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Introduction to Environmental Health

Jonathan M. Links, PhD

Johns Hopkins University
Section A

Objectives and Definitions

Course Learning Objectives
„ Define the major types, sources, and environmental
distribution of environmental agents
„ Describe how these agents interact with biological systems,
and describe the mechanisms by which they exert adverse
effects
„ Predict the nature of the agent’s adverse effects from its
physical, chemical, or infectious properties, and how that may
influence environmental or public health

4
Course Learning Objectives
„ Describe and use models for prediction of the magnitude of
adverse effects in biological systems
„ Identify significant gaps in the current knowledge base
concerning health effects of environmental agents, and areas
of uncertainty in the risk-assessment process
„ Describe current legislation and regulation regarding
environmental issues

5
Definitions: Environment
„ The circumstances, objects, or conditions by which one is
surrounded
or
„ The complex of climatic, edaphic (soil-based), and biotic
factors that act upon an organism or an ecologic community

6
Public Health Definition of “The Environment”
„ All that which is external to the individual host. [It] can be
divided into physical, biological, social, and cultural factors,
any or all of which can influence health status in populations.
− Last, J. M. (Ed.). (1995). A Dictionary of Epidemiology (3rd
ed.). New York: Oxford University Press.

7
Definitions: Health
„ The condition of being sound in body, mind, or spirit
„ A flourishing condition or well-being—not just the absence of
disease
or

8
Definitions: Health
„ A state of complete physical, mental, and social well-being
and not merely the absence of disease or infirmity
− WHO. (1948).

9
Definitions: Disease
„ Trouble or a condition of the living animal or plant body or
one of its parts that impairs the performance of a vital
function

10
Definitions: Safe
„ Free from harm or risk
„ Secure from threat of danger, harm, or loss
„ Zero risk

11
Definitions: Risk
„ Possibility of loss or injury, peril
„ The chance of loss; the degree of probability of such loss

12
What Is Environmental Health Sciences?
„ NIEHS charter: “The study of those factors in the environment
that affect human health”
− Factors (“pollutants” or “toxicants”) in air, water, soil, or
food
− Transferred to humans by inhalation, ingestion, or
absorption
− Production of adverse health effects

13
Contributors to the “Environment”
„ Chemical
− Air pollutants, toxic wastes, pesticides, VOCs
„ Biologic
− Disease organisms present in food and water
− Insect and animal allergens
„ Physical
− Noise, ionizing and non-ionizing radiation
„ Socioeconomic
− Access to safe and sufficient health care

14
WHO Definition of Environmental Health
„ Environmental health comprises those aspects of human
health, including quality of life, that are determined by
physical, biological, social, and psychosocial factors in the
environment. It also refers to the theory and practice of
assessing, correcting, controlling, and preventing those
factors in the environment that can potentially affect
adversely the health of present and future generations.

15
Facets of Environmental Health
„ Environmental epidemiology
− Associations between exposure to environmental agents
and subsequent development of disease
„ Environmental toxicology
− Causal mechanisms between exposure and subsequent
development of disease
„ Environmental engineering
− Factors that govern and reduce exposure
„ Preventive medicine
− Factors that govern and reduce disease development
„ Law
− Development of appropriate legislation to protect public
health

16
Section B

Environmental Health Issues

Question
„ Do you think that environmental issues are among the top
three public health issues in this country?

18
The “Right” First Question
„ What criteria do you use to identify an important public
health issue?

19
Traditional Public Health Approach
1. Define the problem
2. Identify and characterize the parameters governing the
problem
3. Design appropriate PH interventions
4. Implement and evaluate the interventions

20
Another Possible Approach
1. Define the health parameters of importance
2. Identify the problems most impacting the health parameters
3. Identify and characterize the parameters governing the
problem
4. Design appropriate PH interventions
5. Implement and evaluate the interventions

21
 Measure of Disease Burden and NIH Funding
„ Source: (1999). NEJM, 340, 1181.

Measure Correlation
Units P Value
(Year Assessed) Coefficient ( r )
Incidence No. of new cases
-0.05 0.82
(1990) per year
Prevalence No. of existing
0.25 0.23
(1990) cases
Hospital days Days in acute care
0.24 0.21
(1994) hospitals
Mortality
Deaths per year 0.40 0.03
(1994)
Years of life lost
Years 0.42 0.02
(1994)
Disability-
adjusted life- Years 0.62 < 0.001
years (1990)*
*Loss of one year of healthy life to disease
Source: Adapted from (1999). NEJM, 340, 1181 22
 Disability-Adjusted Life-Years and NIH Funding
„ Relationship between NIH disease-specific research funding
and disability-adjusted life-years

Source: Adapted from (1999). NEJM, 340, 1181.

