Environmental Conditions in Low-Income Urban Housing: Clustering and Associations With Self-Reported Health

Objectives. We explored prevalence and clustering of key environmental conditions in low-income housing and associations with self-reported health.Methods. The Health in Common Study, conducted between 2005 and 2009, recruited participants (n = 828) from 20 low-income housing developments in the Boston area. We interviewed 1 participant per household and conducted a brief inspection of the unit (apartment). We created binary indexes and a summed index for household exposures: mold, combustion by-products, secondhand smoke, chemicals, pests, and inadequate ventilation. We used multivariable logistic regression to examine the associations between each index and household characteristics and between each index and self-reported health.Results. Environmental problems were common; more than half of homes had 3 or more exposure-related problems (median summed index = 3). After adjustment for household-level demographics, we found clustering of problems in site (P < .01) for pests, combustion byproducts, mold, and ventilation. Higher summed index values were associated with higher adjusted odds of reporting fair–poor health (odds ratio = 2.7 for highest category; P < .008 for trend).Conclusions. We found evidence that indoor environmental conditions in multifamily housing cluster by site and that cumulative exposures may be associated with poor health.Home environments can be important determinants of resident health, especially in low-income populations. The underlying mechanisms for these associations may be driven by attributes of the social1,2 or physical3 environments in these settings, as well as by specific environmental exposures shaped by residents'' behaviors, the physical structure, or products and appliances used in the home. These housing-related environmental exposures may be important contributors to observed health disparities in low-income communities.4 Unfortunately, risks associated with the physical environment are rarely assessed concurrently, which may highlight the presence of risk clusters and provide insight on shared pathways that may be amenable to intervention.Housing conditions are influenced by a combination of building characteristics and household characteristics. In multifamily housing, building characteristics can be shaped by construction and renovation practices, as well as by the actions of both professional staff involved in building operation and maintenance and building residents. In the home, the proximate (i.e., causal) determinants of environmental exposures include pollutant sources, product usage and resident activity patterns, presence and performance of ventilation systems, design and maintenance of building systems, and pest infestation levels.5In recent years, significant evidence has emerged that broadens our view of the health effects that may be caused by indoor exposure disparities. Asthma, for example, has been linked to many indoor environmental exposures6 and indicators of housing quality.7 Studies have shown elevated respiratory8 and cancer risks from indoor exposure to specific volatile organic compounds that are emitted from household furnishings or products, including air fresheners. Exposure to semivolatile organic compounds that are commonly found in residential settings, such as flame retardants and plasticizers,9 may impart significant risk; however, the evidence on exposure disparities10 and the health effects attributable to recurrent exposures to concentrations typically found in the home is limited. Previous studies in low-income housing settings have demonstrated that these indoor environments contain elevated exposures to many agents with known or suspected health effects, such as pesticides,11,12 pest allergens,13,14 secondhand smoke (SHS),15 combustion byproducts,16 and other chemicals. Specific health endpoints include respiratory irritation, asthma development and exacerbation, and cancer. A notable example of the link between disparities in indoor environmental exposures and health effects is childhood lead poisoning attributable to deteriorating lead paint and lead-contaminated soil.17As we attempt to eliminate health disparities that may have environmental causes, it will be critical to address indoor environmental exposures, and this will require an understanding of the root causes for these uneven distributions in exposure. Despite the multiple known hazards in the home, few studies have examined the effect of cumulative risks in this setting. In this study, we examined the degree of clustering for key indoor environmental hazards in low-income housing developments and their association with self-reported health. We assessed individual hazards through questionnaires and in-home visual inspections.     

