Environmental Health:  Children in minority communities David Jones Environmental Health and Safety Duval County Health De...
What is Environmental Medicine? <ul><li>Environmental Medicine focuses on the person and the environment. </li></ul><ul><l...
Environmental Medicine <ul><li>There are four types of environmental media </li></ul><ul><ul><ul><li>Air </li></ul></ul></...
The Media of Environmental Hazards <ul><li>Air, water and food are the major environmental media or vectors through which ...
The Media of Environmental Hazards <ul><li>While soil is often overlooked as a route of exposure, in some cases such an ov...
The Discipline of Environmental Medicine <ul><li>A broad discipline involving:  </li></ul><ul><ul><ul><li>Understanding th...
How do chemicals enter the environment? <ul><li>There are six ways in which hazardous substances can enter the environment...
How do chemicals enter the environment? <ul><li>Illegal Dumping (dumping of oil in backyards, or mass dumping of toxic che...
Environmental hazards cont… <ul><li>The major environmental hazards and their relative importance in various environmental...
Interaction between hazardous exposures and humans <ul><li>Four characteristics critical to exposure assessment: </li></ul...
Interaction between hazardous exposures and humans cont… <ul><li>All of the environmental media are possible exposure rout...
Relationship of magnitude, duration, and frequency <ul><li>The concept of “dose” in environmental medicine is a function o...
Soil Ingestion
Environmental Medicine and Human Health <ul><li>Environmental medicine plays two major roles in human health. </li></ul><u...
Recognition of Human Hazardous Exposures <ul><li>The only way to accurately determine to what extent persons come in conta...
Chronology of Children's Environmental Health <ul><li>1776 - Young Chimney Sweeps, Cancers Linked to Environmental Toxican...
Chronology of Children's Environmental Health <ul><li>1970 - Clean Air Act Enacted. </li></ul><ul><ul><li>President Nixon ...
Chronology of Children's Environmental Health <ul><li>Feb 1994 - President Issues Executive Order on Environmental Justice...
Chronology of Children's Environmental Health <ul><li>Jan 1997 - Training of Pediatricians To Include Environmental Health...
Children's Environmental Health <ul><li>Environmental health is an ongoing concern within the pediatric clinical practice....
Children's Environmental Health <ul><li>Developing Organ Systems </li></ul><ul><ul><ul><li>Environmental toxicants can cau...
Children's Environmental Health <ul><li>Behavior </li></ul><ul><ul><ul><li>Hand-to-mouth activity and crawling can increas...
Children's Environmental Health <ul><li>The health care provider should serve as an: </li></ul><ul><li>Investigator </li><...
Children's Environmental Health <ul><li>Advocate </li></ul><ul><ul><ul><li>Prevention is the key to protection! </li></ul>...
Children's Environmental Health   <ul><li>Children are more vulnerable than adults to exposures. </li></ul><ul><li>“ A lit...
Children's Environmental Health <ul><li>In its first environment, its mother's womb, the fetus may be permanently damaged ...
Environmental Justice <ul><li>All children are affected by environmental hazards.  </li></ul><ul><li>Pollution and environ...
Environmental Justice <ul><li>Poverty can compound the adverse effects of exposure to toxicants such as: </li></ul><ul><ul...
Environmental Justice <ul><li>Sixteen percent of White-Americans or Non-Hispanic children live in poverty. </li></ul><ul><...
Known Hazards for Children <ul><ul><ul><li>Radiation </li></ul></ul></ul><ul><ul><ul><li>Solvents </li></ul></ul></ul><ul>...
Environmental Medicine <ul><li>Various diseases encountered in environmental medicine are:  </li></ul><ul><ul><ul><li>Cont...
Outcomes from Environmental Hazards <ul><li>Effects </li></ul><ul><li>Carcinogenicity </li></ul><ul><li>Heritable genetic ...
Known Hazards for Children <ul><li>They fall into categories such as: </li></ul><ul><ul><ul><li>Neurotoxins </li></ul></ul...
Known Hazards for Children <ul><li>The following are three selected environmental hazards known to seriously impact childr...
Lead <ul><li>Exposure to lead has been associated with an array of neurodevelopmental effects including: </li></ul><ul><ul...
Lead <ul><li>Childhood lead exposures can occur through: </li></ul><ul><ul><ul><li>Ingestion of paint chips </li></ul></ul...
Air Pollution <ul><li>Air pollution affects children more than adults because of their narrow airways, rapid rate of respi...
