The explosion of new scientific knowledge in recent decades has had two extraordinary and contradictory effects that bear upon issues of environmental justice. First, the public has enormous faith that most questions can be readily answered once scientists take the time to focus on them; second, and conversely, scientists themselves are keenly aware of their inability to keep pace with every new development in their own and related fields. This is often true for health care providers as well, who struggle to understand and stay current on issues such as the effects of the environment on health. Moreover, as described by participants in the committee's site visits, current efforts at educating health professionals and the public about the importance of the influences of the environment on human health do not seem adequate.
During the site visits, the committee was struck by the extent to which the citizens of communities of concern felt virtually defenseless against what believed to be unreasonable and unfair environmental impacts. They felt that they had been abandoned by both the government and the local industry. When attention was drawn to their issues, they felt exploited by lawyers and others, who were seen as taking advantage of their situation. The irony is that both government and industry are now trying to establish more cooperative joint efforts with community-based groups to control or even reverse environmental degradation. Neither government nor industry, however, fully appreciates the deficit of knowledge about the local hazards under which the residents of those communities must live and work. Such ignorance can lead to both neglected and exaggerated problems.
An important part of the solution to the needs and problems that have been described involves building a well-informed community response. The goal, therefore, is not only to augment the knowledge of each participant in the process of identifying, correcting, and preventing environmental risks but also to link each participant in a network that can help the community work as a whole.
Building this network requires improvements in professional and public education. This chapter examines the educational issues in communities of concern, including the education of both health professionals and the general public, and presents an overarching recommendation with related strategies for addressing these issues.
HEALTH PROFESSIONAL EDUCATION
During the committee's site visits, the symptoms and health conditions that people commonly tended to attribute to environmental causes included respiratory disorders, skin rashes, hair loss, gastrointestinal stress, blurred vision, fetal abnormalities, blood disorders, and a variety of cancers. It seems clear that physicians in all medical specialties need to be alerted to the possible relationship between these types of complaints and environmental phenomena and that the means of diagnosis of environmental causes of disease and illness need to receive more attention within the community of health care providers. Addressing the problem of diseases caused by environmental and occupational exposures is an issue shared among all health professionals, and it is the major focus of environmental and occupational medicine (EOM). EOM training focuses on diagnosing and caring for people exposed to chemical, biological, and physical hazards in the workplace, home, and community environments. Thus, EOM is the medical discipline most appropriate for addressing health issues related to environmental and occupational exposures. Unfortunately, but as expected, the site visits revealed that primary health care providers in the community lack specific training in EOM and that community residents lack access to clinical EOM services (Institute of Medicine, 1991, 1995a).
Enhancing Health Professional Education
Certain irreducible minimums of education and training need to be established, particularly with reference to minority and low-income communities, if the trends of environmental degradation that have thus far prevailed in many communities are to be corrected and reversed and if any more communities are to be prevented from experiencing the same fate. These minimums are needed in many areas, including medical education, public health professional education, and nursing and allied health sciences.
Most medical students and residents receive very little training in environmental health or occupational medicine. In most medical schools, the average classroom time for occupational and environmental medicine combined is an estimated 6 hours. Even though national policy and scholarship support are weighted heavily and properly toward the specialty of primary care, physicians in training are already in their residencies before they receive any effective instruction in ways to include occupational and environmental data in their history taking. Yet, for many patients, the etiologies of their illnesses are rooted in the environments where they live, work, and play. Thus, it is important to ensure that primary care physicians can do the basics of EOM, such as taking an adequate occupational and environmental history, and that they know the signs and symptoms of the most common occupationally and environmentally related diseases. In a prior report (Institute of Medicine, 1988b) the Institute of Medicine (IOM) recommended a minimum standard of competency for primary care physicians: “At a minimum, all primary care physicians should be able to identify possible occupationally or environmentally induced conditions and make the appropriate referrals for follow-up” (p. 63). However, the present committee also recognizes that health professionals practicing in these communities may have difficulty finding appropriately trained colleagues to whom they can refer their patients.