Electronic Health Records and US Public Health: Current Realities and Future Promise

Electronic health records (EHRs) could contribute to improving population health in the United States. Realizing this potential will require understanding what EHRs can realistically offer to efforts to improve population health, the requirements for obtaining useful information from EHRs, and a plan for addressing these requirements. Potential contributions of EHRs to improving population health include better understanding of the level and distribution of disease, function, and well-being within populations. Requirements are improved population coverage of EHRs, standardized EHR content and reporting methods, and adequate legal authority for using EHRs, particularly for population health. A collaborative national effort to address the most pressing prerequisites for and barriers to the use of EHRs for improving population health is needed to realize the EHR’s potential.The potential contributions of electronic health records (EHRs) to clinical care, on the one hand, and to population health and public health on the other, were delineated in the United States in the 1990s and early 2000s.1–4 (Population health is defined as “The health outcomes of a group of individuals, including the distribution of such outcomes within the group”5^(p381); public health is “The practices, procedures, institutions, and disciplines required to achieve the desired state of population health.”6^(p138) For other definitions used in this article, see appendix, available as a supplement to the online version of this article at http://www.ajph.org.) Data flows would be simplified and streamlined, and burdens on data providers and data collectors reduced; EHRs would enable collection of data just once, which then could be repurposed for multiple uses.The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Standards for Privacy of Individually Identifiable Health Information (Privacy Rule) established national legal authority permitting, though not requiring, “covered entities” to transmit individually identifiable health information from EHRs and health care transactions to public health authorities. The Privacy Rule authorizes public health authorities to receive such information for the purpose of preventing or controlling disease, injury, or disability and for specified uses including “reporting of disease, injury, and vital events” and “conducting public health surveillance, investigations, and interventions.”7^(p2) Covered entities can also disclose deidentified data and limited data sets, as defined in the Privacy Rule.7Whereas the Privacy Rule established national legal authority for sharing EHR data for specific public health purposes, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 established funding for sharing specified EHR data with public health authorities. The EHR Incentive Program mandated under HITECH provides Medicare and Medicaid incentive payments and penalties for specified “meaningful uses” of EHRs.8 For the first stage of meaningful use implementation, EHR systems certified under HITECH must be able to perform 3 functions for public health population-based programs: interfacing with immunization registries to transmit electronic data as directed by public health agencies; electronically recording, modifying, retrieving, and submitting syndromic surveillance data; and electronically recording, modifying, retrieving, and submitting reportable clinical laboratory results using Health Level Seven standards.9 The second stage of meaningful use adds 2 more functions: identifying and reporting cancer cases to a state cancer registry, and identifying and reporting specific cases to a specialized registry (other than a cancer registry).10 For those public health purposes currently included within HITECH’s meaningful use provisions, initial data and transmission standards are specified.9 Through January 2011, the Office of the National Coordinator issued $548 million in grants to help states develop health information exchanges for transmitting electronic health data among health care providers, and with Medicare, Medicaid, and public health agencies.11In addition to the HIPAA Privacy Rule and the HITECH meaningful use provisions, long-standing state statutes and regulations require transmission of health care provider data for specified surveillance and civil registration purposes, such as reportable diseases and conditions, vital records, and cancer registries. State legal authority typically also enables collection of data in response to threats to public health.Our purpose in this article is fourfold: (1) to describe briefly current US efforts to use EHRs for population and public health; (2) to identify potential contributions of EHRs to population and public health; (3) to delineate barriers and prerequisites to achieving those potential contributions; and (4) to suggest next steps for realizing this potential.     

The Use of Health Impact Assessment for a Community Undergoing Natural Gas Development

The development of natural gas wells is rapidly increasing, yet little is known about associated exposures and potential public health consequences. We used health impact assessment (HIA) to provide decision-makers with information to promote public health at a time of rapid decision making for natural gas development. We have reported that natural gas development may expose local residents to air and water contamination, industrial noise and traffic, and community changes. We have provided more than 90 recommendations for preventing or decreasing health impacts associated with these exposures. We also have reflected on the lessons learned from conducting an HIA in a politically charged environment. Finally, we have demonstrated that despite the challenges, HIA can successfully enhance public health policymaking.Many regions of the United States hold large natural gas reserves.1 Colorado is one of the states experiencing rapid natural gas development. Applications for permits to drill rose from 1939 in 2003 to 7870 in 20082,3 and natural gas production rose 110% from 2003 to 2010.4 The natural gas development process can be divided into the well development phase—involving well pad construction, pipeline installation, drilling, hydraulic fracturing, and well completion—and the production phase, when natural gas is routed into pipelines, compressed, processed, and distributed to end users. Concerns about potential drinking water contamination from hydraulic fracturing have dominated public discourse on natural gas development and public health.5–10 We conducted a health impact assessment (HIA) to systematically and comprehensively evaluate the possible health effects of natural gas development in a residential community in western Colorado.     