Asthma <ul><li>African Americans < 24 are 3X - 4 X more likely to be hospitalized for asthma as white children. </li></ul>...
Pesticides <ul><li>Children are often exposed to toxicants through the agricultural and home use of pesticides or the inge...
Number of Calls to Poison Control Centers About Pediatric Pesticide Poisonings,1999*
Childhood Diseases <ul><li>Researchers are working hard to determine whether an increase in childhood diseases is linked t...
Future Concerns <ul><li>Research that identifies patterns of environmental diseases in children. </li></ul><ul><li>The dev...
Policy Implications <ul><li>THE KEY TO PROTECTION IS PREVENTION . </li></ul><ul><li>There has been a dramatic shift in the...
Conclusion <ul><li>Environmental medicine is the clinical arm of environmental health. </li></ul><ul><li>Involves diagnosi...
Conclusion cont.. <ul><li>Since it’s establishment in 1975 environmental medicine has become a vital tool in the preventio...
References & Resources <ul><li>American Academy of Pediatrics, Handbook of Pediatric Environmental Health </li></ul><ul><l...
References & Resources <ul><li>The Institute of Medicine (IOM) 1995 report </li></ul><ul><li>Environmental Medicine: Inves...
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Aetna Presentation Environmental Health

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Environmental Health: Children in minority communities

David Jones, Environmental Health and Safety, Duval County Health Department

April 22, 2005 - UNF Hispanic Health Issues Seminar
This is part 3 of an 8 part series of seminars on Hispanic Health Issues brought to you by the University of North Florida’s Dept. of Public Health, College of Health, a grant from AETNA, and the cooperation of Duval County Health Department.

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  • Great Power Point. Here's a link to a site that has lots of great information on Hispanic worker safety - http://www.safetyawakenings.com/category/employees/hispanic-employees/
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Aetna Presentation Environmental Health

  1. 1. Environmental Health: Children in minority communities David Jones Environmental Health and Safety Duval County Health Department
  2. 2. What is Environmental Medicine? <ul><li>Environmental Medicine focuses on the person and the environment. </li></ul><ul><li>Emphasizes: </li></ul><ul><ul><ul><li>Identification </li></ul></ul></ul><ul><ul><ul><li>Diagnosis </li></ul></ul></ul><ul><ul><ul><li>Treatment </li></ul></ul></ul><ul><ul><ul><li>Prevention </li></ul></ul></ul>
  3. 3. Environmental Medicine <ul><li>There are four types of environmental media </li></ul><ul><ul><ul><li>Air </li></ul></ul></ul><ul><ul><ul><li>Water </li></ul></ul></ul><ul><ul><ul><li>Soil </li></ul></ul></ul><ul><ul><ul><li>Food </li></ul></ul></ul>
  4. 4. The Media of Environmental Hazards <ul><li>Air, water and food are the major environmental media or vectors through which exposure to hazardous environmental agents occur. </li></ul><ul><li>Disease Vectors - mosquitoes, rats, birds </li></ul><ul><li>Additionally, fire in the form of incineration has emerged as a major and somewhat controversial issue in environmental medicine. </li></ul>
  5. 5. The Media of Environmental Hazards <ul><li>While soil is often overlooked as a route of exposure, in some cases such an oversight may result in a critical underestimate of actual exposure. </li></ul><ul><li>Home gardens may be an exposure route dermal or through inhalation to contaminants in soil, dust, or chemical update in the plants. </li></ul>
  6. 6. The Discipline of Environmental Medicine <ul><li>A broad discipline involving: </li></ul><ul><ul><ul><li>Understanding the impact of the environment on human health </li></ul></ul></ul><ul><ul><ul><li>Eliciting appropriate exposure history </li></ul></ul></ul><ul><ul><ul><li>Recognizing exposure-related diseases </li></ul></ul></ul><ul><ul><ul><li>Identifying and Accessing resources </li></ul></ul></ul><ul><ul><ul><li>Discuss environmental risks to patients </li></ul></ul></ul><ul><ul><ul><li>Treating Patients </li></ul></ul></ul>
