Indoor Air Quality

Indoor air quality contributes to health outcomes as bad indoor air quality affects respiratory function and can potentially lead to cancer. If indoor air quality is severe, prolonged exposure can lead to death.

Home Assessment

The air quality in my home is good considering all the windows that provide ventilation. However, the house was built around 1950, which means there is no air conditioning. My room has a HEPA filter to help my poor year-round allergies. In this article, studies have shown that HEPA filters significantly reduced indoor air pollution. I started purchasing a HEPA filter from Amazon after noticing them (nicer, higher quality ones) in the hospital hallways especially after the Camp Fire last year that had affected the Bay Area indoor (and outdoor) air quality immensely.

There are concerns about formaldehyde or carpets in my area because I have always had carpets in my house. I am more aware of my risk for exposure now knowing that formaldehyde is a toxic chemical.

In my future practice, I believe it is important to educate my patients and communities about indoor cooking risks to promote safer indoor air quality.

Having Faith

I thought this book was captivating as Sandra Steingraber records the intricate details of her pregnancy and provides readers with scientific history and perspective of fetal development. Furthermore, Steingraber educates the reader on the harmful effects of toxic exposures that cross the umbilical cord from mother to baby, as she highlights events in history that brought devastating outcomes, such as congenital defects, neurological impairments, and physical deformities, to children. It is important that we learn from history (methylmercury in Minamata, Rubella, Diethylstilbestrol, and Thalidomide) to reduce and prevent harm in the different stages of fetal development.

Air Pollution

Some of the health effects that are caused by common air pollutants are respiratory issues, such as asthma and lung cancer. I had some awareness of the effects of the immune system; however, I did not know of the direct pathophysiology regarding air pollutants suppressing the immune system's regulatory T cells.

After reading the AirNow website, I can reduce my impact on air quality by carpooling, biking and walking as my transportation. When I am out and about, I tend to combine my errands to decrease "cold starts" and avoid idling on my vehicle. I always check the tire pressure, bring my car in for tune-ups, and check the gas cap is secured after fueling gasoline. At home, I try to purchase environmentally-safe cleaning products to reduce the evaporation of chemicals in the air. I have solar panels at home, so that helps reduce greenhouse gas emissions.

Using the Scorecard website, I did discover environmental risks in my geographic area by utilizing the air quality assessment tools.

The top polluters in my zip code are:

• San Francisco Drydock Inc.
• Chevron Prods. Co. San Francisco Terminal
• Pacific Gas & Electric Co. Hunters Point Power Plant

The major pollutants are:

• Xylene (mixed isomers)
• N-Butyl Alcohol
• N-Hexane
• Benzene
• Toluene
• Copper Compounds
• Ethylbenzene
• Naphthalene
• Mercury

7% of the homes in my zip code have lead-based paint. There is one Superfund site in my zip code, and that is the Treasure Island Naval Station - Hunters Point Annex. This Superfund site is located on an island away from the city populated by low-income residents, which draws attention to environmental justice.

Below is the report from Scorecard on San Francisco's air quality:

In terms of water quality, 76% of water bodies are affected by pesticides, 24% by sediments, 12% by pathogens and 12% by nutrients.

I believe the Environmental Protection Agency (EPA) is responsible for regulating quality in my community and country. The "Spare the Air" Program was created by the Bay Area Air Quality Management District to inform the public about the air quality status. Moreover, the program also promotes activities that lessen community impact on air quality.

The journals provided in this week's module were relevant to my practice, as I can help mitigate the effects of particulate matter air pollution on my patients by educating them on the risks and promoting safer practices. In terms of the pediatric population, I can educate parents on air quality by providing them information about safe outdoor air quality, promoting carpooling to/from school and encouraging walking and biking as a family.

Environmental Justice

This is the definition of "environmental justice" provided by the United States Environmental Protection Agency:

"Environmental justice 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."

Environmental justice is something that I have seen or heard about, and you would think that it is something that should not exist. But it does.

