-ventilated area and by ensuring the chemical detectors are present throughout the home to maintain safe living conditions.

Healthcare providers who extends their practice to the home visit should include an assessment that include symptoms that are more common to carbon monoxide poisoning including those outlined by the Mayo clinic (https://www.mayoclinic.org/diseases-conditions/carbon-monoxide/symptoms-causes/syc-20370642). In addition to the H & P assessment the home visit might also include taking a portable reading using a tool from one of the top choices in consumer reports (https://www.consumerreports.org/cro/smoke-carbon-monoxide-detectors/buying-guide/index.htm). Taking a quick reading in portions of the home will ensure patients are safe from this particular hazard.

Sources:

 https://www.epa.gov/sites/production/files/201602/documents/2012_a_citizens_guide_to_radon.pdf

Week Twelve|Healthy Schools

If you live in the Santa Barbara county area and need to find out Environmental Health Services, then go to – https://countyofsb.org/phd/ehs/about.sbc. The Santa Barbara County Environmental Health Services (EHS) is dedicated to protecting the health and well-being of its community through the various programs that we provide. If you have a young child with special needs go to – California Children’s Services(CCS) is a program for people under 21 years of age with certain serious health problems. CCS arranges medical care for these special health care needs. Child Health and Disability Prevention(CHDP) provides free well child check-ups for low income children and youth in California. If a serious medical condition is found, a referral to CCS may be made.

The indoor air quality is generally associated with the outdoor quality. Santa Barbara county air quality is considered the GREEN compared to other counties and the nation.

As a health care advocate with would want to ensure that schools are up to code related to proper ventilation and cleanliness to decrease accumulation of dust particles from chemical residue (i.e. pesticides, exhaust particles, etc.).  

Lastly, be aware of students with asthma and have an activity symptom-free action plan on file. The plan provides details on an individual’s peak flow zones, asthma symptoms, medications and actions to take during a breathing emergency. Educate all school personnel so everyone understands how to read a student’s asthma action plan.

Additional Resources

https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/asthma-education-advocacy/asthma-friendly-schools-initiative/toolkit/strategy-4.html

https://www.epa.gov/iaq-schools

Week Eleven |Transportation

Research suggest that California is considered a car state. In addition, the individuality of a person is linked to the type of car he/she/they are driving. As for public transportation – Californians have in general been slow to adopt the utilization of this resource. According to the American Public Health Association, public transportation has the following positive benefits on the community:

• 95% less carbon monoxide emitted
• 92% less volatile organic compounds (VOCs)
• 45% less carbon dioxides
• 1/25^thaccident rate of public transportation vs. personal automobile
• 6% less likely to be overweight

The central coast is a unique blend of universities, agriculture, poor folks, rich folks, urban settings, and small communities.  As a result of this diversity the transportation system has been updated numerous times to include options. For example, Westmont offers students ride shares to and from campus. The Metropolitan Transit District (MTD) offers bus service between Ojai and Goleta. MTD also offers a steeply discounted fare options for older residents of the area. Amtrak is another option given the train station is right downtown and service includes stops between Seattle and San Diego. While schedules might not always align to requirements, the good news is that planners and city officials are attempting to provide options that don’t involve cars.

Santa Barbara County has a number of planning committees whose sole focus appears to be limiting the sprawl that is taking over other communities in southern California.  Two of the most notable on the central coast are:

• Montecito Planning Commission – http://sbcountyplanning.org/boards/pc/mpc.cfm
• Santa Barbara Architectural Review Board – https://www.santabarbaraca.gov/gov/brdcomm/ac/abr/
• Santa Barbara Planning – https://www.santabarbaraca.gov/services/planning/default.asp

These groups work together to minimum new construction, ensure green space is maintained, monitor permitting process and oversee the community’s general responses to new demands from the state and national government.