  7. 7. How do chemicals enter the environment? <ul><li>There are six ways in which hazardous substances can enter the environment. </li></ul><ul><ul><ul><li>Direct exposure (pesticides, cigarettes, lead in paint) </li></ul></ul></ul><ul><ul><ul><li>Direct discharge (toxic emissions from transportation, smokestacks, incinerators) </li></ul></ul></ul><ul><ul><ul><li>Inadequate landfills (runoff or leaching of contaminants into drinking water and food chain) </li></ul></ul></ul>
  8. 8. How do chemicals enter the environment? <ul><li>Illegal Dumping (dumping of oil in backyards, or mass dumping of toxic chemicals) </li></ul><ul><li>Catastrophic events (accidental releases of large quantities of extremely virulent toxins) </li></ul><ul><li>Ecological catastrophic events (events that lead to human health consequences such as volcanoes, floods, famine and hurricanes) </li></ul>
  9. 9. Environmental hazards cont… <ul><li>The major environmental hazards and their relative importance in various environmental settings. </li></ul><ul><ul><ul><li>Chemical agents: pesticides, VOC’S, and PCB’S </li></ul></ul></ul><ul><ul><ul><li>Physical agents: ionizing and nonionizing radiation, vibration, temperature, and noise. </li></ul></ul></ul><ul><ul><ul><li>Biological agents: infectious and allergic disorders </li></ul></ul></ul>
  10. 10. Interaction between hazardous exposures and humans <ul><li>Four characteristics critical to exposure assessment: </li></ul><ul><ul><ul><li>Route ( Inhalation, Ingestion, Dermal) </li></ul></ul></ul><ul><ul><ul><li>Magnitude (Concentration or Dose) </li></ul></ul></ul><ul><ul><ul><li>Duration ( Minutes, Hours, Days, Lifetime) </li></ul></ul></ul><ul><ul><ul><li>Frequency (Daily, Weekly, Monthly, Seasonally) </li></ul></ul></ul>
  11. 11. Interaction between hazardous exposures and humans cont… <ul><li>All of the environmental media are possible exposure routes, and should be considered in a risk assessment. </li></ul><ul><li>Humans have access to environmental toxicants by contaminated food, drinking contaminated water, and breathing contaminated air. </li></ul><ul><li>Hazardous pollutants may also enter the human body through the skin or a combination of these routes,rarely are humans exposed to a single pollutant along a single route. </li></ul>
  12. 12. Relationship of magnitude, duration, and frequency <ul><li>The concept of “dose” in environmental medicine is a function of the amount of the toxicant absorbed and time factors. </li></ul><ul><li>A toxicant may be present in very low, perhaps minute concentrations,and stimulate biological responses in the host. </li></ul><ul><li>Even a very small concentration of a highly toxic substance can cause a significant clinical response. </li></ul>
  13. 13. Soil Ingestion
  14. 14. Environmental Medicine and Human Health <ul><li>Environmental medicine plays two major roles in human health. </li></ul><ul><ul><ul><li>Provides the diagnosis and treatment of health complaints attributable to the environment. </li></ul></ul></ul><ul><ul><ul><li>Contributes to a much broader understanding of the unity of human health and environmental quality. </li></ul></ul></ul>
  15. 15. Recognition of Human Hazardous Exposures <ul><li>The only way to accurately determine to what extent persons come in contact with a specific environmental hazardous pollutant is to actually measure the exposure. </li></ul><ul><li>There are three ways to accomplish this: </li></ul><ul><ul><ul><li>Use of micro-environmental samplers </li></ul></ul></ul><ul><ul><ul><li>Use of personal monitors </li></ul></ul></ul><ul><ul><ul><li>Use of biologic measurements in human tissue </li></ul></ul></ul>
  16. 16. Chronology of Children's Environmental Health <ul><li>1776 - Young Chimney Sweeps, Cancers Linked to Environmental Toxicants. </li></ul><ul><ul><li>London physician Percival Pott notes incidence of scrotal cancer in young chimney sweeps. </li></ul></ul><ul><li>1904 - Paint Linked to Lead Poisoning in Children. </li></ul><ul><ul><li>J.L. Gibson of Queensland, Australia, is the first to recognize paint as the source of lead poisoning. </li></ul></ul>