There is evidence of environmental racism even in the San Francisco Bay Area. One of the articles provided in the lecture examines how companies treat African Americans with environmental racism, and one of the examples takes place in our very own backyard - The Chevron Richmond Refinery. The company's pipelines transport gasoline and other chemicals resulting in toxic emissions and environmental health risks within the community that is predominantly populated by African Americans. Another example would be San Francisco's Bayview-Hunter's Point District that also has a higher percentage of African-Americans. From 1946-1969, the district used to be a shipyard for the U.S. Navy to fumigate ships and other military equipment used for atomic bomb testing. To this day, the shipyard has yet to be cleaned from the radiation contaminants causing health hazards to the community (San Francisco Chronicle, 2018).

When I hear of the phrase "social determinants of health," I do believe environmental justice is one of them, because the population that faces those challenges have an increase in environmental health risks. We can incorporate environmental justice into our work to address the negative social determinants of health by working with non-profit organizations and coalitions to improve environmental health disparities within communities through collaboration, education, and research.


In Harm's Way

I thought this read was very informative on the subject associating developmental disabilities with environmental and genetic factors. The statement that resonated with me was:

"Toxicologic exposures deserve special scrutiny because they are readily preventable."

I was surprised by the increasing incidences of childhood developmental disabilities over the years, yet there is still limited research or information on toxic chemical exposures and its effect on neurological development. A reason for the drastic rise in developmental disabilities could be due to the consistent revision to the "safe thresholds" for toxic chemicals. For example, the safe threshold for lead was 60 microgram/dL in 1960 compared to 10 microgram/dL in 1990. Another topic that I thought was fascinating was how chemical exposures can affect different stages of brain development. As a result, neurological disabilities might not be identified until later stages in childhood development. Additionally,  animal testing is done to study toxic exposures; however, the effects on animals might not foresee the effects on humans.

Children + Environmental Health

As nurses, I think we tend to focus more on the health impact of environmental conditions, and we do not realize how the conditions can lead to financial burdens. According to reports from the Public Health Institute in 2015, the state of California spends $254 million annually on preventable environmental exposures. Below is an image providing additional data on expenses as a result of environmental health conditions amongst children in California:

The city of San Francisco identifies, manages, and pays for the cost of environmentally-related conditions with the help of The San Francisco Department of the Environment (SF Environment), as their mission is to "create visionary policies and innovative programs that promote social equity, protect human health, and lead the way toward a sustainable future." SF Environment also has a five-year strategic plan that involves working with stakeholders and non-profit organizations to attain their goals.

The San Francisco Department of Public Health (SFDPH) also focuses on environmental health issues and one of the programs they offer includes childhood lead prevention. In addition, they also regulate hazardous materials including petroleum storage, chlorofluorocarbon recycling, medical waste and prevention of accidental spills and exposures. Last but not least, the SFDPH have air quality, smoking, and tobacco programs to execute laws within the community regarding air pollution.

As a nurse, I can alleviate the costs of environmental conditions by educating patients and the community of environmental risks. I think it is also valuable to join organizations that promote and implement policies that address environmental health issues.

Prior to the lecture, I was slightly aware of the potential relationship between environmental health exposures and neurodevelopmental disorders. This will allow me to change my practice by incorporating better risk assessment, education and health promotion on the subject with my patients. I think it is also beneficial to take advantage of all the programs that the SFDPH has to offer and provide those resources to my patients and the community.

One of my brothers studied child development, and he worked with children with autism and other developmental disorders as a paraprofessional in the past. He currently works as a family advocate for a non-profit organization assisting low-income children and their families to meet their educational, health, social, and nutritional needs. My brother provided me with a copy of educational material made by The Department of Pesticide Regulation given to families about the use of safer household products.  It also contained a list of toxic chemicals for parents to watch out for. Below is the form:

I do believe the relationship between environmental health exposures and reproductive effects can be complex and I will integrate what I have learned from the UCSF - Reproductive Health & the Environment video into my practice by being more culturally sensitive and aware of environmental conditions that attribute to my patients' reproductive health. The video discussed how it was a cultural norm for indigenous pregnant women to smoke during spiritual ceremonies, so it is essential to be culturally competent during smoking cessation education.  I was also very interested in the fact that some toxins persist in our bodies and can be passed on to our children without them ever having direct exposure to the toxic chemical. It gave me a broader perspective of environmental health and how everything is connected.

