Course Impression

In honor of National Nurses Day, I want to recognize all the nurses for their role in this trusted profession, as they strive to create a positive impact in the lives of their patients. 

Through the Environmental & Occupational Effects of Health course, I have gained so much knowledge regarding nurses' potential to shape the health of not only patients in the clinical setting, but for the community as well. The modules have motivated me to transition to a lifestyle that is more sustainable in benefitting the environment, as well as my well-being. With all the knowledge I have gained, I will certainly apply them throughout my practice as a nurse. 

Radiation, Electric + Magnetic Fields

iPhone

Following the instructions below:

• Go to General
• > About
• > Legal

Regarding radiation, I was always aware of the radiation that can be transmitted through certain technologies like a smartphone. However, in light of this week's module content and the instructions above, I was oblivious to the warning and information about radio frequency (RF) exposure until today. 

Personally, I thought the legal information on the iPhone is valuable because it is very specific and provides consumers with ways to reduce RF exposure. 

Given the rise of innovative technology, I believe nurses should be more active in staying abreast of information regarding radiation associated with tech devices and their associated potential risks especially if those risks, such as cancer, can be reduced by decreasing radiation exposure.

If I wanted to develop a position statement for nurses on technology and health, it would be:

To people that possess smartphones, smartphones can transmit radio frequency leading to your risk of exposure that can be detrimental to your health, because radio frequency exposure is known to be linked to a list of potential health risks based on scientific research. 

Greening Healthcare

Regarding this week's module on greening healthcare, I was astonished to learn that 36% of nurses reported exposures to anesthetic gases and exposures led to an increased risk of congenital anomalies by sevenfold. As a former circulatory nurse working in the operation room, the data does concern me, and it allows me to be more mindful of all the chemical exposures that can occur in the healthcare setting. Also, I will consider choosing DEHP-free products in the hospital to reduce patients' risk for PVC and phthalate exposure. Furthermore, I am more conscious about handling medical waste so it can be appropriately disposed of.

This article stated that the health care industry is a significant contributor to climate change, as "healthcare creates a tenth of U.S. greenhouse gas emissions." In a separate article, Harveston revealed that the health care industry produces at least 4 billion pounds of waste annually. As a result, hospitals can convert to clean energy to reduce their environmental impact, and healthcare professionals can collaborate with policymakers to raise awareness regarding health risks due to climate change.

UCSF's green team is known as the "UCSF Office of Sustainability," and there is a specific page on their website involving "Greening the Medical Center." In 2015, the institution was recognized and given the Practice Green Health Environmental Excellence Award. After some research, the UCSF Supply Chain Management are the ones that make purchasing decisions.

Climate Change + Energy and Health

(Tehran Times, 2017)

Climate Change

As Earth Day is approaching, it is essential to address the issue of climate change. Climate change can have various impacts on human health, which is why it is crucial for healthcare professionals, such as nurses, to reduce health risks influenced by climate change by educating and advocating for their communities, as well as future generations. I believe that nurses, such as myself, can become prepared to address the effects of climate change that are likely to be experienced in my community by applying evidence-based research related to climate change into our practices.

(CDC, 2014)

The nursing community can use our trusted voices about health to strengthen climate change policies and practices by participating in organizations, promoting the use of environmentally safer products, reducing the use of products harmful to the environment, encouraging sustainable food purchasing, and advocating for vulnerable communities. Moreover, nurses can educate patients, as well as friends and families to reduce the health effects of climate change. More importantly, nurses must take the initiative to apply the knowledge of climate change and adapt the practices into our own lives to bring more awareness to the people around us.


Energy and Health

While the production of energy has a significant impact on the environment, human health and the well-being of many communities, I would say I am pretty comfortable with transitioning to sustainable and healthier energy choices. Currently, my house has solar panels installed, which I think is a big step. However, I can understand that renewable energy might not be feasible for everyone considering the cost, which is why I am in favor of the United Nations' Sustainable Development Goals of "ensuring access to affordable, reliable, sustainable, and modern energy."

Regarding incentives, the City of San Francisco established the GoSolarSF Incentive that "provides a monetary incentive to help residents and businesses install solar panels." The goal of the program is to reduce electricity bills and the city's carbon footprint. Furthermore, low-come residents can participate in the program as well, where customers can "save up to 100% off the installed cost of a solar electric system."

