The EJ Movement
As described by the US Environmental Protection Agency (EPA), EJ is:
...the fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies. Fair treatment means that no group of people, including racial, ethnic, or socioeconomic group, should bear a disproportionate share of the negative environmental consequences resulting from industrial, municipal, and commercial operations or the execution of federal, state, local, and tribal programs and policies.[2]
The EJ movement in the United States goes back to the end of the 20th century, and was officially recognized as an area of governmental concern during the administration of President William J. Clinton.[3] US Supreme Court rulings not allowing the use of race for making most governmental regulations have made addressing EJ issues more burdensome. The rulings make it more challenging to find an appropriate definition to label communities as EJ communities, and put in place rules to try and better protect citizens in such settings. Given that housing stock is often poorer, the addition of significant community outdoor pollution to existing indoor air-quality problems further exacerbates potential health issues in such communities. No federal regulations exist in regard to EJ, therefore leaving it up to the states and communities to take action. At the moment little legal recourse is available for many of these communities, and action often only takes place if the community comes together to address the addition of potential new sources of pollution.
Health Effects of Pollution
A number of issues affect EJ, including:
Percentage of poor or minority residents;
Access to jobs;
Home values; and
Historic exposure to industrial pollution.
This being said, the remediation of brownfields can have a tremendous impact on communities. Brownfields are previously contaminated parcels of land, usually due to prior industrial uses, which after they receive some level of cleanup or restoration can then be used for the placement of new homes, businesses, or public spaces, such as golf courses or parks. Some, but perhaps not total, cleanup takes place and then re-use of the land can begin. Often, this does not help the originally distressed community if high-end homes are built, a process called gentrification, and no provisions are made for prior neighborhood residents. Advice from professionals is often helpful to local boards of health, zoning commissions, and building code regulators with regard to such land use matters.
Outdoor Air Pollutants
The EPA regulates outdoor air pollutants in the United States and oversees exposures from air, water, and soil. Increasing the awareness of these hazardous exposures within communities and among healthcare professionals is an integral part of EJ. A number of agents are of particular interest to the general topic of outdoor air pollution, and others are of special interest in other, often localized settings. Of special concern are the oxides of nitrogen, called NOx; the oxides of sulfur, called SOx; and "particulate matter." Until a few years ago, particulates were simply referred to as total particulate matter, or with a view toward those most likely to cause ill health, particulate matter of 10 μm or smaller in aerodynamic diameter (PM10's). Then it was appreciated that a subfraction of PM10's had the most significant biological impact, and special attention was then given to PM2.5's having an aerodynamic diameter of 2.5 μm or smaller.
Nitrogen oxide. NOx can have deleterious effects on the lungs. At high concentrations, it can cause significant acute disease with pulmonary edema, whereas chronic exposures at lower concentrations can lead to significant pulmonary fibrosis. This has been reported among farmers who maintain silos filled with organic materials for feeding their animals. They have reported layering of a brownish gas on top of silage, with both acute and repeated subacute exposures to this mixture of NOx over the years.
Sulfur oxides. SOx's are the component of outdoor air pollution that leads to what is referred to as "acid rain." SOx's combine in the air with water vapor to create sulfuric acid. This acid air has been known to denude forests, and obviously the inhalation of such air cannot be good for human lungs. In workplace settings sulfuric acid mists lead to pulmonary fibrosis, and some have suggested lung cancer as another outcome.
PM2.5's and nanoparticles. Particulates, especially PM2.5's, have been shown to cause disease. Lung damage from such air pollutants is now supported by clear evidence, although it is not of the order of magnitude of smoking in terms of producing lung disease. Among the documented problems seen with increasing exposures to PM2.5's are:
Chronic obstructive pulmonary disease (COPD);
Lung cancer; and Blood clots.
EJ access can be affected by increases in PM from industrial operations and/or increased vehicular traffic, especially diesel exhaust. Of recently developing interest has been even smaller particles, referred to as nanoparticles. Nanoparticles find their way into many organs in the body, including the bloodstream, liver, and brain, through inhalation. Exposures to nanoparticles show definitive toxic effects in many laboratory test systems, some with significant toxicity.[4]
Radon and asbestos. Two other air pollutants require some mention: radon and asbestos. Radon, the radioactive gas given off from the decay of naturally occurring uranium in soil, has been noted by the EPA to be a major environmental cause of lung cancer.[5] The workplace hazard of radon has been recognized for many years, given the elevated lung cancer risk among uranium miners on the Colorado Plateau.[6] The EPA has noted that several thousand cases per year of lung cancer come from elevated levels of radon in homes. The level above which there is concern is 4 pCi, and if levels above this amount are noted in living spaces, then a mechanism should be in place for venting such spaces and diluting the radon to the outdoors.