Considering Dr. Lamphear's video, I will educate pregnant women on newborn care by sharing the same video with them. Other education topics include: reduce fish consumption with high mercury levels; avoid products with toxins (toys, personal care products, food); avoid pesticides; and inspect homes for lead.

An article from the Environmental Health News discussed early childhood exposures to phthalates and its association with decreased motor skills, which is a concern because children are more vulnerable to toxic exposures.

Public Health Institute. (2015). Costs of Environmental Health Conditions in California Children. Retrieved from http://www.phi.org/resources/?resource=cehtpkidshealthcosts

Biomonitoring + Body Burden

After watching CNN's special on "Body Burdens" with Anderson Cooper, I was shocked to learn about the numbers of toxic chemicals that could potentially be in our bodies. I was even more surprised that babies and children are more vulnerable to acquiring these toxic chemicals in their bodies. What interested me the most was the maternal/fetal burdens because I was always focused on the idea that the umbilical cord transferred nutrients from mother to baby rather than pollute and expose the baby with toxic chemicals. I would definitely incorporate this knowledge into my practice by educating pregnant women and parents in family planning about the risk of toxic chemicals that could potentially harm their baby and/children in order to prevent and reduce that risk. 

Lab Results

Chemical(s)	Potential Health Effects
Dioxins	Carcinogen, endocrine disruptor, cognitive dysfunction
DDT	Reproductive toxicant
Organophosphate	(pesticide) neurotoxicant, Parkinson’s
Lead	Neurotoxicant, kidney toxicant, insomnia, impotence
Solvent	Liver toxicant, neurotoxicant
PCBs	Carcinogen, toxic to immune, neuro, and repro systems
Phthalates	Repro toxicant (infertility), testicular damage, endometriosis, endocrine disruptor

These lab results are concerning and I would tell my patients about them by educating them on what the chemicals are and how they might have been exposed. It all comes down to education and providing resources to prevent or reduce the risk for further exposure. I was surprised to hear about chemicals being in the body that do not have "safe levels," because it can potentially cause serious health effects. 

One's Zip Code Matters More than Our Genetic Code

It is important to consider and assess the environmental health of my patients when collecting their health history. As a nurse with a medical-surgical background, I rarely have the opportunity to assess the environmental health of my patients aside from asking them about their allergies. I guess I never really thought about questioning my patients' air and drinking water quality of the location they live in. From a personal perspective of a patient being seen in a primary care setting, I do not recall being asked about my environmental health. The only time I was asked about my environment was from my asthma and allergy doctor. But hey, that is literally their job. Overall, I think it is crucial to consider the environmental aspects of health to see and understand the bigger picture of my patients' health.

The Developing Baby 

I was not aware of how sensitive the developing brain is to maternal exposures. In an article on the Washington Post, it states that doctors do not often educate pregnant woman about chemical exposures and pollutants that can affect the fetal brain and body. As a nurse, I would change that and make it one of the priorities when it comes to pre- and peri-natal education. From the article, I came across this quote that stuck with me and I find it very true:

"Fetal development is a critical window of human development, and so any toxic exposure during that time, during pregnancy, doesn't only have a short-term effect at that moment, but really an effect that lasts the entire lifetime." - Nathaniel DeNicola, the committee that reaffirmed the American Congress of Obstetricians and Gynecologists (ACOG) opinion

After putting some thought into that quote, I might want to consider or assess the number of toxic chemicals in maternity patients to understand what are the potential risks for their developing baby.

BPA

I have heard of BPA prior to reading the articles and my knowledge about BPA mainly came from reading labels on products that say, "BPA-free." Knowing the health risks of BPA, I will educate my patients by informing them about BPA, asking if they use BPA-containing products then making recommendations to replace BPA-containing products. Understanding that there might be social disparities between BPA exposures and low-income communities, I would work with community resources or social workers to assist those that lack access or financial means to BPA-free products. It would make a great impact if BPA-free products were made more affordable for the public and if companies eliminate the use of BPA in their products.