Compounding the lack of knowledge is a lack of involvement of health care providers in efforts aimed at educating members of the community (Greenlick, 1992; Ozonoff, 1995). Local health care providers are largely unaware of the scientific nuances involved in addressing the issues of the human health impacts resulting from environmental and occupational exposures (Institute of Medicine, 1988b, 1995a). There is a tremendous need to educate health care providers about the potential environmental impacts and concerns and, most importantly, to involve these providers in the dissemination of accurate information about local environmental health issues.
Enhanced education in EOM in the medical school curriculum has been recommended by IOM for many years (Institute of Medicine, 1988b, 1995a,b), and a variety of innovative approaches have been developed to operationalize these recommendations. The most recent report from IOM (1995a) on this subject developed and described competency-based learning objectives for graduating medical school students (see Box 4-1). General agreement exists that EOM should be integrated into the routine practice of medicine (Institute of Medicine, 1988b, 1995a; Rom, 1997; Rosenstock and Cullen, 1994). The EOM content in the medical school curriculum has not grown rapidly, however, and sustaining an EOM content in the curriculum often requires the ongoing efforts of an energetic and enthusiastic “champion” of EOM in each medical school.
One of the most valuable tools in teaching EOM to clinicians is the use of a list of “sentinel health conditions” that clinicians are expected to know. These are diseases or pathophysiologic conditions that are potentially occupational or environmental in etiology and for which the possibility of an environmental etiology needs to be considered in the differential diagnosis (Kipen and Craner, 1992). The sentinel health condition is the clinical application of the “sentinel health event (occupational)” originally proposed by Rutstein and colleagues (1983) for use in public health surveillance. Some examples of sentinel health conditions include pulmonary fibrosis, bronchitis, lung cancer, mesothelioma, carpal tunnel syndrome, contact dermatitis, and recent-onset asthma. The sentinel health condition is one tool that can be used as an aid in recognizing patients with an environmentally or occupationally related disease. Identification of a patient with a sentinel health condition is not diagnostic however, and must be followed by an appropriate clinical evaluation to confirm or rule out the environmental or occupational diagnosis.
In addition to the need for enhanced EOM training for primary care physicians, previous publications (Castorina and Rosenstock, 1990; Institute of Medicine, 1988b) have clearly documented the shortage of physicians with specialty training in EOM. They have called for large increases in the numbers of physicians being trained in EOM to meet current and future needs for these specialists. This need is particularly pressing in health care organizations that provide medical care to communities of concern. Physicians committed to working in these communities need to be trained in EOM both at the primary care level and at the EOM specialist level. Particularly needed are EOM specialists who can provide informational and clinical support to the primary care physicians who serve these communities.
Attracting physicians to a specialty in EOM can be difficult, however, because of the labor-intensive and time-consuming nature of the work. Providing effective care for a single patient with an environmentally or occupationally related disease can require the investment of many hours of taking a detailed exposure and medical history, searching the literature and critically evaluating epidemiologic and toxicologic studies, making difficult judgments about causal relations, discussing risk, negotiating with patients and employers on the basis of the physician's knowledge and understanding of the available evidence (often in an adversarial setting), interacting with government agencies, and possibly being required to prepare and deliver testimony in court or at a workers' compensation hearing.
Moreover, mechanisms for reimbursement for these activities within the general framework of clinical medicine are not adequate, whether in fee-for-service, managed care, or Medicaid and Medicare environments. Special reimbursement mechanisms, such as workers' compensation, rarely provide timely payment at a rate commensurate with the physician's investment of time and effort. Although a detailed discussion of reimbursement issues is outside the scope of this report, this is an important issue and is probably even more important for physicians who choose to practice in minority or low-income communities.
Finally, training the currently practicing local physicians about what hazardous substances exist in their communities and what diseases these substances can cause is an important need. State and local departments of health and environment should play a role in this, as should industry. The availability of free continuing medical education for physicians and other health professionals in conjunction with the work of public health departments will greatly enhance the ability of caregivers to protect the public.
