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. 

Radon, Carbon Monoxide, VOCs + Water

Radon, Carbon Monoxide, VOCs

Given that there are an estimated 21,000 excess deaths from lung cancer associated with exposure to radon in the US alone, I would develop a national radon awareness campaign by collaborating with the National Radon Safety Board, the EPA, and community healthcare providers to help alleviate and reduce exposures. The month of January is Radon Action Month, and this website provides a National Radon Action Month event planning kit for people that would like to organize an event in the community.

I would incorporate carbon monoxide exposure into my patient assessments by asking if they have any symptoms of carbon monoxide poisoning (shortness of breath, nausea, headache, dizziness, lightheadedness). Furthermore, I would like to have my patients describe how they typically use fuel-burning appliances at home and if needed, I would educate them on safer practices to prevent carbon monoxide exposures. This link has a carbon monoxide prevention guide developed by the CDC that is very helpful.

The three volatile organic compounds (VOCs) in my home are:
1) Butanal (hot pot)
2) Ethanol (laundry detergent)
3) Acetone (nail polish remover)

The three VOCs in my workplace are:
1) Sevoflurane (anesthetic)
2) Propanol (hand hygiene disinfectant)
3) Formaldehyde

I can reduce my exposure to the mentioned VOCs by avoiding allowing better ventilation in the house; buying products that do not contain VOCs and if they do, contain the product in areas of the house that limit the exposure.

Considering the risks of hair straighteners, I would coach my pregnant patients about potential harms. I cannot ultimately force my patients to do things a certain way; however, I can help them make educated decisions to reduce their exposure.

According to this article, more than 70% of hair products made for black women contained toxic chemicals, such as formaldehyde. I personally think that is a huge percentage considering the population of women that use these products. What concerns me the most is that some products might contain toxic ingredients despite that they are advertised as "natural" or "organic." The Federal Food, Drug, and Cosmetic Act of 1938 and the Fair Packaging and Labeling Act of 1967 were established to keep consumers safe; however, products can hit the shelves before actual approval. The article also stated to follow the "five-ingredient rule," which is to be aware of the first five ingredients in a product; 90% of the product contains those five ingredients. Below is a list from the article that I found useful:

Healthy Hair Ingredients

• Aloe vera (contains proteolytic enzymes good for healing scalp problems and stimulating hair growth)
• Avocado (dermatological benefits for scalp, with vitamins A, D, and E; effectively lubricates hair strand, preventing breakage)
• Shea butter (a hydrating emollient; protects the hair strand)
• Castor oil (antifungal; cleans the scalp, clearing follicles and promoting hair growth)
• Coconut oil (a hydrating emollient that seals moisture around the hair follicle)
• Extra virgin olive oil (a hydrating emollient and moisturizer, effective at softening hair)
• Grapeseed (lightweight conditioner and moisturizer; mildly astringent, thus effective at fighting dandruff; easily absorbs into hair and scalp and is packed with healthy fatty acids)
• Honey (humectant and antifungal)
• Jojoba (hair strengthener, rich in vitamins C, E, and B; dermatological benefits for repairing scalp dryness and inflammation)

Hazardous Ingredients to Avoid

• “Fragrance” or “parfum” (this is a widely used smoke screen in the cosmetics industry, denoting a vague mixture of unknown chemicals)
• Calcium hydroxide
• Formaldehyde or methylene glycol (formaldehyde is also released by DMDM hydantoin, diazolidinyl urea, and imidazolididinyl urea)
• Lead acetate (common in hair dyes)
• Methylisothiazolinone
• Parabens (propylparaben, butylparaben, or methylparaben)
• Petroletum
• Retyinal palmitate
• Specific alcohols:
• Alcohol denat, ethanol, propanol, isopropyl, propyl, SD alcohol #4 (also known by stylists as wood alcohol)
• Sulfates

Water

To ensure that the surface and groundwater in my community are safe, I stumbled upon this list from The Groundwater Foundation:

 

Go Native

Use native plants in your landscape. They look great and don't need much water or fertilizer. Also choose grass varieties for your lawn that are adapted for your region's climate, reducing the need for extensive watering or chemical applications.

Reduce Chemical Use

Use fewer chemicals around your home and yard, and make sure to dispose of them properly - don't dump them on the ground!

Manage Waste

Properly dispose of potentially toxic substances like unused chemicals, pharmaceuticals, paint, motor oil, and other substances. Many communities hold household hazardous waste collections or sites - contact your local health department to find one near you.

Don't Let It Run

Shut off the water when you brush your teeth or shaving, and don't let it run while waiting for it to get cold. Keep a pitcher of cold water in the fridge instead.

Fix the Drip

Check all the faucets, fixtures, toilets, and taps in your home for leaks and fix them right away, or install water conserving models.

Wash Smarter

Limit yourself to just a five-minute shower, and challenge your family members to do the same! Also, make sure to only run full loads in the dish and clothes washer.

Water Wisely

Water the lawn and plants during the coolest parts of the day and only when they truly need it. Make sure you, your family, and your neighbors obey any watering restrictions during dry periods.

Reduce, Reuse, and Recycle

Reduce the amount of "stuff" you use and reuse what you can. Recycle paper, plastic, cardboard, glass, aluminum and other materials.

Natural Alternatives

Use all natural/nontoxic household cleaners whenever possible. Materials such as lemon juice, baking soda, and vinegar make great cleaning products, are inexpensive, and environmentally-friendly.

Learn and Do More!

Get involved in water education! Learn more about groundwater and share your knowledge with others.

I would use the list above and incorporate it into policies to better protect the water in my community. 