Cernansky, R. (2018, August 04). Environmental toxins are seen as posing risks during pregnancy. Retrieved from https://www.washingtonpost.com/national/health-science/environmental-toxins-are-seen-as-posing-risks-during-pregnancy/2018/08/03/770fab98-7643-11e8-9780-b1dd6a09b549_story.html?noredirect=on&utm_term=.356ccdcc9f24

Household Products + Body Burdens

The two household products that I chose to look up on were the Scrubbing Bubbles Foaming Bleach Bathroom Cleaner with Fantastik and the Palmolive Gel Dishwashing Soap using the National Library of Medicine's Household Products Database. I have the results provided below:

From what I have gathered, both products have a "slight" Health Materials Identification System (HMIS) rating scale and both are "not identified as carcinogens or potential carcinogens by NTP, IARC, and OSHA." To my surprise, I was actually expecting the results to be more harmful. I do not currently have any products in my knowledge that I would recommend to my patients; however, I would gladly research safer household products using the National Library of Medicine's Household Products Database. Furthermore, it would also be beneficial to assess the household products that my patients are currently using to see if it poses any risks and if so, I would educate my patients to avoid the products. 

Mom's Clean Air Force Quiz

I found the quiz to be very informative and was quite shocked to learn about neurotoxins, such as lead, to be in cosmetics. A lot of people, including all genders, wear makeup on a daily basis and do not realize their exposure to toxins from the cosmetics. Another toxic chemical that appeared on the quiz that intrigued me was phthalates in plastic containers and wraps because my family frequently uses wraps for leftover foods. Lastly, to know that my special, comfy and cozy place on the couch or mattress might contain flame retardants is actually scary. I am certain that I will now be more mindful about the chemicals that might linger in my products.

We might shift our policies regarding potentially toxic chemicals to reduce the risk of exposure from our personal and household products by improving testing on the products or preventing companies from producing products that contain harmful chemicals. Furthermore, education about toxic chemicals is key as I use myself as an example. I was unaware of all this information prior to the lectures and now I have the ability to make informed decisions about the products I buy. 

Environmental Health News

I stumbled upon an article that discusses the research of identifying low levels of perfluorinated compounds (PFCs) in hair and blood samples of people that consume caribou in Old Crow, Yukon. The article is mainly about the fate and transport of PFCs as the contaminant is found in "firefighting equipment and stain repellants" landing in lichens from the atmosphere and eventually consumed by caribou. Then consumed by people. 

Toxic Chemicals

Toxicology

My new knowledge regarding toxicology does make me want to question my patients regarding their potential exposures in their homes, schools and workplaces, because their exposures can affect their overall health. Although everyone can be exposed to toxins, knowing the direct causes of ones' exposures allows me, as a healthcare professional, to educate the patient and reduce or limit their risk for being further exposed to toxins. For example, some occupations might have greater risks of exposure compared to others and I would want to ensure that my patients are in a safe environment when performing their jobs. I will definitely add this new knowledge about toxicology in my practice to have a better understanding of its harmful effects on my patients' health.

Fracking

I am not aware of any gas or oil activity in my community in the San Francisco Bay Area. I was doing some research and stumbled upon this page on Center for Biological Diversity, which contains a press release regarding San Francisco's approval of a resolution to oppose President Trump's plan to expand offshore fracking in the Pacific Ocean. According to the Center for Biological Diversity (2018), it is stated that "there are already more than 30 offshore drilling platforms and hundreds of miles of underwater oil and gas pipelines off California's coast. Operators want permits to frack offshore wells, using chemicals that are toxic to wildlife."

Lead

I do feel comfortable educating patients about lead-based paint poisoning prevention as lead can have detrimental effects to their health. The Centers for Disease Control and Prevention (CDC, 2017) provided a very detailed infographic to educate the public about lead poisoning shown below:

There are tips from the CDC regarding the actions to take if there are elevated lead levels in my community's water.