Public Health Education
The accredited schools of public health have been in the process of redefining their roles and missions. This process has been driven in part by public funding. Funding for public health practice, research, and education has been neglected, whereas funding for basic research has expanded. While the neglect of funding for public health practice research and education has continued, the public health workforce that was trained for such positions as sanitarians, air and water analysts, soil testers, food inspectors, epidemiologists, and public health educators has been graying and shrinking. In its place has come a new generation of public health school graduates who consequently focus their careers on basic research rather than the once traditional track of community-based public health assessment, surveillance, and service. This trend causes the committee to be concerned that the public health needs of communities are not being adequately addressed. In addition, resources are often inadequate to support basic public health services as well as the training of public health professionals. Moreover, when additional research is needed to inform decisionmaking regarding public health actions, resources may not be available to support the research or the research that is being done may not be designed or conducted in a way that will provide the needed information. Enhanced funding for participatory research may be one effective approach to ensuring that the research addresses the public health needs of the community.
It seems evident that the nation's schools of public health need additional resources to effectively continue their role in protecting and enhancing the health of the U.S. population in the next century (Institute of Medicine, 1988a). As stated in IOM's 1988 report The Future of Public Health:
Schools of public health should establish firm practice links with state and/or local public health agencies so that significantly more faculty members may undertake professional responsibilities in these agencies, conduct research there, and train students in such practice situations. Recruitment of faculty and admission of students should give appropriate weight to prior public health experience as well as to academic qualifications.
Schools of public health should provide students an opportunity to learn the entire scope of public health practice, including environmental, educational, and personal health approaches to the solution of public health problems; the basic epidemiological and biostatistical techniques for analysis of those problems; and the political and management skills needed for leadership in public health. (Institute of Medicine, 1988a, pp. 157–158)
Nursing and Allied Health Sciences
Through its site visits, the committee became aware that public health nurses, nurse practitioners, social workers, and others were often responsible for providing the link between the residents of communities of concern and health care providers. As inspiring as those stories are, they also indicated not only the haphazard nature of those connections but also how few connections exist relative to the communities' needs.
Similar to the role that nurses play in the health care system in general, nurses play a critical role in these communities, as do other professionals. Nurses are often the first point of contact for people seeking health care, especially those in rural or underserved populations. They are also the largest group of health care providers in the United States (an estimated 2.2 million), and in occupational health practice, nurses outnumber physicians by six to one (Institute of Medicine, 1995b). For these reasons, among others, nurses should be trained in and should be familiar with environmentally related health conditions.
The education of nurses and other health and social service caregivers needs to reflect environmental concerns as well. This matter has been addressed in prior reports of IOM and the National Academy of Sciences, most recently, Nursing, Health, and the Environment: Strengthening the Relationship to Improve the Public's Health (see Box 4-2), a report of the Committee on Enhancing Environmental Health Content in Nursing Practice (Institute of Medicine, 1995b). Like nursing, all areas of health science need to make environmental health competence a priority in education and training.
Increasing the Number of Minority Health Professionals
In addition to the problems identified above, the community of health professionals seems in danger of losing its earlier zeal for recruiting more new professionals from among the country's racial and ethnic minorities. In many regions of the country where environmental insults have occurred (e.g., Tucson, Arizona), the presence of large numbers of minority health professionals could well have sensitized the residents of those affected communities as well as their political and business leadership and could have mitigated, if not prevented, the environmental damage. On the basis of the experiences of a variety of professionals, notably in the fields of public education, medicine, and law, increased participation by racial and ethnic minorities facilitates the delivery of vital services to ethnic and racial minority communities in the United States.
Increasing the number of individuals from the affected populations in the ranks of health professionals strengthens the tie between the profession and the community. Access to care can also be influenced by this. Individuals in many at-risk communities have inadequate medical care. An important approach to improving health care in the communities of concern would be to increase in medical schools the numbers of students who have demonstrated a commitment to providing medical care in such communities. Commitment to communities and to public health is probably more important than a preexisting interest in environmental medicine. Otherwise, unselected students who come from minority communities may be more likely than students from other communities to return to those communities to practice medicine (Moy, 1995). These students could be targeted for training in EOM at the medical student, house staff, and attending levels and would be more likely than students who went on to practice in other communities to have a significant impact in the affected communities. A targeted scholarship program might facilitate the recruitment process.