Nurse Practitioners are often concerned about the health and wellness of their patient population. One of the ways people can maintain good physical health is to get out and walk. In the case of Santa Barbara County this means getting out and enjoying the sidewalks, bike paths, parks, beaches, mountains, and walking trails.  Since the planning teams are making the extra effort to maintain these spaces, citizens should look to enjoy them as often as possible.

Generally, with assessment plans the goal is to first identify and fully describe a problem.  The Health Impact Assessment (HIA) serves as a methodology for how this assessment might best be performed. In terms of population health or nursing policy, the key is to select a problem or a slice of the medical practice where a systematic approach can be used to completely flush a problem statement and more importantly associated actions and benefits. For example, in the SNF/LTC medical setting HIA can be used to outline a plan of attack on hospital re-admittances. One a plan is implemented, the findings can be shared with the broader community. #PublicTransportation #EnvironmentalHealth #AirPollution

References

https://www.laweekly.com/news/la-is-still-car-crazy-and-we-shouldnt-apologize-for-that-4759210

 https://ncst.ucdavis.edu/wp-content/uploads/2016/10/NCST-TO-033.1-Circella_Shared-Mobility_Final-Report_MAR-2018.pdf

 https://www.apha.org/~/media/files/pdf/topics/transport/apha_public_transportation_fact_sheet_march2012.ashx

https://www.westmont.edu/student-life/living-campus/student-services

 https://sbmtd.gov/maps-schedules/line-14-montecito/

Week Ten |Indoor Air Pollution

The potential risk of mold in homes is worth diving into.  While California homes along the coast are not likely to have basements, they are likely to be bombarded with humid air from the ocean. This moisture and humidity can become trapped in the walls and ceilings of homes.  Older homes likely have plenty of ventilation to dry this moisture but newer homes are often built with modern technology that is often focused on reducing natural ventilation. Home owners need to be more aware of these risks and incorporate fans and air filters to provide improved air flow. The effects of mold are well documented so creating an inhospitable habitat will have positive long-term health benefits.

Research would suggest that hospitals are attacking air flow seriously.  The attached article states that the local building code/requirements for airflow is in the 15-20 ACH (air changes per hour) while more hospitals are in the 20-25 ACH range (https://www.hfmmagazine.com/articles/3246-studying-airflow-in-the-or).  The research suggests that operating rooms are even more aggressive in managing air flow to ensure an unwelcoming environment for germs, air borne particulates, etc.

Many homeowners do a good job of keeping dangerous chemicals in outdoor sheds and work buildings that are well ventilated. On the other hand, homeowners commonly store cleaning supplies under the kitchen sink or in a pantry located close to the kitchen. Research would suggest that volatile organic compounds (VOCs) risks can be greatly reduced if homeowners spend an hour or two periodically inventorying what’s under the sink to ensure the risk of VOC build up is not present. To be fair many homes in California or the central coast areas have hardwood or tiled floors so the risk of absorption is lower than in states where carpet is more common.

While insurance companies often provide a discounted rate for homes with smoke or carbon monoxide detectors, the building codes for the central California coast only asks residents to self-report carbon monoxide detectors (http://sbcountyplanning.org/pdf/C/e-PV%20Permit%20Submittal%20Package.pdf). This suggests an opportunity for both regulatory bodies as well as homeowners and insurance companies to more aggressively attack this potential hazard. Creating a win/win proposal will offer incentives for all stakeholders to get onboard while also saving more than 1300 lives in the US alone (https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201604-318OC).

Homeowners in the US do a good job of annually checking fire alarms.  These annual checks can easily be extended to include carbon monoxide detectors.  Creating more awareness is everyone’s role. #IndoorAirPollution #AirQuality # #EnvironmentalHealth

Week Nine |Air Pollution

In the video – Air Pollution– the speaker talks about air pollution and noted three health effects: cancer, heart disease and lung disease. The narrator went on to state that the effects can occur over long periods of time after the body has ingested a number of common pollutants.

There are two websites that helps determine how a county stacks up against others in the state (and across the country). 