  17. 17. Chronology of Children's Environmental Health <ul><li>1970 - Clean Air Act Enacted. </li></ul><ul><ul><li>President Nixon establishes the US Environmental Protection Agency and Congress adopts the Clean Air Act. </li></ul></ul><ul><li>Sept 1990 - Pediatric Environmental Health Curriculum Developed. </li></ul><ul><ul><li>Kids and the Environment Project develops the first curriculum on environmental health hazards for children. </li></ul></ul>
  18. 18. Chronology of Children's Environmental Health <ul><li>Feb 1994 - President Issues Executive Order on Environmental Justice. </li></ul><ul><ul><li>The Executive Order requires all federal agencies to make achieving environmental justice part of their missions. </li></ul></ul><ul><li>May 1996 - Pediatric Faculty Trained in Children's Environmental Health. </li></ul><ul><ul><li>The first training of pediatric faculty at the Ambulatory Pediatric Association Annual Meeting takes place. </li></ul></ul>
  19. 19. Chronology of Children's Environmental Health <ul><li>Jan 1997 - Training of Pediatricians To Include Environmental Health. </li></ul><ul><ul><li>The Pediatric Residency Review Committee requires the inclusion of pediatric environmental health training for pediatric residents. </li></ul></ul>
  20. 20. Children's Environmental Health <ul><li>Environmental health is an ongoing concern within the pediatric clinical practice. </li></ul><ul><li>Children live in a very different environment today than previous generations. </li></ul><ul><li>Advancements in information technology have contributed to the discovery and use of thousands of new chemicals. </li></ul><ul><li>Unlike our pharmaceutical drugs, many of the 70,000 chemicals used in the U.S. have not been tested for safety when exposed to humans. </li></ul>
  21. 21. Children's Environmental Health <ul><li>Developing Organ Systems </li></ul><ul><ul><ul><li>Environmental toxicants can cause permanent damage to developing nervous, immune, and respiratory systems. </li></ul></ul></ul><ul><li>Biological Sensitivity </li></ul><ul><ul><ul><li>Children’s skin, respiratory and gastrointestinal absorption is greater than adults. </li></ul></ul></ul>
  22. 22. Children's Environmental Health <ul><li>Behavior </li></ul><ul><ul><ul><li>Hand-to-mouth activity and crawling can increased probability of exposure to toxicants. </li></ul></ul></ul><ul><li>Diet </li></ul><ul><ul><ul><li>Children eat more pound for pound than adults. So they will absorb more hazardous residues in food. </li></ul></ul></ul>
  23. 23. Children's Environmental Health <ul><li>The health care provider should serve as an: </li></ul><ul><li>Investigator </li></ul><ul><ul><ul><li>Frontline investigator of environmental related illnesses within the clinical society and community. </li></ul></ul></ul><ul><li>Educator </li></ul><ul><ul><ul><li>Credible source of information to patients, their families and communities. </li></ul></ul></ul><ul><ul><ul><li>Information by provider can inform individuals and communities how to reduce or eliminate toxic exposure. </li></ul></ul></ul>
  24. 24. Children's Environmental Health <ul><li>Advocate </li></ul><ul><ul><ul><li>Prevention is the key to protection! </li></ul></ul></ul><ul><ul><ul><li>Policy development at Local, State, and Federal levels. </li></ul></ul></ul>
  25. 25. Children's Environmental Health <ul><li>Children are more vulnerable than adults to exposures. </li></ul><ul><li>“ A little kid goes from a single cell to a laughing, sociable, intelligent, friendly human being over a course of two years - that’s dramatic growth!” </li></ul><ul><li>They are in a dynamic state of growth, with cells multiplying and organ systems developing at a rapid rate. </li></ul><ul><li>In the first four months of life an infant more than doubles its weight. </li></ul>
  26. 26. Children's Environmental Health <ul><li>In its first environment, its mother's womb, the fetus may be permanently damaged by exposure to a wide variety of chemicals that can cross into its bloodstream through the placenta. </li></ul><ul><li>These chemicals include: </li></ul><ul><ul><ul><li>Lead </li></ul></ul></ul><ul><ul><ul><li>Polychlorinated Biphenyls </li></ul></ul></ul><ul><ul><ul><li>Methylmercury </li></ul></ul></ul><ul><ul><ul><li>Ethanol and Nicotine from environmental tobacco smoke </li></ul></ul></ul>