Occupational Health + Waste

Occupational Health

Materials Safety Data Sheet (MSDS)

I chose sevoflurane as a product that I wanted to look up using the University of California, San Francisco's (UCSF) Safety Data Sheets Database provided in the UC Safety Resources. I thought the MSDS was an adequate tool for a worker to use and gain an understanding of the potential health risks. It also provided simple safety instructions on how workers can protect themselves from the product. I would not consider the MSDS to be adequate or appropriate for the general public that reads at or below the 6th-grade level, considering some of the medical terminologies. 

Below is a comparison of UCSF's MSDS and TOXNET's report on sevoflurane:

(UCSF)

(TOXNET)

I thought both provided sufficient information for medical workers to follow. However, TOXNET elaborated more on human health effects, as the source also incorporated case reports and peer-reviewed data. 

Occupational Health Safety Program

The World Health Organization (WHO) occupational health and safety program that I chose was needlestick injuries because, in the past, I have experienced a needlestick injury. The WHO stated that "of the 35 million health-care workers, 2 million experience percutaneous exposure to infectious diseases each year," according to a report in 2002. As an effort to reduce needlestick injuries, the WHO implemented projects to promote injection safety by providing a toolkit and guidelines. 

The Cal/OSHA safety program I chose was safe patient handling because I sustained musculoskeletal injuries from mobilizing patients. As a result of the injury, I had to be placed on modified duty for two months, and it was debilitating to feel limited in mobility. The hospitals want to do their part to help reduce musculoskeletal injuries amongst hospital staff by incorporating the Cal/OSHA safety program and providing mandatory in-services on safe patient handling twice a year. 

Waste

I believe that nurses can play a role in addressing food waste by educating patients on practices to reduce waste. It troubles me when I see patients order trays of food, yet they only consume a portion of it, and the rest goes in the garbage. When patients are not placed on specific diet restrictions, individual hospitals allow them to order an unlimited amount of food items. I think hospitals can help reduce food waste by regulating the quantity of food that patients are ordering. Besides, hospitals can also implement practices to reduce the packaging of food products. I know some coffee shops give customers discounts if the customers bring in their own reusable tumbler/coffee mug, which can undoubtedly decrease waste if you can imagine how many Starbucks cups are used every day. After watching the clip on food waste in the United States on Last Week Tonight with John Oliver, I was surprised that grocery stores and restaurants were more willing to throw away food that was still good for consumption rather than donating because it was more expensive to do the latter. There is so much food wasted when there are families facing food insecurity globally. 

Nurses can exert leadership in addressing pharmaceutical waste by following hospital guidelines on proper disposal practices. Nurses can also promote these practices by educating colleagues, and if there is ever any doubt, I think it is essential to consult with the pharmacist or research the materials safety data sheet. 

After watching Lauren Singer talk about her zero-waste lifestyle on TED Talk, I was inspired to make some changes to lead a more sustainable and minimal lifestyle for myself. I find it frustrating that there is so much unnecessary packaging of materials in the world we live in today. 

Kathryn from Going Zero Waste provided "101 Easy Eco Friendly, Zero Waste Tips" in her blog. Below are a few tips extracted from her site:

• Ask for no straw in your drink order when out.
• Don't leave your house without a full reusable water bottle.
• Ditch tissues for handkerchiefs.
• Pick up a lonely banana.
• Always say no thank you to free promotional items. They tend to be cheap and break easily.
• Get a library card to support your local sharing economy.
• Donate unused items in good condition to support the second-hand market.
• Think second-hand first when purchasing something.
• Try elderberry syrup if you feel a cold coming on instead of immediately reaching for a plastic pill bottle.
• Swap your plastic toothbrush for a bamboo toothbrush.
• Turn old sheets and towels into handkerchiefs, rags, napkins, and cloth produce bags.
• Build a zero waste kit and put in the trunk of your car or carry it with you when you'll be out so you'll always be prepared. It doesn't have to be large just a few items!
• Wash clothes when they are actually dirty, instead of after only one wear.
• Open a window to cool down your home or air it out.
• Try to avoid palm oil.
• Buy food without packaging or minimal packaging.
• Instead of buying something when you're having a bad day, do something. I.e. go on a walk, take a yoga class, meet up with a friend.
• Repurpose stale bread.
• Make dry shampoo to stretch between washes.