• http://scorecard.goodguide.com/env-releases/land/site.tcl?epa_id=CAD020748125#maps
• https://www.lung.org/our-initiatives/healthy-air/sota/city-rankings/states/california/santa-barbara.html

American Lung’s website suggested that Santa Barbara county is among the best in air pollution while at the same time is subject to ozone risks (like much of the country).  The ozone risk was not surprising given the number of cars, massive farms and volume of industry in the state.  The good news is that California often leads the way in environmental regulation as law makers are keenly aware of these pollution statistics.

The Goodguide website also highlighted the Casmalia Superfund site was once very active in the storage of harmful chemicals that could both impact air quality and/or impact the quality of well water. In reading the website it appears that a cleanup program is under way but there could also be longer term impacts that have not quite surfaced.

There a number of state level agencies that are involved in the regulatory, legal and environmental aspects of pollution control.  These efforts currently impact and/or cover Santa Barbara county.  In addition, the Santa Barbara County Air Pollution Control District (APCD) also takes a very active role. In looking at thewebsite (https://www.lung.org/our-initiatives/healthy-air/sota/city-rankings/states/california/santa-barbara.html) it seems that APCD’s role is one of overseer or enforcer.  The agency provides permits, performs site reviews and educates the public on the facts and figures of the county’s pollution control activities.  This body serves a critical function especially the translation of state laws and policies into local impact and regulation.

While Santa Barbara County has very clean air (low pollution levels in the air) many in the county commute into more congested areas like Ventura, Thousand Oaks and LA. This means that they are more likely to encounter smog or dirty air including CO and NOx from cars and industry. For my practice the key will be to create more awareness for the patients and their families.  It is easy to forget the potential long-term threat to one’s health when going about our daily business so being more aware is a good first step. #AirPollution #EnviromentalHealth

Week Eight | Environmental Justice is Social Justice 

Week Seven | Environmental Health & Neurodevelopmental / Reproductive Risks

There are of course obvious and less obvious ways in which a community can pay for resources to assist those in need. The first method is in the form of taxes which are translated into services that are used to treat those impacted by these conditions. These services are often criticized as being too few and, in some cases, not as impactful as they could be but they are incredibly necessary. For example, neighborhood clinics are needed in order to provide services for those on the lower economic scale. Taxes from cannabis sales or from the sale of cigarettes help to pay for health services but there is still an issue related to health care equity, reach and impact.

As a Nurse Practitioner and health care advocate I am positioned to conduct quality improvement projects that will help implement new policies designed to decrease or eliminate exposure to environmental health hazards. It has been well documented that even with increased health care access the medical non-compliance will remain high if the surrounding environment does not support job security (Hamad, Modrek, & Cullen, 2015).

Studying the impact of hazards on adolescents, the natural follow on question is – what’s the long-term impact to society if IQs are lower by 5 or 10% vs. previous generations (all because of lead or PCB poisoning)?  It has been identified that women with stored lead in their body  will re-mobilize in the event of pregnancy. When a fetus begins developing, the woman’s body releases stored calcium, vital building blocks of life and toxins impacting the baby’s development (Silbergeld, 1991).

Increasing the knowledge base of the everyday citizen can have a huge impact on the community at large. This awareness can occur in consultation sessions or over the internet through social media. Some of the consequences of more awareness is that patients become smarter consumers – opting for organic products for example vs. genetically modified organisms (GMOs) and/or products with less safe ingredients. Making better choices around the type of food could have a generational impact in the fight against diabetes and other chronic common diseases. More knowledge means more power for the patient and for the consumer. Stopping for a moment and thinking about this reality is helpful (and frightening). #EnvironmentalHealth #GMOs #HealthHazards

References

Hamad, R., Modrek, S., & Cullen, M. R. (2015). The Effects of Job Insecurity on Health Care Utilization: Findings from a Panel of U.S. Workers. Health services research, 51(3), 1052–1073. doi:10.1111/1475-6773.12393