23
Should You Care about EHS?
„ Acute environmental catastrophes (high-level exposures)
„ Chronic (low-level) exposures
„ Indirect effects of global environmental changes

24
The Wake-up Calls: Environmental Catastrophes
„ Minamata disease (1953–1961)
− Methyl mercury poisoning
„ Seveso, Italy (1976)
− Leak of toxic gas (TCDD)
„ Bhopal (1984)
− 16.5 tons of toxic pesticide released

25
The Wake-up Calls: Environmental Catastrophes
„ Chernobyl (1986)
− Nuclear reactor accident
„ Milwaukee incident (1993)
− Cryptosporidium in drinking water

26
Major Air Pollution Episodes

Date Place Xs Deaths

Dec. 1882 London, England 1,000
Meuse Valley,
Dec. 1930 63
Belgium
Oct. 1948 Donora, Penn. 20
Dec. 1952 London, England 4,000

Dec. 1962 Osaka, Japan 60

Jan. 1963 New York City 200–405

Nov. 1983 New York City 250
Excess deaths refers to the additional number of fatalities counted
above the number expected under otherwise normal conditions.

27
 The London “Killer” Smog of 1952

Source: Adapted from Turco, R. P.

28
Chemicals in the Environment
„ Roughly 70,000 different synthetic chemicals are on the
global market; many others are emitted as by-products of
their production, use, or disposal
„ Production of synthetic organic chemicals (e.g., dyes, plastics,
solvents) has increased from less than 0.15 billion kilograms
(1935) to more than 150 billion kilograms (1995)

29
 World Production of Synthetic Organic Chemicals

1000000
Millions of Kilograms

100000

10000

1000

100
1915 1935 1955 1975 1995

Data from Mitchell, J.D. 30

Substance-Specific Toxicity and Health Information
„ Substance-specific toxicity and health information (NRC/NAS,
1984)
100%

80%

60% compl HHE

partial HHE
40% mim toxtox
minimal
none
20%

0%
meds pest food cosm chem
HHE = health hazard evaluation; meds = medications; pests = pesticides;
food = food additives; cosm = cosmetics; chem = commercial chemicals
31
Why Don’t We Know More about These Chemicals?
„ Number of chemicals (1984—NRC/NAS)
− Pesticides 3,350
− Drugs 1,815
− Cosmetics 3,410
− Food additives 8,627

32
Why Don’t We Know More about These Chemicals?
„ Chemicals in commerce (1984)
− >1 million lbs/yr 12,860
− <1 million lbs/yr 13,911
− Production unknown 21,752

33
Why Don’t We Know More about These Chemicals?
„ Each year ~1,000 new chemicals come on line
„ It costs ~ $ 2 million to do a cancer toxicology screen on each
chemical (NTP guidelines)
„ The cancer toxicology screen takes ~2 years

34
Routes of Exposure
„ Routes of exposure through gaseous, liquid, and solid media

Air
Lungs

GI GI
Tract Tract
Water Food
Skin

GI
Skin
Tract
Soil
Adapted from Moeller, D.W. 35
 Pollutant Source Pathways

Pollutant Source

Soil Runoff Root Uptake

Air
Air Water
Water Soil
Soil Plant
Plant
Concentration
Concentration Concentration
Concentration Concentration
Concentration Concentration
Concentration

Soil Soil Plant

Water
Ingestion Ingestion Consumption
Consumption
Plant
Consumption

Inhalation
Inhalation Fish
Fish Cattle
Cattle && Poultry
Poultry
Concentration
Concentration Concentration
Concentration
Fish
Consumption

Breast
Breast Dermal Egg and Poultry Dairy and Beef
Milk
Milk Exposure Consumption Consumption

Human Receptor
Adapted from Derelanko, M. J. 36
Environmental Pathways for Selected Toxic Agents

Agent Disease Source Pathway

Air, building
L. Legionnaire’s Soil, cooling
ventilation
pneumophila disease towers
systems
Acute Human or Water, meat,
Salmonella
diarrhea animal feces eggs
Chloracne, Herbicides,
Air, water,
Dioxin soft tissue paper mills,
food
tumors incinerators
Nervous
Pesticides Agriculture Food, water
system tox.
Asbestosis, Insulation,
Asbestos Air, water
lung cancer auto brakes

37
Agents and Vectors
„ Agents
− Chemical, biological, and physical
„ Vectors
− Water, air, soil, and food
„ Routes of entry
− Inhalation, ingestion, absorption

38
 The Toxicological Paradigm

Exposure

Internal dose
Effect modifiers
Diet
Habits
Susceptibility Biologically effective dose
Health
Genetic factors
Medication
Co-exposure
Early biologic effects

Altered structure and function

Clinical disease
39
 The Toxicological Paradigm

Exposure

Internal dose
Effect modifiers
Diet
Habits
Susceptibility Biologically effective dose
Health
Genetic factors
Medication
Co-exposure
Early biologic effects