Regulations & Policies

According to an article on the San Francisco Chronicle site, Tesla Motors is being fined for violating "hazardous-waste and air-emissions standards" at the manufacturing site in Fremont. The Environmental Protection Agency (EPA) made a statement on Monday that the company is fined a total of $86,000 "in penalties and equipment costs as part of the settlement." The EPA, Department of Toxic Substances Control and the Bay Area Air Quality Management District were involved in the inspection of the manufacturing site in 2017. The settlement requires the company to make improvements, which includes training workers on proper waste management. I found the article to be ironic considering Tesla is advertised as a sustainable brand that produces "clean energy" and has "zero emission." However, this article sheds light on the environmental impact that is caused by manufacturing "environmentally-friendly" vehicles. 

Regarding the article, I can see how poor hazardous waste management and air emissions by Tesla Motors can be directly related to human health. For example, it can affect workers that come into contact with the waste, and it can also change the air quality of residents that live near the manufacturing site. 

I am not aware of all the local elected officials, but this link provides an entire list of names for the City and County of San Francisco.

I have not personally tracked any health policies through my professional nursing organization or nursing union; however, I can become more involved in promoting health policies by collaborating with nursing leaders and government organizations, attaining knowledge about health policy through my doctorate program, and take advantage of resources regarding policy making. 

Pesticides + Sanitation

Pesticides

According to ‘What’s on My Food?’ I discovered there might be 45 pesticides in or on the strawberries that I have been consuming for the past week. The results are alarming considering there are six known/probable carcinogens, 16 suspected hormone disruptors, seven neurotoxins, six developmental or reproductive toxins, and 12 honeybee toxins.

Below is a list of pesticide residues found in strawberries taken from the website:

The pesticides and how often it is found:

Tetrahydrophthalimide (THPI) 55.3%
Pyraclostrobin 43.5%
Captan 42.6%
Fenhexamid 39.3%
Pyrimethanil 36.8%
Boscalid 36.3%
Fludioxonil 35.4%
Myclobutanil 29.8%
Cyprodinil 29.6%
Carbendazim (MBC) 28.8%
Bifenthrin 22.4%
Malathion 21.6%
Acetamiprid 20.5%
Bifenazate 14.2%
Quinoxyfen 13.9%
Imidacloprid 13.9%
Spiromesifen 12.5%
Spinosad A 11.3%
Triflumizole 10.9%
Azoxystrobin 10.4%
Methoxyfenozide 10.4%
Malaoxon 10.4%
Propiconazole 10.3%
Fenpropathrin 8.6%
Hexythiazox 7.4%
Dichlorvos (DDVP) 7.2%
Spinosad D 6.7%
Methomyl 6.7%
Thiamethoxam 6.2%
Propiconazole II 2.4%
Piperonyl butoxide 2.2%
Endosulfan sulfate 2.0%
Carbaryl 1.9%
Metalaxyl/Mefenoxam 1.6%
Propiconazole I 1.4%
Trifloxystrobin1.3%
Chlorpyrifos 1.3%
Pyriproxyfen 0.9%
Thiabendazole 0.8%
Endosulfan II 0.5%
Iprodione 0.5%
Endosulfan I 0.4%
Tebuconazole 0.1%
Oxamyl oxime 0.1%
Dimethoate 0.1%

In terms of public health, I would urge my patients and the community to purchase organic foods as much as they can to limit pesticide exposure. I also think it is essential to assess and educate people with occupational exposures about the potential risks of pesticides and to identify ways to protect their health. My responsibility would be providing primary, secondary, and tertiary prevention to reduce pesticide exposure.

The Occupational Safety & Health Administration (OSHA) site offers tips to protect the health of teens from pesticide exposures; however, I was not able to find anything on their site regarding adult protection. After some more research, I found the Pesticide Educational Resources Collaborative (PERC) from the EPA website. PERC is a collaborative agreement with the EPA that was developed to inform the public about pesticides by providing free educational material. Additionally, there is PERC-Med, which was established to “create pesticide-related outreach and educational materials for health-care providers, promoting the recognition, management, and treatment of pesticide poisoning.”

If I had children and discovered a posting at my children’s playground stating that pesticides have recently been used there, I would not bring my children there. I would inform others in the neighborhood to be careful of pesticide exposure and educate them on the potential risks to protect the health of the children and their parents. I know there was an instance when I was running along a trail, and I saw a sign that said, “Caution: Pesticides in Use.” I thought it was concerning and felt that pesticides should not be used in public places.