Silbergeld, E. K. (1991). Lead in Bone: Implications for Toxicology during Pregnancy and Lactation. Environmental Health Perspectives, 91, 63. doi:10.2307/3430984

Week Six | Body Burdens Due to Environmental Exposures

After reviewing the CNN YouTube news special on “Body Burdens”of Potentially Toxic Chemicals with Anderson Cooper the realization about these exposures became real. I find it interesting how biomonitoring data has evolved and becoming readily available. It is well understood that besides occupational exposure scenarios, exposures can also occur through air, dust, water, food and using consumer and personal-care products. However, human biomonitoring determines internal exposure (i.e. body burden) by measuring the chemicals, their metabolites or specific reaction products in human specimens (e.g. urine or blood). Biomonitoring represents an integral measure of exposure from multiple sources and routes (Angerer et al. 2006; Needham et al. 2007). According to the CNN special biomonitoring data permit a new approach to exposure assessment even when the quantity and quality of external exposures are unknown or ambiguous, (Koch & Calafat 2009).

As a member of the health care advanced practice registered nurse profession, we have an ethical obligation to advocate for safe and efficient environmental resources for the community at large, ANA Provision 6. 

For example, we continue to use hand sanitizer within various patient settings. However, studies are questioning the makers of antibacterial hand sanitizers and related products to provide data showing the products’ active ingredients actually reduce bacteria and if these ingredients are harmless to those using the product. Clearly, we lack the enforcement of regulatory processes to monitor premanufacturing of such chemicals and how they could impact the human body.

Moving forward health care providers should include within the patient History & Physical examination documentation if the person is living next to environmental hazardous communities or using hazardous products / chemicals.

For instance, I live near what’s consider the world’s largest cannabis market located in Santa Barbara County. In fact, according to Cannabis Business Times, “Santa Barbara County has more cultivation licenses than any other location in California (2,221 to runner-up Humboldt County’s 1,525, according to Cannabiz Media).” The Network Environmental Systems, have shown there are some hazards associated with direct contact with marijuana plants: biological, chemical, and physical.

 

• Biological – employees who cultivate and/or trim marijuana may be susceptible to mold
• Chemical – Carbon Dioxide (CO2) is used in liquid gas or dry ice form to increase plant growth and during the extraction process
• Physical – those managing the plants are handling compressed gas contained in heavy equipment,repetitive postures(Ergonomics) from trimming and exposure to photokeratitis due to the UV rays used for the plant growth.

#BodyBurdens #EnvirnomentalHealth 

References

Koch, H. M., & Calafat, A. M. (2009). Human body burdens of chemicals used in plastic manufacture. Philosophical transactions of the Royal Society of London. Series B, Biological sciences, 364(1526), 2063-78.

FDA – Hand Sanitizers Carry Unproven Claims to Prevent MRSA Infections. Retrieved from https://www.fda.gov/forconsumers/consumerupdates/ucm251816.htm

Marijuana Industry Hazards. Industrial Hygiene, NES Safety Topic – (2018). Retrieved from https://www.nesglobal.net/marijuana-industry-hazards/

Week Five | How Green Are Your Home Cleaning Supplies?

Moving Forward – We only get one planet and we need to create pieces of legislation that is sustainable for the community at large. According to The World Counts, “we already need 1.5 planets for our consumption, waste and our current consumer society is based on a system that’s not sustainable.” It is said that some companies make claims about implementing Green standards but are actually lobbying Brown.

We need primary legislation to utilize a tool rating how a product would impact our planet. This rating system could possibly give a compass to how a company should be taxed and/or be required to implement a green initiative improving their negative rating to better protect our planet.

In the Past, I grew up on Lysol, Pine Sol, Bleach and Tide as our staple home cleaning products. Coming home and smelling anyone of these products meant that our home or clothes were clean. Today, I realize that clean is not equivalent to a specific odor or smell. In fact, clean air should smell like…NOTHING!