  27. 27. Environmental Justice <ul><li>All children are affected by environmental hazards. </li></ul><ul><li>Pollution and environmental degradation recognize no county, state, regional, or national border. </li></ul><ul><li>Children living in poverty and children in racial or ethnic communities are at disproportionate risk for exposure to environmental hazards. </li></ul>
  28. 28. Environmental Justice <ul><li>Poverty can compound the adverse effects of exposure to toxicants such as: </li></ul><ul><ul><ul><li>Inadequate Housing </li></ul></ul></ul><ul><ul><ul><li>Poor Nutrition </li></ul></ul></ul><ul><ul><ul><li>Limited access to health care </li></ul></ul></ul>
  29. 29. Environmental Justice <ul><li>Sixteen percent of White-Americans or Non-Hispanic children live in poverty. </li></ul><ul><li>The rates in the African-American and Hispanic communities are 42% respectively. </li></ul>
  30. 30. Known Hazards for Children <ul><ul><ul><li>Radiation </li></ul></ul></ul><ul><ul><ul><li>Solvents </li></ul></ul></ul><ul><ul><ul><li>Asbestos </li></ul></ul></ul><ul><ul><ul><li>Mercury </li></ul></ul></ul><ul><ul><ul><li>Arsenic </li></ul></ul></ul><ul><ul><ul><li>Sulfur Dioxide </li></ul></ul></ul><ul><ul><ul><li>PM2.5 </li></ul></ul></ul><ul><ul><li>Nitrates </li></ul></ul><ul><ul><li>Molds/Mildew </li></ul></ul><ul><ul><li>Bacteria </li></ul></ul><ul><ul><li>Parasites </li></ul></ul><ul><ul><li>Ozone </li></ul></ul><ul><ul><li>Petroleum by-products </li></ul></ul>
  31. 31. Environmental Medicine <ul><li>Various diseases encountered in environmental medicine are: </li></ul><ul><ul><ul><li>Contact Dermatitis </li></ul></ul></ul><ul><ul><ul><li>Obstructive Lung Disease </li></ul></ul></ul><ul><ul><ul><li>Nephritis </li></ul></ul></ul><ul><ul><ul><li>Neuropathy </li></ul></ul></ul><ul><ul><ul><li>Various Cancers </li></ul></ul></ul><ul><ul><ul><li>Gastrointestinal </li></ul></ul></ul>
  32. 32. Outcomes from Environmental Hazards <ul><li>Effects </li></ul><ul><li>Carcinogenicity </li></ul><ul><li>Heritable genetic & chromosomal mutation </li></ul><ul><li>Developmental </li></ul><ul><li>Reproductive </li></ul><ul><li>Neurotoxicity </li></ul><ul><li>Culprits </li></ul><ul><li>Benzene, PAH’S </li></ul><ul><li>Ionizing radiation </li></ul><ul><li>Lead, Methylmercury </li></ul><ul><li>Benzo[a]pyrene </li></ul><ul><li>Organophosphate </li></ul>
  33. 33. Known Hazards for Children <ul><li>They fall into categories such as: </li></ul><ul><ul><ul><li>Neurotoxins </li></ul></ul></ul><ul><ul><ul><li>Endocrine Disruptors </li></ul></ul></ul><ul><ul><ul><li>Carcinogens </li></ul></ul></ul><ul><ul><ul><li>Respiratory Irritants and Inflammatants. </li></ul></ul></ul>
  34. 34. Known Hazards for Children <ul><li>The following are three selected environmental hazards known to seriously impact children's health. </li></ul><ul><ul><ul><li>Lead </li></ul></ul></ul><ul><ul><ul><li>Air Pollution </li></ul></ul></ul><ul><ul><ul><li>Pesticides </li></ul></ul></ul>
  35. 35. Lead <ul><li>Exposure to lead has been associated with an array of neurodevelopmental effects including: </li></ul><ul><ul><ul><li>Attention Deficits </li></ul></ul></ul><ul><ul><ul><li>Decreased IQ scores </li></ul></ul></ul><ul><ul><ul><li>Hyperactivity and Juvenile Delinquency </li></ul></ul></ul><ul><li>Lead-based paint in older homes is still the most common source of high-dose lead exposure for preschool-aged children. </li></ul>
  36. 36. Lead <ul><li>Childhood lead exposures can occur through: </li></ul><ul><ul><ul><li>Ingestion of paint chips </li></ul></ul></ul><ul><ul><ul><li>Dust from deteriorating surfaces </li></ul></ul></ul><ul><ul><ul><li>Chewing on painted cribs, or through inhalation of lead paint dust. </li></ul></ul></ul>
  37. 37. Air Pollution <ul><li>Air pollution affects children more than adults because of their narrow airways, rapid rate of respiration and the fact that they inhale more pollutants per pound of body weight. </li></ul><ul><li>Common indoor air pollutants include: </li></ul><ul><ul><ul><li>Carbon Monoxide </li></ul></ul></ul><ul><ul><ul><li>Radon </li></ul></ul></ul><ul><ul><ul><li>Environmental Tobacco Smoke </li></ul></ul></ul><ul><ul><ul><li>Asbestos </li></ul></ul></ul><ul><ul><ul><li>Formaldehyde and Mercury </li></ul></ul></ul>