I have not done any work on lead poisoning in the past; however, I have recently discovered that the lead problem in my community and in San Francisco Bay Area is primarily from paint from old housing. According to an article published two years ago on Reuters, the state of California had higher rates of childhood lead poisoning than Flint, Michigan. (The primary source of lead exposure was water in Flint.) The image below from Reuters and the California Department of Public Health shows the percentage of lead exposure in the state of California in 2017:

Asthma

I am not aware of the specific risks of adult onset asthma as a nurse but I am very interested to learn more due to exposure of particulate matter in the hospitals and other institutions. So far, I do not know of any nurses who developed asthma. However, I can see where the issue would arise as nurses (and other hospital staff) are constantly exposed to cleaning products (potential trigger to asthma) in order to keep hospitals clean and protect everyone that visits the hospitals from organisms. I suppose some ways of eliminating or reducing the exposures would be wearing masks to prevent inhaling the product and donning gloves to prevent direct contact with the product. It would be a lot easier if these products were toxic-free so everyone wins in a safe environment.

Perchlorethylene

I am not sure if there are any dry cleaners near me that uses perchlorethylene, because I, surprisingly and honestly, have never been to the dry cleaners. I did not know there are non-toxic alternatives to perchlorethylene but that is good to know after learning that it is a carcinogen posing risks to workers that work with the liquid. If I ever have to do any dry cleaning, I will now turn to "wet cleaning."


Center for Biological Diversity. (2018, January 10). San Francisco Passes Resolution Against Offshore Drilling, Fracking. Retrieved from https://www.biologicaldiversity.org/news/press_releases/2018/offshore-drilling-01-10-2018b.php
Centers for Disease Control and Prevention. (2017, January 26). Infographic. Retrieved from https://www.cdc.gov/nceh/lead/infographic.htm
Centers for Disease Control and Prevention. (2016, February 18). Water. Retrieved from https://www.cdc.gov/nceh/lead/tips/water.htm
Schneyer, J. (2017, March 22). Exclusive: Lead poisoning afflicts neighborhoods across California. Retrieved from https://www.reuters.com/article/us-usa-lead-california-exclusive/exclusive-lead-poisoning-afflicts-neighborhoods-across-california-idUSKBN16T18Y

Toxic Chemicals in Our Everyday Lives

Prior to Module #3's lecture, I guess I was not fully aware of the toxic chemicals that I use on a daily basis, because using products, such as body wash, shampoo, and conditioner, have become so routine. After using the Skin Deep database to find information about the toxicity level of my personal care products, these are the results:

I was actually really surprised by the results for this Trader Joe's sunscreen. As an athlete that exercises outdoors, I douse myself with this product while thinking that I am protecting my skin from sun exposure and UV rays. 

Dove is a brand that loves to target the female population and empower the female body; therefore, I was very interested to see the rating for the deodorant I have been using for years. Surprisingly, the score is on the lower side.

After my discoveries, I started looking into other personal care products without all the unnecessary chemicals through the MADE SAFE website. Considering that I have sensitive skin, I have always been a bit more careful about my skin care products. 

I believe that everyone has the right, as consumers, to know about the risks of the products they purchase. Everyone might not be aware of the risks, because they are not educated about the hazards of the products. They might lack the literacy skills to read the ingredients/chemicals listed or maybe corporations do a great job of selling the product so well that consumers overlook the risks. 

I would like to integrate this new knowledge about toxic chemicals in our everyday lives and apply it to my clinical practice by being more aware of the personal care products that my patients use. Perhaps a patient has a respiratory issue and it could be due to the allergens or other ingredients in the products that they use everyday. Furthermore, I would like to educate my patients on the matter to promote safer choices. The elements of a policy that would better protect us from toxic chemical exposures from our everyday products would ultimately be discontinuing production of products with chemicals. That is easier said than done as we are surrounded by toxins everywhere. A more logical approach would be discernible labeling of toxic chemicals on products to bring more awareness to the public. I suspect that corporations have an issue with the latter approach, because this is likely to decrease product sales. 

With the potential health effects related with fragrances in our personal care products, I would develop and implement a fragrance-free policy in a hospital or other institutional setting by collaborating with managers, CNOs, clinical nurse leaders/educators to inform staff, patients, and visitors about the health risks. Additionally, it is important to make sure the institution supplies non-fragrant personal care products. Based on my past experiences with patients sensitive to fragrances, I would post a "No Fragrance/Scents" sign outside the patients' rooms. If a colleague of mine have some fragrance to their personal care products, I would communicate the matter with them as it is in my best interest to provide a safe environment for everyone.