After doing some research I discovered that my favorite cleaning products contained the following toxins and/or health hazards.

According to U.S Department of Health & Human Services – Household Product Database, a resource with links to over 18,000 consumer brands to health effects from Safety Data Sheets (formerly Material Safety Data Sheets), has a website listing the chemical ingredients of products for scientist and consumers to research. The database is designed to help answer the following typical questions:

• What are the chemical ingredients and their percentage in specific brands?
• Which products contain specific chemical ingredients?
• Who manufactures a specific brand? How do I contact this manufacturer?
• What are the acute and chronic effects of chemical ingredients in a specific brand?
• What other information is available about chemicals in the toxicology-related databases of the National Library of Medicine?

After researching the following items used frequently in our home.

• Bleach | Clorox Clean Up Spray
• Lysol Brand All Purpose Cleaner, Lemon Scent-Old Product
• Pine-Sol Multi-Surface Cleaner, Original
• Tide Liquid Laundry Detergent HE Turbo Clean, Original

I found what was already understood about the associated risk of ingestion, inhalation and/or skin contact. It was also discovered “from MSDS that these products contained no substances that are considered carcinogenic or potentially carcinogenic by NTP, IARC, and/or OSHA.”

Outcome: Will I continue to use these products.

Answer: Yes. However, with the goal to eliminate as many chemicals from our home I will most likely make changes to the selection of our cleaning products.

Presently, to help with finding more Green cleaning products. I have decided to use the Think Dirty app. This app allows me to scan the barcodes of various products while shopping to help me make better informed decisions about the products I want to use our home.

The Think Dirty® app is considered to be the easiest way to learn about the ingredients in your beauty, personal care and household products. Just scan the product barcode and Think Dirty will give you easy-to-understand info on the product, its ingredients, and shop cleaner options.

You can also get the latest news, read more about the effects of ingredients in the products you use every day, or even ask a question about personal care products.

The Think Dirty Methodology for rating the products are determined on data that has been publicly released by non-profit and government agencies. The area analyzed evaluates for the following:

• Carcinogenicity
• Developmental & Reproductive Toxicity
• Allergenicity & Immunotoxicity

When was the last time you evaluate the products you used in your home? How Green are the cleaning agents and are they safe because they “smell good?”

Sources

http://www.theworldcounts.com/about

https://householdproducts.nlm.nih.gov

https://www.who.int/heli/tools/legis_regul/en/

Week Four |What’s in the Water

In 2014 the community of Flint, Michigan made a cost saving decision to switch their drinking water supply from Detroit’s system to the Flint River. Michigan Governor Rick Snyder appointed an emergency manager, Ed Kurtz, to cut city costs. Prior to the decision to use water from the Flint River the community had a history of polluting the Flint River. This waterway was the unofficial waste disposal site for raw sewage, toxics chemical leached from nearby landfills, car factories and meatpacking that align river shore. In addition to the Flint River being extremely polluted the pipeline used to deliver water to the home were made of lead. The Flint residence drinking water was polluted Flint water carrying high levels of lead to be use as their drinking water.

Shortly after the Flint water supple decision a survey was conducted analyzing the drinking water in several homes. The water sample results indicated high levels of lead, above the federal action level of 15 parts per billion (ppb). At the same time hundreds of Flint residence were reporting symptoms such as skin rashes, hair loss, itchy skin decreased cognitive abilities and developmental delays in the Flint children located in northeast of downtown and old neighborhoods.

For example, “a state government report showed that, from the year 2014 to the year 2017, third-grade reading proficiency in the city dropped from 41.8 percent to 10.7 percent,” reported by Emily Atkin.

After reviewing Pharmacology and Toxicology Science and Policies presentation and Lead Poisoning and Its Prevention by Dr. Barbara Sattler, DrPH, RN, FAAN I could not help but think about the generational negative health impact for the community of Flint, Michigan.