  38. 38. Asthma <ul><li>African Americans < 24 are 3X - 4 X more likely to be hospitalized for asthma as white children. </li></ul><ul><li>Children of Hispanic mothers have an asthma rate 2.5X whites and 1.5X of African Americans. </li></ul><ul><ul><ul><li>Puerto Ricans-11.2% </li></ul></ul></ul><ul><ul><ul><li>Cuban Americans-5.2% </li></ul></ul></ul><ul><ul><ul><li>Mexican Americans-2.7% </li></ul></ul></ul><ul><li>Non-Hispanic blacks-2.9% non-Hispanic whites-3.3% </li></ul><ul><li>Much of disparity is thought to be due to poverty not race. </li></ul>
  39. 39. Pesticides <ul><li>Children are often exposed to toxicants through the agricultural and home use of pesticides or the ingestion of pesticide residues on food or in water. </li></ul><ul><li>Pesticides used today generally fit into five main categories: </li></ul><ul><ul><ul><li>Insecticides </li></ul></ul></ul><ul><ul><ul><li>Herbicides </li></ul></ul></ul><ul><ul><ul><li>Fungicides </li></ul></ul></ul><ul><ul><ul><li>Nematocides </li></ul></ul></ul><ul><ul><ul><li>Rodenticides </li></ul></ul></ul>
  40. 40. Number of Calls to Poison Control Centers About Pediatric Pesticide Poisonings,1999*
  41. 41. Childhood Diseases <ul><li>Researchers are working hard to determine whether an increase in childhood diseases is linked to environmental exposures. </li></ul><ul><li>Childhood asthma has increased by more than 40% since 1980, affecting more than 4.2 million children under the age of 18 nationwide. </li></ul><ul><li>Childhood cancers have risen significantly over the past 15 years: Acute Lymphocytic Leukemia is up 10% and brain tumors are up more than 30%. </li></ul>
  42. 42. Future Concerns <ul><li>Research that identifies patterns of environmental diseases in children. </li></ul><ul><li>The developmental process, including the critical periods of vulnerability during which environmental exposures can cause adverse health effects. </li></ul><ul><li>The health effects of low level exposures to environmental toxicants such as dioxins, endocrine disruptors and lead. </li></ul><ul><li>The health effects of cumulative and multiple exposures to environmental hazards. </li></ul>
  43. 43. Policy Implications <ul><li>THE KEY TO PROTECTION IS PREVENTION . </li></ul><ul><li>There has been a dramatic shift in the recognition of children's environmental health issues in Congress and Federal Agencies. </li></ul>
  44. 44. Conclusion <ul><li>Environmental medicine is the clinical arm of environmental health. </li></ul><ul><li>Involves diagnosis and prevention of illness caused or influenced by external agents in a persons environment. </li></ul><ul><li>Once an environmental disease has occurred, it’s treatment is often within the domain of internal medicine, but it’s recognition and prevention is the essence of the environmental health practice. </li></ul><ul><li>Once a hazard has been recognized, control, and reduction of exposure should follow swiftly. </li></ul>
  45. 45. Conclusion cont.. <ul><li>Since it’s establishment in 1975 environmental medicine has become a vital tool in the prevention and diagnosis of many environmental related illnesses. </li></ul><ul><li>Environmental medicine will play an even greater role in the lives of everyone as we continue to educate the public as well as public policy makers on environmental related issues. </li></ul>
  46. 46. References & Resources <ul><li>American Academy of Pediatrics, Handbook of Pediatric Environmental Health </li></ul><ul><li>ATSDR Case Studies in Environmental Medicine </li></ul><ul><li>U.S. Department of Health and Human Services, Public Health Services Washington, D.C. </li></ul><ul><li>Environmental Health Perspectives Volume 110, Number 8, August 2002 </li></ul>
  47. 47. References & Resources <ul><li>The Institute of Medicine (IOM) 1995 report </li></ul><ul><li>Environmental Medicine: Investigating a Missing Element into Medical Education, Nursing, Health, and the Environment. </li></ul><ul><li>Pediatric Environmental Health Units. </li></ul><ul><li>Environmental Medicine Brooks, Stuart, Gochfeld, Michael, Herzstein, Jessica, Jackson, Richard </li></ul>

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