The Groundwater Foundation also contains an abundance of information for the public to get involved in protecting the water in their community - there are campaign kits and educational material. 

I think the people of San Francisco relies heavily on the San Francisco Public Utilities Commission as they manage the water supply system and is "the third largest municipal utility in California. Their website contains annual reports of the water quality; how the water is treated with chloramine; plans to protect San Francisco's drinking water. 

There are also non-government organizations in my community that advocate for clean water and the list includes:

• Bay Area Audubon Council
• The Bay Area Open Space Council
• The Bay Institute
• Bay Planning Coalition

Water is an important molecule that affects everyone and everything, yet part of the world's population lacks access to safe water supplies. With that said, I would be interested in becoming a "groundwater guardian" to ensure safe water for my community. 

Transportation + Healthy Schools

Transportation

Public transportation planning can affect illness and injury in a community in various ways; it can affect one's physical fitness, contribute to environmental pollution emissions and increase one's exposure to air pollution due to traffic pollution. Furthermore, it can also affect traffic accidents. With the example of my community, the modes of public transportation include walking, biking, rideshares, taxis, Cable Cars, San Francisco Municipal Transportation Agency (SFMTA) includes buses and trains that connect to other Bay Area public transits, such as Amtrak, Bay Area Rapid Transit (BART), and Caltrain. Rideshares like Uber and Lyft are the modes of transportation that seem to be dominating the streets of San Francisco as people are trying to get to point A to point B in a matter of time. I was born and raised in San Francisco, and I remembered taking the Muni across the city for a mere price of 35 cents. Given the change in the economy, everything is more expensive now and riding the Muni is now $2.25. I believe public transportation is subsidized for students because some schools or universities offer student discounts. However, I did inquire about the Muni student discount/service at the University of San Francisco, and I was unfortunately denied. The university no longer offers the Muni discount to graduate students due to the lack of students taking advantage of the benefits over the past years. With public transportation, there are also differences in pricing between the general public, students, low-income and the elderly. I am also aware of programs in SF that helps to serve the low-income by providing them with free/discounted public transportation.

Given the topic of urban planning initiatives, I feel like there is always some building or road construction in San Francisco and I do believe they are considered environmental concerns. The city is constantly developing to accommodate and adapt to the ever-changing population. As a nursing professional, I can advocate for this in my community by collaborating with city officials, businesses, agencies, and other healthcare professionals to promote health and safety in the populations that are negatively affected by urban planning. An example would be educating the community of the risks of the "built environment." I think every city could benefit from "green" urban planning especially with the two cities in my area: San Francisco and San Jose. I have noticed the increase of electric standing scooters and hybrid bikes available in the city for rent, which promotes healthy transportation options. As for rural areas, I would work with policymakers, stakeholders, the community, and other agencies to increase access to health services and other resources to protect the health of the population. The Health Impact Assessment (HIA) process can be translated to a population-based nursing action or policy by involving nurses to assess and identify the risks and benefits of urban planning/community design to ensure positive public health outcomes.

The HIA Steps are very similar to the Nursing Process.

• Screening 
• Scoping 
• Assessment
• Recommendations 
• Reporting 
• Monitoring and evaluation 

Healthy Schools

I am not aware of whether the schools in my area have an environmental health team or if the school or community health nurses are involved, but I sure do hope so. This article stated that some schools in Florida do not test for lead levels, which is very concerning for the health of the students and school staff. Some schools claimed to perform "partial testing," which is frustrating. My question is: If they are already doing the test, why not fully complete the testing? I would take action to assess indoor air quality in my local schools by using the "Walkthrough Inspection Checklist" that is provided by the US Environmental Protection Agency that is available through this site. 

From a community health standpoint, I can advocate for air quality standards in local schools by educating school staff, students and parents on ways to improve indoor air quality and identifying some of the health risks associated with bad indoor air quality. I would work with facility managers to ensure healthy and safe environments for students to learn.

President's Cancer Panel: 2008-2009 Annual Report


The statistics for cancer in Americans are devastating, and there needs to be better regulations and policies to protect the health of the public with the help of continued scientific research.

Some important key points taken from the Presidential Cancer Panel include the following:

• The United States can reduce the impact of environmental exposures if the government focuses on the precautionary regulatory approach rather than the reactionary.

• According to the National Institutes of Health (NIH), it is reported that the cost of cancer in the United States was $243.4 billion in 2009. 

"We are not creating a sustainable society in this country if we continue to bring chemicals to market that are almost untested, disseminate them widely in consumer products, and then wait decades to take action only after people have become sick. It’s just not wise." 

- Philip Landrigan, Mount Sinai School of Medicine

• It concerns me that some toxic chemicals are listed as "inactive" ingredients on pesticide labels; however, the chemicals are not required to be tested for the potential health risks it may cause.

• Another piece of information that I find interesting is the amount of radiation exposure that Americans receive from medical imaging. The panel stated, "People who receive multiple scans or other tests that require radiation may accumulate doses equal to or exceeding that of Hiroshima atomic bomb survivors." With that said, I think it is important for medical providers to order imaging when it is deemed medically necessary to reduce further radiation exposure amongst patients. 

• The topic of environmental justice needs to be addressed given that underprivileged populations have higher risks of environmental exposures from their occupations or the locations of residence. 

It is noted that the regulation of environmental contaminants in the U.S. is unsuccessful due to the following five problems:

1) Inadequate funding and insufficient staffing
2) Fragmented and overlapping authorities coupled with uneven and decentralized enforcement
3) Excessive regulatory complexity
4) Weak laws and regulations
5) Undue industry influence.