Dr. Sattler provided a great analysis comparing pharmacology versus toxicology. Toxicology covers ONLY the adverse effects on our health. As medical providers we look for the toxic effects which is usually associated with increasing exposure to a toxic chemical. The households in Flint were showing symptoms of high leads of lead poisoning. According to the authors Hanna-Attisha, LaChance, Sadler, & Champney Schnepp, (2016) an analysis identified disadvantaged neighborhoods as having the greatest elevated blood lead level increases and was declared public health emergency.

As a Nurse Practitioner – if having to manage the health care needs for these children and adults it would require a collective interprofessional team approach due to the possible long-term effects of the lead poisoning exposure. Studies have shown that more than 90% of body lead is stored in bone and has been associated with cognitive decline among the elderly, possible causes of degenerative dementia, renal disease, reproductive problems and anemia.

According to (Laidlaw et al., 2016), “children can absorb 40% – 50% of an oral dose of water-soluble lead compared with 3% to 10% for adults. In a dose–response relationship for children aged 1 to 5 years, for every 1-ppb increase in water lead, blood lead increases 35% The greatest risk of lead in water may be to infants in reconstituted formula. Among infants drinking formula made from tap water at 10 ppb, about 25% would experience a blood lead level above the Centers for Disease Control and Prevention (CDC) elevated blood lead level (EBLL) of 5 micrograms per deciliter (µg/dL). Tap water may account for more than 85% of total lead exposure among infants consuming reconstituted formula. A known abortifacient, lead has also been implicated in increased fetal deaths and reduced birth weights.”

It is clear that the decisions of the elected and appointed officials had devastating consequences for the Flint committee and will negatively impact the health of the citizens for generations to come.

For information about lead testing and results within California visit the Department of Public Health – https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/Pages/LRCRegs.aspx

#LeadPoisoning #Toxicology #NursePractitioners #HealthCare #USFCA #PopulationHealth #DoctorOfNursingPractice #DNP

Reference & Resources:

Hanna-Attisha, M., LaChance, J., Sadler, R. C., & Champney Schnepp, A. (2016). Elevated Blood Lead Levels in Children Associated With the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health Response. American Journal of Public Health, 106(2), 283-290. doi:10.2105/ajph.2015.303003

Laidlaw, M., Filippelli, G., Sadler, R., Gonzales, C., Ball, A., & Mielke, H. (2016). Children’s Blood Lead Seasonality in Flint, Michigan (USA), and Soil-Sourced Lead Hazard Risks. International Journal of Environmental Research and Public Health, 13(4), 358. doi:10.3390/ijerph13040358

http://lecture.envirnevidence.org/toxicology/

http://lecture.envirnevidence.org/lead/

https://www.nrdc.org/stories/flint-water-crisis-everything-you-need-know#sec-summary

https://www.epa.gov/sites/production/files/2015-11/documents/transmittal_of_final_redacted_report_to_mdeq.pdf

http://flintwaterstudy.org/2015/09/commentary-mdeq-mistakes-deception-flint-water-crisis/

https://newrepublic.com/article/147066/flints-water-crisis-damage-kids-brains

https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/CDPH%20Document%20Library/Zip_code_top_200.pdf

https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/Pages/data.aspx

Week Three|Cosmetics & Chemicals

I recently discovered what the law requires for cosmetic products in terms of how they list the ingredients for cosmetics and what is considered a cosmetic. According to the U.S. Food and Drug,  “the law does not require cosmetic products and ingredients, other than color additives, to have FDA approval before they go on the market, but there are laws and regulations that apply to cosmetics on the market in interstate commerce.”

The FD&C Act defines cosmeticsby their intended use, as “articles intended to be rubbed, poured, sprinkled, or sprayed on, introduced into, or otherwise applied to the human body…for cleansing, beautifying, promoting attractiveness, or altering the appearance” (FD&C Act, sec. 201(i)) Among the products included in this definition are skin moisturizers, perfumes, lipsticks, fingernail polishes, eye and facial makeup, cleansing shampoos, permanent waves, hair colors, and deodorants, as well as any substance intended for use as a component of a cosmetic product. It does not include soap.”