EDUCATION OF THE PUBLIC
Making the community aware of the environmental risks to its health is a vital step in combating morbidity and mortality. According to the participants in the committee's site visits, however, not only does the public receive little information about environmental health issues but the information that is presented is often delivered in language that is too technical or full of jargon and is illustrated with examples that are obscure or culturally insensitive. Moreover, the communities most at risk of a lack of environmental justice are frequently the least likely to receive information, and the information that they do receive tends to stop short of providing any guidance as to what the community can do on the basis of that information for its own protection. The site visit participants also reported that the information that is provided is typically prepared by and for nonminority communities and is seldom evaluated for its comprehensibility by the intended audience.
Many of the people who spoke with the committee during the site visits were optimistic about raising the level of knowledge of members of the community to a level where they could be effective participants in the creation of solutions. For example, the belief in community potential is the heart of the Community Outreach and Education Program (COEP) in New York City's South Bronx. Using “bidirectional communication,” COEP engages “neighborhood residents … as partners in a collaboration that seeks to address their needs and concerns while finding answers to fundamental scientific questions” (Claudio, 1996b). In this way, the residents “become actual experts in their own neighborhood.” Belief in the potential of people in the community is also the basis of the Ohio Outreach Strategy for Equity in Environmental Issues program, which is an outreach strategy committed to helping “inform, educate, and empower people of color on issues of environmental hazards that may exist in their communities” (King, 1996). The committee was also heartened by the description of the program called Responsible Care: A Public Commitment begun by the Chemical Manufacturers Association, a program that gives laypeople access to environmental information to help them become effective members of community advisory panels that will be involved in an interactive dialogue with the industry. These programs are good examples of the types of activities that would be helpful in all affected communities.
The challenge of educating and informing members of an affected community is complex, but the informed participation of citizens is needed to correct past injustices and prevent future ones. Addressing environmental justice concerns in this way will also serve to increase the human capital of the affected communities. Individuals who are better able to understand and deal with environmental justice issues should also be better able to deal with other challenges in their lives.
Education of the community should meet the following objectives: (1) make the community more aware of basic environmental health concepts, issues, and resources; (2) increase the role of the community in identifying problems related to environmental exposures; (3) involve the community in shaping potential research approaches to the problem; and (4) link community members who are (or who may be) directly affected by adverse environmental conditions with researchers and health care providers in developing and prioritizing responses. Methods of achieving these objectives include educating children, enhancing community leadership, and involving the community in research, that is, conducting participatory research.
The committee believes that children should be helped to understand, as early and as clearly as possible, how their health responds to external stimuli and what specific environmental hazards exist in their own communities. That information should be theirs by right, and they should be encouraged to become familiar with all real and potential environmental insults at the level of their own school, neighborhood, play area, and home.
The committee heard of many modest but successful efforts to bring environmental health and environmental justice concerns to the attention of kindergarten to 12th-grade students (Box 4-3 provides an example of such an activity). For example, the committee was impressed with Barbara Sattler's achievements with young people in Baltimore, Maryland. In a low-cost, low-key program of her design, Sattler significantly raised the young people's level of understanding of ambient noise, vehicular exhaust, industrial effluence, neighborhood degradation, and other discernible and measurable contaminants of their home environments.
Luz Claudio also reported on schoolchildren of the South Bronx, New York City, who sampled the Hudson River for evidence of polychlorinated biphenyls (toxic heat-transfer agents used as insulators in electrical equipment) and reported their findings to their communities. This activity is part of an overall Community Outreach and Education Program supported by National Institute of Environmental Health Sciences (NIEHS) and based at the Department of Community Medicine, Division of Occupational and Environmental Medicine, Mount Sinai Medical Center.