The other carcinogen of concern, with regulations being set by the EPA, comes from the release of asbestos with asbestos removal activities. Not only is asbestos sometimes removed from inside homes, but the tearing off of old roofing material, which is known to contain asbestos in many cases, also puts those nearby at risk and can lead to fines from the EPA if removal is not done properly. The cancers of concern with airborne asbestos include lung cancer and mesothelioma.[7]
Inventory lists of major pollutants. The EPA documents and publishes inventory lists of major pollutants introduced by industrial sites. This includes a wide range of organic compounds, such as benzene, a cause of leukemia, and other hematologically related diseases, as well as other toxic materials. Major polluters must keep track of their emissions, and these data are collected and then published by the EPA.
Health professionals can support organizations, such as the American Lung Association and the American Thoracic Society, as they endeavor to reduce air pollution. These groups provide written materials for the education of health professionals and the lay public. By further probing patients complaining of respiratory problems and taking an environmental health history, healthcare professionals will gain a better understanding of the source of the problem.
Indoor Air Pollutants
In contrast to the EPA's regulatory activity of outdoor air pollutants, there is little in the way of regulation of indoor pollutants.[8] Even in the case of radon, only guidelines for action are available. One of the only regulatory activities with regard to indoor air quality comes from the rules of the Occupational Safety and Health Administration (OSHA). OSHA requires employers to provide a safe, healthy workplace, but sets no specific limits for indoor pollutants with only a few exceptions, such as CO and CO2 levels. The only other regulatory activity is related to state or local regulations that restrict or do not allow environmental tobacco smoke (ETS).[9] California has the strictest regulations in regard to ETS, and some communities in that state have even gone so far as to try to restrict smoking in one's own apartment when a common ventilation system is shared by several apartment units.
Asthma
As noted above, asthma is more prevalent in communities of color and poorer communities. Children with asthma react to ETS, dust mites, mold arising from dampness in housing units, and the presence of pets in a household. Efforts to do each of the following have been associated with fewer asthma attacks[10,11]:
Educating families about such hazards;
Providing bed coverings and cleaning supplies; and
Fixing leaky plumbing.
It is important to remember that it's not only children who suffer, but parents also experience the consequences, eg, losing workdays -- often uncompensated -- when they must take care of their child and his or her asthma attack.
Another aspect of this problem is control of asthma among children in these populations. Asthma is often not managed as well as it should be in these cases due to lack of education, access to healthcare, and access to drug regimens that prevent recurring attacks.
Children who are taught to monitor their own lung function and are given medications for both chronic and acute use are better able to manage their asthma. Excellent documentation now shows that in communities with special programs to educate families and provide regular medication to children, the number of asthma deaths and visits to emergency departments can be greatly diminished.[12] By working with local hospitals, pediatricians, and community clinics, efforts can be made to further implement programs to reduce childhood asthma. Such programs are often run out of community hospitals or academic health centers.
Among adults, another area of concern is the buildup of potentially harmful materials in indoor air. With the advent in the 1970s of much better insulation of buildings, coupled with far fewer air exchanges per hour, so-called "tight building" or "sick building" syndrome can occur. This is especially prevalent in new or renovated construction when there is off-gassing of potentially harmful materials from carpeting, furniture made from pressed boards with glues, and other products that enter the indoor air and build up over time.[8] Airing out of facilities after construction or renovation can help, as can ensuring sufficient fresh air exchanges each hour.
Conclusion
Health effects of air pollutants need to be better understood and controlled. Future concerns should include an increased focus on the growing use of nanoparticles of many types for many purposes because these, too, may carry significant health risks, and we are only at the beginning of their use.
As outlined, justice-related issues may come into play when communities of color and poorer communities are disproportionately exposed to environmental pollutants. Health professionals should consider the cumulative exposures of their patients that come from work, personal habits, and living locations. Patients with recognized social vulnerabilities need to be appreciated and efforts made to assist individuals in such communities to coalesce around positive changes that could be made in regard to exposures. Interaction with policy makers who often control what occurs in such communities can be helpful. Lastly, healthcare providers should remember their own role in the improvement of the collective health of communities, not just the care and well-being of their own individual patients.
Resource
For more information from the American College of Preventive Medicine (ACPM) on EJ and the legal rights of patients, check out the free CME/MOC Webcast, "The Right to Breathe: The Medical-Legal Effort to Clean Up Indoor Air," available at www.acpm.org/education/IAQ/index.htm.
References
Medscape Education © 2009
https://www.medscape.org/viewarticle/589135
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Radon is the #1 cause of lung cancer among nonsmokers
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