After discovering that the law does not require cosmetic products to disclose  and ingredients, other than color additives. I wanted to assess the chemical content of two products used daily within my home. I utilized the Environmental Working Group (EWG) website database to gather the following information. The mission of EWG is to protect human health and the environment. EWG’s Skin Deep database gives you practical solutions to protect yourself and your family from everyday exposures to chemicals. My two products analyzed are Aquaphor and Rembrandt toothpaste. Initially, I was shocked to see that they both had some negative data points related to developmental toxicity and immunotoxicity. I also discovered more information about Endocrine Disruptors – chemicals that may interfere with the production or activity of human hormones. According to NIH, Tox Town, the disruptors include dioxins, polychlorinated biphenyls (PCBs), pesticides, pharmaceuticals, and plasticizers such as bisphenol A (BPA) and phthalates.

Endocrine disruptors may be found in some plastic bottles, metal food can linings, cosmetics, detergents, medicines, flame retardants, food, toys, and pesticides.

Some endocrine disruptors have been banned in the United States because of their human or wildlife health effects. The U.S. Food and Drug Administration advised physicians to stop prescribing DES (diethylstilbestrol) in 1971.

My Cosmetic Discovery  – We will most likely continue to use the Rembrandt toothpaste. However, we might consider seeking a substitute body ointment to replace Aquaphor. I find it interesting that no matter WHAT price point – hygiene products contain chemicals associated with a negative impact on our health and wellness. Society operates by trust and thus the community is not trained to investigate the ingredients of their cosmetic products.  Society by default trusts manufacturers to do what is right. That is until there is a direct hazard or health risk identified like smoking cigarettes causes cancer. After this type of information becomes available especially with correlated increases in costs (healthcare, legal, tax, product, etc) society will more easily accept the truth about a product’s impact the individual’s health. Current disclosure practices don’t normally cover everyday products that are viewed to be safe in the eyes of society.

As a medical provider I will take more time to ask my patients if they are aware of the ingredients related to the processed foods and/or cosmetics used in their daily lives. I believe there should be a full disclosure law of any chemicals considered toxic and associated with all products. Such a law will allow the public to make better informed decisions about what they ingest and use on their bodies. 

Members of the health care team should join together to increase the use of going green within hospitals, ambulatory outpatient clinics and long-term care / skilled nursing facilities. Institutions delivering any type of health care for the public at large should be the leading example and ambassador of energy-efficient features utilizing sustainable green products and practices. According to data from the Environmental Protection Agency (EPA), each day the nation’s hospitals generate close to 7,000 tons of infectious, hazardous and toxic waste. To incentivize the use of more green products and practices health care centers should receive a Green Rating and this number be placed in the entrance of the facility.

Week Two|Entry – Environmental Health for the Medical Provider

I currently sit on the executive board as the California Association for Nurse Practitioners (CANP) – Health Policy & Practice (HPPC) Co-Chair. HPPC oversees the Association’s government relations activities, working in conjunction with CANP’s legislative lobbyist to help formulate legislative priorities, including the adoption of official Association positions on pending legislation.

Presently, our HPPC is comprised of 21 members not including our current CANP President, Immediate Past President and President Elect. The HPPC mission is to remain at the forefront of all California legislation involving Nurse Practitioners and how healthcare is accessed by the community at large. I too believe that a conversation with the Alliance of Nurses for Healthy Environments and CANP should be made to arrange for a workshop at the 43^rdCANP Educational Conference.

The CANP Board of Directors, in consultation with its Health Policy and Practice Committee conducts root cause analysis, review of the literature and examined several documents in support of our position on the contributions and continuing role of Nurse Practitioners in primary and specialty care settings. We support legislation regarding the competency, quality and pivotal role that NPs play in the delivery of health care services across multiple domains of practice and the significant impact NPs have upon the outcomes of patient care. 