Racial/Ethnic Disparities in Cumulative Environmental Health Impacts in California: Evidence From a Statewide Environmental Justice Screening Tool (CalEnviroScreen 1.1)

Objectives. We used an environmental justice screening tool (CalEnviroScreen 1.1) to compare the distribution of environmental hazards and vulnerable populations across California communities.Methods. CalEnviroScreen 1.1 combines 17 indicators created from 2004 to 2013 publicly available data into a relative cumulative impact score. We compared cumulative impact scores across California zip codes on the basis of their location, urban or rural character, and racial/ethnic makeup. We used a concentration index to evaluate which indicators were most unequally distributed with respect to race/ethnicity and poverty.Results. The unadjusted odds of living in one of the 10% most affected zip codes were 6.2, 5.8, 1.9, 1.8, and 1.6 times greater for Hispanics, African Americans, Native Americans, Asian/Pacific Islanders, and other or multiracial individuals, respectively, than for non-Hispanic Whites. Environmental hazards were more regressively distributed with respect to race/ethnicity than poverty, with pesticide use and toxic chemical releases being the most unequal.Conclusions. Environmental health hazards disproportionately burden communities of color in California. Efforts to reduce disparities in pollution burden can use simple screening tools to prioritize areas for action.Communities of color in the United States often reside in neighborhoods with worse air quality,1 more environmental hazards,2 and fewer health-promoting environmental amenities such as parks.3 This unequal distribution of exposures may contribute to racial/ethnic health disparities in environmentally sensitive diseases such as cancer and asthma.4 Research has shown that communities of color in California experience higher cancer risk from toxic air contaminants5 and higher average levels of nitrate contamination in their drinking water6 and that they live closer to hazardous waste sites7 and traffic.8 However, less is known about the extent to which communities of color are simultaneously exposed to multiple potential sources of pollution and the implications of such coexposures for health.There is, thus, an increasing need for analytic frameworks and decision-making tools that account for exposures to multiple environmental hazards through a variety of routes. Such frameworks should also consider differential vulnerability to the health effects of those exposures, which can vary across the population because of both individual and community-level factors.9–11 For example, age and health status, including suffering from preexisting cardiovascular disease or asthma, have been shown to increase susceptibility to the adverse health effects of air pollution.12–14Several studies suggest that an individual’s educational attainment modifies the health effects of air pollution: greater effects are observed among the less educated.15,16 Poverty can hinder access to adequate nutrition and medical care to prevent and manage the health impacts of pollution. At the community level, the concentration of poverty in disadvantaged neighborhoods can lead to conditions that increase levels of chronic psychosocial stress that weaken the body’s ability to defend against external challenges.17 A cumulative impact approach that considers differential vulnerability and environmental stressors is particularly important for assessing racial/ethnic environmental health disparities because communities of color in the United States experience lower average levels of education18 and wealth19 and, for some groups, higher rates of chronic health conditions20 that increase susceptibility to environmental health hazards.Although the field is still in its infancy, several proposed methods are used to better reflect the cumulative impacts of environmental exposures and population vulnerabilities and provide assessments that can support the incorporation of equity and environmental justice goals into policymaking.21–24 The California Environmental Protection Agency first released such a method—the California Communities Environmental Health Screening Tool, or CalEnviroScreen—in April 2013, and an updated version, CalEnviroScreen 1.1, was published in September 2013.25 CalEnviroScreen is a screening tool that considers both pollution burden and population vulnerability in assessing the potential for cumulative impacts across California zip codes. It was developed following consultation with government, academic, business, and nongovernmental organizations and 12 public workshops in 7 regions of the state that resulted in more than 1000 oral and written comments on 2 preliminary drafts.26 The tool employs a model that can be adapted to different applications and as new information becomes available. For example, subsequent iterations have been developed using a finer geographic resolution and the addition of new indicators.27 It purposefully relies on publicly available data sets for transparency and relatively simple methods so that it can be understood by a general audience.We used CalEnviroScreen 1.1 to assess the extent of geographic and racial/ethnic disparities in the potential for cumulative environmental health impacts from multiple environmental hazards in California. We employed a concentration index to examine which environmental hazards are most inequitably distributed, and we considered variations to CalEnviroScreen to evaluate the sensitivity of our findings to the structure of the model.     