Before this module, I was not prepared at all in identifying the signs and symptoms of pesticide poisoning. As a result, I was able to locate information from the Cornell site as provided:

Mild Poisoning or Early Symptoms of Acute Poisoning: Headache, fatigue, weakness, dizziness, restlessness, nervousness, perspiration, nausea, diarrhea, loss of appetite, loss of weight, thirst, moodiness, soreness in joints, skin irritation, eye irritation, irritation of the nose and throat.
Moderate Poisoning or Early Symptoms of Acute Poisoning: Nausea, diarrhea, excessive saliva, stomach cramps, excessive perspiration, trembling, no muscle coordination, muscle twitches, extreme weakness, mental confusion, blurred vision, difficulty in breathing, cough, rapid pulse, flushed or yellow skin, weeping.
Severe or Acute Poisoning: Fever, intense thirst, increased rate of breathing, vomiting, uncontrollable muscle twitches, pinpoint pupils, convulsions, inability to breathe, unconsciousness.

This article discusses the ban of a widely-used pesticide, chlorothalanil, in the United Kingdom after research showed evidence that the pesticide is harmful to the environment, wildlife, and human health.

Sanitation

Below is a map of displaying San Francisco's sewage treatment facilities:

Based on the map, it does not look like an environmental justice concern, as the facilities are spread out in the city. 

In consideration of the failed attempts to encourage people of India to use toilets, a creative solution could be providing an incentive, such as awards, for using toilets each time. I think it is important for healthcare providers to continue educating the population about the issues of open defecation. 

Agriculture: Food Safety

After reviewing the code standards for the one thing of avocado that I ate today using the Codex Alimentarius, I can only imagine all the health standards that might have been invoked for all the meals and snacks I consumed the entire day. The Codex was created in 1963 to "protect the health of consumers and ensure fair trade practices."

Before I examined the Codex Standard for Avocado, the two things I only knew were that my avocado was not ripe yet, and it came from Southern California. Little did I know that the following are the minimum requirements for avocados before distribution to consumers:

In all classes, subject to the special provisions for each class and the tolerances allowed, the avocados must be:
- Whole
- Sound, produce affected by rotting or deterioration such as to make it unfit for consumption is excluded
- Clean, practically free of any visible foreign matter
- Practically free of pests and damage caused by them affecting the general appearance of the produce
- Free of abnormal external moisture, excluding condensation following removal from cold storage
- Free of any foreign smell and/or taste
- Practically free of damage caused by low and/or high temperatures;
- Having a stalk not more than 10 mm in length which must be cut off cleanly. However, its absence is not considered a defect on condition that the place of the stalk attachment is dry and whole.

Source: http://www.fao.org/3/a1389e/a1389e00.pdf

Given the example of my experience working with neutropenic patients, I can help reduce the risk of infection and other foodborne illnesses through education about the neutropenic diet.

The following is taken from the University of Pittsburgh Medical Center website regarding neutropenic diet tips:

- Avoid all fresh fruits and vegetables, including all fresh garnishes. Cooked vegetables, canned fruits, and juices are fine.
-Avoid raw or rare-cooked meat, fish, and eggs. Meat should be cooked to the “well- done” stage. All eggs should be thoroughly cooked (no runny yolks).
-Avoid salad bars, fruit bars, and deli counters. Buy vacuum-packed lunch meats rather than freshly sliced meats.
-Avoid raw nuts. You may eat baked products with these ingredients.
-Make sure all of the dairy products you eat are pasteurized.
-Avoid yogurt and yogurt products with live and active cultures.
-Be safe in the way you handle foods. Wash your hands before handling food. Wash all surfaces, cutting boards and cutting utensils thoroughly. Keep hot food hot and cold food cold.
-At home, you may use tap water. If you choose to use bottled water, be sure it is labeled as follows:
Reverse osmosis or
Distillation or
filtered through an absolute1 micron or smaller filter
Well water is OK if it is boiled for at least 1 minute.

The FDA also has a handbook for transplant patients available through this link.

Given the increase in antibiotic resistance infections, especially those that are hospital acquired, some initiatives that nurses can propose to promote safe uses of antibiotics in agriculture are: participating in campaigns; educating the public; working with policymakers; and supporting sustainable food policies. With the concerns of the superbug and misuse of antibiotics, it is important for us, as healthcare professionals, to implement the antibiotic stewardship program into our practice to improve health outcomes.

After reading this article, I was surprised by the fact that 70% of the fruits and vegetables in the United States contain pesticides residue. I have been more conscious about the foods I purchase to make sure they are organic since I follow a plant-based diet.

Agriculture: Food Systems and Farmworkers

When it comes to sustainable eating, one might perceive the idea as expensive, inconvenient and limiting. However, sustainable eating allows us to make healthier food choices, while we become more mindful of our environment.