Altered structure and function

Clinical disease
40
 The Toxicological Paradigm

Exposure

Internal dose
Effect modifiers
Diet
Habits
Susceptibility Biologically effective dose
Health
Genetic factors
Medication
Co-exposure
Early biologic effects

Altered structure and function

Clinical disease
41
Severity of Adverse Health Effects

Death
Significant disease
Manifest dysfunction
Clinical nuisance effects
Sub-clinical chronic alterations
Acute reversible (functional) effects
Population exposed

42
Health Effects
„ Adverse vs. beneficial
„ Acute vs. delayed onset
„ Clinical vs. subclinical manifestations
„ Transient (reversible) vs. chronic (irreversible)

43
Examples of Manifestations
„ Lung disease
„ Reproductive effects
„ Teratogenic effects
„ Neurologic effects
„ Immunosuppression and hypersensitivity
„ Cancer

44
Environment Pulls the Trigger

Environmental
Intrinsic Exposure
Genetic

Human
Health/
Disease

“Genetics loads the gun,

but environment pulls
the trigger.”
— Judith Stern
Age/Time UC Davis 45
Vulnerable Groups
„ Low socioeconomic status
„ Women
„ Children
„ Elderly
„ Ethnic minorities
„ Disabled
„ Indigenous peoples
„ All of whom are often more vulnerable because of—
− Genetics
− They are not empowered to change their environment

46
Section C

Problem Solving
Problem-Solving Paradigm: Six Steps
1. Define the problem
2. Measure its magnitude Risk assessment
3. Understand key determinants
4. Develop intervention/
prevention strategies
Risk management
5. Set policy/priorities
6. Implement and evaluate

48
Selecting Priorities
„ Risk assessment
− The determination of the probability that an adverse
effect will result from a defined exposure
1. Hazard identification
2. Exposure assessment
3. Dose-response assessment
4. Risk characterization
− Pure “science” activities

49
Selecting Interventions
„ Risk management
− The process of weighing policy alternatives and selecting
the most appropriate regulatory actions based on the
results of risk assessment and social, economic, and
political concerns

50
Commonplace Risks Calculated
„ Commonplace risks calculated as number of deaths per
100,000 per year

Activity or Exposure Risk/Year

Motorcycling 2,000
Smoking (all causes) 1,000
Hand gliding 80
Driving 24
Fires 2.8
4 TBS peanut butter per day
0.8
(aflatoxin)
Being struck by lightning 0.05
Being hit by a meteor 0.000006

51
 Major Environmental Legislation

70

60
Number of Laws

50

40

30

20

10

0
1935 1945 1955 1965 1975 1985 1995
52
The Cost of Cleanup
„ The closer we get to the goal of zero emissions of a pollutant,
the more costly it becomes to eliminate each unit of pollution

53
The Cost of Cleanup
„ Reason
− First control method is usually the most effective and
easiest to implement, and produces the largest benefit at
the lowest cost
− Continued progress requires using more and more
expensive methods that remove smaller amounts of
pollutant
− At some point, costs outweigh benefits

54
The Law of Diminishing Returns

High
Pollution
10
Pollutant Emissions

0
Low 1 3 5 7 9 11 13 15 17 19 21
Pollution Cost of Emission Controls ($ Million)

55
Societal Determinants
„ Human needs and wants drive choices that produce
environmental impacts which, in turn, may result in adverse
health consequences

56
Societal Determinants Flowchart

57
Factors
„ Factors influencing environmental health problems and
solutions
− Objective (technical/scientific)
− Subjective (non-scientific)

58
Examples of Technical/Scientific (“Objective”) Factors
„ Sources of agents
„ Measurement of environmental change
„ Toxicological process
„ Biological susceptibility
„ Engineering approaches
„ Human needs

59
Examples of Non-Scientific (“Subjective”) Factors
„ Human wants
„ Religious beliefs (“world view”; e.g., humankind vs. other
species and the planet)
„ Political systems
„ Economic systems
„ Societal values
„ Population dichotomies (e.g., rich vs. poor; developed vs.
developing countries)

60
Basic Requirements for a Healthy Environment
„ Clean air
„ Safe and sufficient water
„ Safe and adequate food
„ Safe and peaceful settlements
„ Stable global environment

Source: Yassi et al. (2001). UNEP. 61

Improving Human Health and Environment: 3 Models

62
 Improving Human Health and Environment: 3 Models

Source: Adapted from Moeller, D. W.

63
Environmental Health Sciences

64
Key Points
„ EHS is the study of those factors in the environment that
affect human health
„ These factors represent chemical, biological, or physical
agents contained in air, water, soil, or food, and are
transported to humans via inhalation, ingestion, or skin
absorption
„ Adverse health effects may be acute or delayed in onset,
clinical or subclinical, and reversible or irreversible

65
Key Points
„ Environmental health sciences includes
− Environmental epidemiology and toxicology as the basis
of environmental health risk assessment
− Environmental engineering and regulation/risk
communication as the basis of environmental health risk
management

66