Risk Factors for and Behavioral Consequences of Direct Versus Indirect Exposure to Violence

Research suggests that direct exposure (personal victimization) and indirect exposure (witnessing or hearing about the victimization of a family member, friend, or neighbor) to violence are correlated. However, questions remain about the co-occurrence of these phenomena within individuals. We used data on 1915 youths (with an average age of 12 years at baseline) from the Project on Human Development in Chicago Neighborhoods to examine this issue. Results indicated that youths who tended to be personally victimized were also likely to witness violence; conversely, youths who disproportionately witnessed violence were relatively unlikely to experience personal victimization. In addition, direct and indirect exposures to violence were associated with subsequent adverse outcomes in similar ways. The key distinguishing factor was, rather, the cumulative level of violence (both direct and indirect) to which youths were exposed.Exposure to violence refers broadly to direct victimization via intentional or threatened physical harm or indirect witnessing of (or hearing about) the victimization of a family member, friend, or neighbor. Exposure to violence may occur in the home, school, or community, and it includes experiencing and witnessing events such as fights, shootings, and threats to injure.1 Although exposure to violence is particularly prevalent among youths living in socioeconomically disadvantaged areas,2–4 nationally representative surveys indicate that up to 60% of all US youths report exposure to some form of violence, either directly or indirectly, in a given year.1,5 Hence, scholars and policymakers consider exposure to violence a “national epidemic.”6^(p28)Recognition of the scope of exposure to violence has prompted several research and prevention efforts. A multidisciplinary workshop on exposure to violence was funded by 10 national agencies in 2002,7 a national task force was launched in fall 2010,6 and the National Survey of Children’s Exposure to Violence (NatSCEV) was initiated in 2007–2008 (and repeated in 2011 and 2014) as part of an ongoing, cross-sectional panel survey.1 These sources, along with a flourishing number of scholarly studies, have documented an array of correlates of and mental health and behavioral problems associated with direct and indirect exposure to violence.Correlates of exposure to violence include demographic characteristics (minority race/ethnicity, male gender, older age among youths)1 and individual or trait differences, such as low self-control or self-regulation,8 associating with delinquent peers,9 and unstructured socializing among peers.10 Relevant family factors include nonintact family structures, low socioeconomic status, residential instability, conflict, and low emotional or social support.11–14 Neighborhood factors associated with exposure to violence include concentrated disadvantage and a paucity of neighborhood youth services.3,4,15–17Exposure to violence has also been associated with adverse emotional, medical, and sociobehavioral problems. Forms of emotional distress include anger, loss of confidence, and fear.18 Anxiety, depression, and posttraumatic stress disorder are among the mental health problems associated with exposure to violence.19–21 Biological maladies include increased heart rate, sleep disturbance, altered endocrine secretion, and stunted pubertal development.19,22 Sociobehavioral problems include substance use, violence, and suicidal behavior.23–25Although the correlates and consequences of exposure to violence are well documented, little is known about the relationship between direct and indirect exposure to violence. The accumulated research suggests that direct and indirect exposures to violence have a similar set of risk factors and associated behavioral problems.26,27 However, the majority of studies have focused on either personal victimization or indirect exposure to violence, with few investigations examining these phenomena concurrently. Thus, questions remain as to whether personal victimization and indirect exposure to violence are merely related in the aggregate or whether, and to what extent, they co-occur within the same individuals.We addressed this issue by examining 3 questions about the relationship between direct and indirect exposure to violence: What is the extent to which the same individuals are particularly vulnerable to direct versus indirect exposures to violence? What are the shared and unique covariates of direct and indirect exposures to violence? Finally, is being differentially vulnerable to direct versus indirect exposures to violence associated with sociobehavioral problems? Next we discuss our rationale for examining differential vulnerability, or susceptibility, to direct versus indirect exposure to violence.     