Here are some ways to promote healthier and more sustainable food purchasing choices:

1) Shop for produce that is in season
2) Support local farmers (e.g. farmer's markets)
3) Follow a plant-based diet (consume less meat)
4) Create a garden to plant your own food
5) Buy fair trade foods
6) Shop organic produce
7) Eat less processed foods

Personally, I started hopping on the plant-based diet over a year ago, and I recently began incorporating more organic foods on my plate after gaining more knowledge about toxic chemical exposures from food consumption. However, I am trying to build the habit of eliminating or reducing processed foods in my diet by experimenting with cooking whole foods in my kitchen.

This link provides a list of raw, whole food, plant-based recipes!

Drinking Water

The source of San Francisco's drinking water is from the Hetch Hetchy Reservoir that collects water from snowmelt running down the Tuolumne River.

According to the City & County of San SF Annual Water Quality Report for 2017, the water from the Hetch Hetchy Reservoir is treated with "ultraviolet light and chlorine disinfection, pH adjustment for optimum corrosion control, fluoridation for dental health protection, and chloramination for maintaining disinfectant residual and minimizing the formation of disinfection byproducts." The two watersheds in the Bay Area are the Alameda Watershed and the Peninsula Watershed. Looking at the chart provided in the Water Quality Report, I did not notice any chemicals in SF water that was higher than expected. Although the range is <1-10.3, I was surprised that lead (4.8 parts per billion) was found in the water due to "internal corrosion of household plumbing systems."

Here are the associated health risks with the chemicals found in SF's water extracted from the EPA website:

Chemical	Health Risks	Source of Contaminant
Carbon tetrachloride	Liver problems; increased risk of cancer	Discharge from chemical plants and other industrial activities
Chloramines	Eye/nose irritation; stomach discomfort; anemia	Water additive used to control microbes
Copper	Short-term exposure: Gastrointestinal distress. Long- term exposure: Liver or kidney damage. People with Wilson’s Disease should consult their personal doctor if the amount of copper in their water exceeds the action level	Corrosion of household plumbing systems; erosion of natural deposits
Ethylene dibromide	Problems with liver, stomach, reproductive system, or kidneys; increased risk of cancer	Discharge from petroleum refineries
Fecal coliform and E. coli	Fecal coliforms and E. coli are bacteria whose presence indicates that the water may be contaminated with human or animal wastes. Microbes in these wastes may cause short term effects, such as diarrhea, cramps, nausea, headaches, or other symptoms. They may pose a special health risk for infants, young children, and people with severely compromised immune systems.	Human and animal fecal waste
Fluoride	Bone disease (pain and tenderness of the bones); children may get mottled teeth	Water additive which promotes strong teeth; erosion of natural deposits; discharge from fertilizer and aluminum factories
Giardia lamblia	Short-term exposure: Gastrointestinal illness (e.g., diarrhea, vomiting, cramps)	Human and animal fecal waste
Haloacetic acids (HAA5)	Increased risk of cancer	Byproduct of drinking water disinfection
Lead	Infants and children: Delays in physical or mental development; children could show slight deficits in attention span and learning abilities; Adults: Kidney problems; high blood pressure	Corrosion of household plumbing systems; erosion of natural deposits
Total Trihalomethanes	Liver, kidney, or central nervous system problems; increased risk of cancer	Byproduct of drinking water disinfection

Despite how clean the water may be in SF, I still use a water filter to give myself the peace of mind that I have the cleanest water possible (even if I am using a Brita filter that is flashing red, signaling the sign that it needs changing). I always try to carry my Hydroflask with me to store my drinking water. However, I do buy bottled water for emergencies, disaster preparation kits, or even long road trips. 

It is understood that climate change is predicted to cause droughts and extreme weather conditions that may create overwhelming floods. These events can impact the quality and quantity of safe drinking water, such as increasing runoff into rivers and lakes in flooding incidences leading pollutants into water supplies. In contrast, droughts can increase salinity in water and disturb aquatic life. 

If I were to develop a nationwide campaign to get people to drink tap water instead of bottled water, my campaign slogan would be: "Drip! Drip! Hooray!  Tap water, any time of day!"

In this article from The New York Times, military families in Fountain Colorado face health issues, such as cancer, thyroid conditions, and fatigue after being exposed to military toxic chemicals that leached into the water supply. Apparently, it has been known for years that the town's water supply is contaminated; however, it was not till recently that EPA announced regulatory action, infuriating the people of Fountain.