For more information about CANP go to http://www.canpweb.org

Week One|Entry – Environmental Risk In Your Home

Did you know that the average American use 25 gallons of toxic chemical products at home every year?

In 2015, scientists from George Washington University, the Silent Spring Institute, NRDC, Harvard University, and the University of California–San Francisco embarked on the first study to comprehensively assess consumer product chemicals of concern in U.S. indoor dust.

The classes of chemicals this study are commonly added to household products and building materials. Like a human family, chemical classes are groups of related chemicals.

How to Reduce Chemical Exposure Inside Your Home – Remove dust from your hands. Wash your hands and your children’s hands frequently, and always before eating. Use plain soap and water, avoiding fragranced and antibacterial soaps.

Keep household dust to a minimum. Dust with a damp cloth, regularly go over floors with a wet mop, and use a vacuum with a high-efficiency particulate air (HEPA) filter.

Use the Silent Spring Detox Me app. This free smartphone app walks you through simple, research-based tips on how to reduce your exposure to potentially harmful chemicals where you live and work, and it keeps track of your progress.

• Explore further resources to find safer products:
• Environmental Working Group Skin Deep
• Healthy Babies, Bright Futures parents’ resource

Environmental Hazards in the Basement – If you live in a single-family home with the hot-water heater, furnace or boiler, in the basement it is suggested that you place a carbon monoxide detector close to the bottom of the stairs. Carbon monoxide (CO) is an invisible, odorless toxic gas that does not irritate the throat—so detecting its presence is impossible. It may be “silent,” but it can kill.

CO builds up rapidly in the blood, inhibiting its ability to carry oxygen throughout the body. The longer one is exposed to it, the worse the damage:

• Mild exposure: flu-like symptoms, like headaches, runny nose, eye irritation, etc.
• Medium exposure: drowsiness, dizziness, vomiting, disorientation, confusion.
• Severe exposure: loss of consciousness, brain damage, death.

Carbon monoxide is released in cases of incomplete combustion of organic matter or when an appliance (e.g., a heater or generator) or vehicle burns fuel such as gasoline, propane or natural gas, wood, heating oil, etc.

For this reason, if your home is equipped with a fuel-burning appliance, or has an attached garage where vehicles are started, you must install a certified carbon monoxide detector. Note that smoke detectors do NOT detect carbon monoxide, even in high concentrations. Here are recommended areas to place a detectors –

How Can We Improve Environmental Health?

Speak with your elected officials both local and state wide about addressing environmental health.

At the national level, the U.S. Consumer Product Safety Commission (CPSC) has banned some phthalates from children’s products and child care articles and is proposing to ban additional phthalates. The U.S. Food and Drug Administration (FDA) is accepting public comments on a petition to ban all phthalates from food. Learn more about how to protect our families and children from toxic chemicals.

Governments and companies should advance policies to remove hazardous chemicals from products and replace them with safer alternatives. Some have already done so. For example, the California Safer Consumer Products program requires companies to carefully choose the safest alternative to toxic chemicals in order to avoid “regrettable substitution” replacement chemicals that are also harmful. Washington State requires reporting of hazardous chemicals in children’s products so that consumers can choose safer products.

References:

Mitro, S.D., R.E. Dodson, V. Singla, G. Adamkiewicz, A.F. Elmi, M. K. Tilly, A.R. Zota. 2016. “Consumer product chemicals in indoor dust: a quantitative meta-analysis of U.S. studies.” Environmental Science & Technology

https://www.nrdc.org/resources/not-just-dirt-toxic-chemicals-indoor-dust

https://www.caaquebec.com/en/at-home/advice/tips-and-tricks/tip-and-trick/show/sujet/assessing-the-potential-health-risks-of-basements/