The Drinking Water Disparities Framework: On the Origins and Persistence of Inequities in Exposure

With this article, we develop the Drinking Water Disparities Framework to explain environmental injustice in the context of drinking water in the United States. The framework builds on the social epidemiology and environmental justice literatures, and is populated with 5 years of field data (2005–2010) from California’s San Joaquin Valley. We trace the mechanisms through which natural, built, and sociopolitical factors work through state, county, community, and household actors to constrain access to safe water and to financial resources for communities. These constraints and regulatory failures produce social disparities in exposure to drinking water contaminants. Water system and household coping capacities lead, at best, to partial protection against exposure. This composite burden explains the origins and persistence of social disparities in exposure to drinking water contaminants.

“Isn’t the issue of contaminated water just an issue of economies of scale, where small systems face the biggest problems?”“In talking about environmental injustices and contaminated drinking water, are you implying that someone is deliberately polluting people’s water?”“If there is no statistical correlation between race, class, and water quality, doesn’t that mean there is no injustice?”—Questions commonly encountered during fieldwork in the San Joaquin Valley

Hundreds of small, rural communities in California and across the United States rely on unsafe drinking water sources that their modest means cannot mitigate. Research and grassroots efforts have drawn attention to high levels of contaminants in California’s San Joaquin Valley (the Valley)1; to inadequate services and infrastructure in US–Mexico border colonias2 and rural communities in the South3,4; and to bacteriological and chemical contamination in unregulated drinking water sources in the Navajo Nation.5 Our own earlier research, conducted between 2005 and 2011, established that race/ethnicity and socioeconomic class were correlated with exposure to nitrate and arsenic contamination and noncompliance with federal standards in community water systems.6,7But why do social disparities in access to safe water exist and persist in a country where most of the population has access to piped, potable water? A rich understanding of how disparities in access to safe drinking water are produced and maintained is essential for understanding environmental justice concerns and developing effective public health interventions. In this article, we highlight the mechanisms through which natural, built, and sociopolitical factors, along with state, county, and community actors, create a composite and persistent drinking water burden in the Valley. This research reflects the call by environmental justice scholars8,9 for more historically informed work on the causes and consequences of environmental injustice (i.e., disproportionate environmental burdens by race and class).The drinking water and environmental justice literature has focused on how unequal access to infrastructure drives unequal access to safe drinking water. Wilson et al. have shown that disparities in “basic amenities” drive adverse health outcomes, especially in conjunction with poorly enforced health laws and building codes.4,10 VanDerslice’s infrastructure-oriented framework posits that the extent to which any aspect of water infrastructure—natural, built, or managerial—differs by racial or income disparities drives disparities in water quality, reliability, and cost.11 The literature also notes that small water systems are vulnerable to inadequate regulatory protection,12 and to uneven monitoring and reporting.13,14Studies on equity and the built environment have discussed how historical and structural conditions shape lack of access to safe drinking water. These conditions include selective enforcement of drinking water regulations,15 noncompliance with federal standards,16,17 inequities in access to funding,18 and (the absence of) a community’s political power in accessing a safe water supply.19 Research has also shown that cost of service extension and low ability to pay drive inadequate service provision2; that municipalities provide or deny access to basic services by determining which areas to annex or exclude from their city boundaries4,10,20; and that segregation allows such determinations to continue.21 Thus the environmental justice and built environment literatures highlight the many causal factors of social disparities, but, to date, do not offer a comprehensive framework for tracing both the origins and persistence of disparities in exposure.Here, social epidemiology offers a theoretical foundation for our analysis. In particular, an ecosocial epidemiological approach underscores the need to (1) explore the social production, or origins, of health disparities22,23; (2) uncover the multilevel factors that drive the distribution of disease,24,25 or, in our case, exposure; and (3) highlight the “agency and accountability” of multilevel actors in creating these