The committee also visited the Deep South Center for Environmental Justice, which trains at-risk youth for environmental careers. Building on its experiences, it should be possible to replicate such programs in other locales. For example, many chemical firms get involved with the communities where their facilities are located, and many others have expressed a desire to do so. Providing jobs for young people and participating in their training is one way to establish better contacts that benefit both the company and the community.
These examples are not the only ways of involving individuals from at-risk communities in environmental health and safety. Topics that capture the interest of environmental activists might be attractive candidates for conventional educational programs. The American Chemical Society (ACS) has attempted to increase interest in the chemistry profession by sponsoring a problem-oriented year-long high school chemistry course for college-bound students, Chemistry in the Community (American Chemical Society, 1998). In keeping with ACS's objectives, there is little social content to these lessons (although there is some treatment of risk issues). The imagination of students in communities of concern might be captured by curricula showing the beneficial and detrimental roles that chemicals play in their lives.
The committee believes, on the basis of these and many other, similar reports, that creative, innovative teachers can engage their students in the neighborhood-relevant and life-pertinent issues of environmental health and safety. In so doing, they would help prepare a generation of individuals who will be less vulnerable than their parents to acts that result in a lack of environmental justice. This will require some additional curriculum development.
How effectively individual communities address environmental justice issues often seems to depend on the presence or absence of local leadership. The committee's site visits gave it the opportunity to meet with several local leaders (see Box 4-4; the committee is also aware of communities that have gone unorganized [Sampson et al., 1997]). From a social science perspective, it would be helpful to know what conditions encourage (or discourage) the emergence of community leaders so that similar situations might be created in other communities. From a practical perspective, one would like to create the conditions in which leaders emerge and work most effectively, focusing the community on its most critical problems. To the extent that they express the concerns of previously voiceless populations, these leaders might also be candidates for other public roles, which they might be trained to fill.
With technical issues, like those associated with environmental justice, lay leaders face the daunting task of becoming educated about complex and unfamiliar topics. They might have to learn the concepts and jargon of toxicology, epidemiology, risk assessment, regulatory procedure, and cost-benefit analysis. How well they succeed depends in part on the accessibility and effectiveness of technical support, training, and education. Various government and private organizations have been created to help them, and informal questioning during the committee's site visits suggested that the usefulness of these organizations varies considerably. As a matter of scientific and practical interest and importance, identification of the causes of success in these situations provides a special research opportunity for collaboration among social, physical, biomedical, and political scientists.
Conducting Participatory Research
As discussed in Chapter 3, the involvement of the members of a community of concern when conducting environmental health sciences research pertinent to environmental justice is essential for many reasons. One important result of participatory research is the educational opportunity for those members of a community of concern who participate. By becoming involved in the development, execution, and analysis of research that addresses their health concerns, they will become more familiar with the issues, the terms, and the methods of investigation. In addition, they will better understand the current state of the knowledge and its limits. This can be a very important means of encouraging participation, disseminating the results of research, encouraging community leaders, and generating trust in the research.
A good example of participatory research that is applied to environmental justice issues is COEP, which was discussed earlier in this chapter. COEP is based in the Mount Sinai Environmental Health Sciences Center in New York City. The aims of this program are geared toward education: (1) increasing the numbers of students from underrepresented minority groups at the high school and college levels, health professionals, and workers; (2) serving as an information resource on environmental and occupational health problems; and (3) assisting the community in identifying and controlling toxic environmental hazards. A highlight of community-researcher collaboration in the South Bronx community served by COEP resulted in a proposal to NIEHS for funding for a research and intervention program that would address childhood asthma. The researchers responded to the questions posed by the community to “find what is in the air that is causing us to suffer respiratory problems and a high asthma rate” (Claudio, 1996a). The residents of the community will serve as study subjects but will also be involved in study design and implementation.
CONCLUSIONS AND RECOMMENDATIONS
Health professionals, community residents, and basic environmental health sciences researchers understand too little about environmental justice and environmental health issues. Building an effective community network that can identify, correct, and prevent environmental health risks requires enhanced efforts in the training of health professionals and education of the public. A collaborative community response to environmental health risks will help limit and prevent environmental insults and their harmful health effects. Such a community response requires that health professionals be able to diagnose environmentally related diseases, that the public understand the risks to community health, and that governmental and industrial leaders be responsive to the needs of the community. To this end, educational programs that will more effectively link all parts of the community and that will build a coherent network to meet the public needs need to be created or enhanced.
Recommendation 3. The committee recommends that environmental justice in general and specific environmental hazards in particular be the focus of educational efforts to improve the understanding of these issues among community residents and health professionals, including medical, nursing, and public health practitioners. This would include the following:
- enhancing health professionals' knowledge of environmental health and justice issues,
- increasing the number of health professionals specializing in environmental and occupational medicine, and
- improving the awareness and understanding of these issues by the general public.
The following strategies are recommended as a means of achieving Recommendation 3.
Strategies for Enhancing Health Professionals' Knowledge of Environmental Health and Justice Issues
- Strategy 3.1 Give environmental and occupational medicine a prominent role in the education of clinicians so that they recognize environmentally related diseases and integrate environmental medicine into their routine practice of medicine and can take a careful environmental and occupational exposure history.
- Strategy 3.2 Educate primary health care providers and other health professionals about the issues of environmental justice as part of an enhanced curriculum in occupational and environmental health.
- Strategy 3.3 Provide access for health care providers in communities of concern to relevant information and expertise in environmental and occupational medicine.
- Strategy 3.4 Make state-mandated, federally certified copies of provider education materials and learning programs available for local care providers in all jurisdictions near sites where environmental toxicants are produced so that community health care providers are properly trained to respond to environmental hazards and accidents.
- Strategy 3.5 Establish in state health departments and managed care organizations training programs in environmental medicine for practitioners in communities at risk. Continuing medical education workshops, fellowships, and other opportunities for clinical training should be made available as part of this activity.
Strategies for Increasing the Number of Health Professionals Specializing in Environmental and Occupational Medicine
- Strategy 3.6 Develop academic, economic, and other incentives to help attract physicians and other health professionals into the practice of environmental and occupational medicine and health.
- Strategy 3.7 Target academic awards and similar support for medical school faculty at all stages of their careers to environmental and occupational medicine specialists who have demonstrated a commitment to research, medical education, and clinical practice devoted to addressing the environmental and occupational health issues of low-income and minority workers and communities. In particular, this support should be targeted to the faculty of medical schools that train the primary care providers who will serve these communities and populations.
- Strategy 3.8 Actively recruit to the public health professions individuals who are representative of those communities most affected or most at risk of environmental health problems.
- Strategy 3.9 Recruit health professionals who have a demonstrated commitment to serving low-income or minority communities for education and training in environmental and occupational health. This training should include instruction in approaches to service delivery that are culturally appropriate. Incentives should be provided to the programs both to make the residents' clinical services accessible to the communities of concern and to implement and demonstrate the success of programmatic initiatives to increase the likelihood that the environmental and occupational medicine specialists will remain accessible to these communities after completion of their training.
Strategies for Community and Public Education
- Strategy 3.10 Develop and establish interactive community education programs (e.g., conferences, videos, and town meetings) on environmental health issues, including possible hazards from subsistence foods (i.e., from hunting, fishing, and private gardens) in communities of concern. Local industry should be encouraged to be involved in these educational outreach programs. In all cases, cultural sensitivity and culturally appropriate communication should improve the effectiveness of the programs as well as the relationship with the community.
- Strategy 3.11 Educate the general public about environmental justice issues. Outreach strategies could include the use of public service announcements, printed materials, and other effective outreach programs.
- Strategy 3.12 Adopt state educational programs that include environmental health in the primary education of children, especially in areas of heightened risk.
National Academies Press (US), Washington (DC)
Institute of Medicine (US) Committee on Environmental Justice. Toward Environmental Justice: Research, Education, and Health Policy Needs. Washington (DC): National Academies Press (US); 1999. 4, Education.