disparities and embodiments of disease.22,24Our work draws on several social epidemiology–inspired frameworks. These frameworks discuss how race, class, social factors,26,27 and multiple levels of decision-making22 can have an impact on exposure pathways.28 Sexton et al.26 expanded the traditional exposure–disease paradigm29 used in environmental health by positing that differential health risks may be associated with race and socioeconomic class because of exposure (e.g., proximity to source) and susceptibility-related (e.g., gender) attributes. Gee and Payne-Sturges refined Sexton et al.’s work with a multilevel perspective that explores how vulnerability intersects the exposure–disease paradigm.27 deFur et al. complemented this approach by showing that vulnerability can have an impact on exposure pathways between environmental factors and receptors (i.e., individual, community, or population) and response pathways between receptors and outcomes.28 In sum, social epidemiology frameworks emphasize how and why health disparities may arise, and, to some extent, why they persist. They do not, however, focus specifically on drinking water.We present the Drinking Water Disparities Framework, which builds on the social epidemiology and the infrastructure-centric frameworks discussed previously in 3 main ways. First, our framework describes which infrastructural factors shape disparities, as VanDerslice11 does, but we add the role of social and political factors. VanDerslice’s article hypothesizes that disparities in water-related infrastructure vary by race and class, and supports this claim through the published literature; we use primary field data to trace how and why these disparities exist and also persist, as a consequence of built, natural, and sociopolitical factors. For instance, we show how the historical marginalization of poor communities, coupled with poor source water quality, determines the condition of their physical infrastructure and results in exposure. Second, in line with Wilson,30 we highlight the role of multilevel actors, but we emphasize how specific decisions at different levels, past or present, intentional or accidental, drive disparities in access to drinking water. For example, we show how municipal redlining, limited county oversight, and low household finances together impede mitigation of contaminated water. Third, our multilevel framework extends the classic exposure–disease paradigm29 to show that water system and household coping mechanisms, intended to alleviate exposure, create a feedback loop through which disparities in drinking water quality may be exacerbated. In this way, the framework shows how drinking water disparities comprise both external stressors and susceptibility to them, as well as the capacity, or lack thereof, to cope.28,31Thus, we emphasize the role of historical and structural factors, and trace the mechanisms through which these lead to exposure disparities. We argue that these structural factors are not deterministic, but that communities and individuals exercise agency within the structures that constrain them. The extent of this agency also has an impact on exposure. A framework that pays attention to history as well as contemporary processes, and to structures as well as agency, reveals both the pathways to unsafe water and the points of leverage at which exposure to contaminants can be reduced.Five years of primary data collection in California’s San Joaquin Valley provide the empirical grounding for our framework. This richly nuanced data set reveals not only the role of multilevel actors in shaping disparities, but also the lived experiences of households and communities who struggle for safe water. Ultimately, our framework outlines a “composite burden,” composed of exposure to contaminants and inability of socially vulnerable communities to mitigate contamination. We argue that this composite burden leads to persistent exposures and social disparities in exposure to poor drinking water.     

Reassuring or Risky: The Presentation of Seafood Safety in the Aftermath of the British Petroleum Deepwater Horizon Oil Spill

The BP Deepwater Horizon Oil Spill was enormously newsworthy; coverage interlaced discussions of health, economic, and environmental impacts and risks. We analyzed 315 news articles that considered Gulf seafood safety from the year following the spill. We explored reporting trends, risk presentation, message source, stakeholder perspectives on safety, and framing of safety messages. Approximately one third of articles presented risk associated with seafood consumption as a standalone issue, rather than in conjunction with environmental or economic risks. Government sources were most frequent and their messages were largely framed as reassuring as to seafood safety. Discussions of prevention were limited to short-term, secondary prevention approaches. These data demonstrate a need for risk communication in news coverage of food safety that addresses the larger risk context, primary prevention, and structural causes of risk.The British Petroleum (BP) Deepwater Horizon oil spill (“the oil spill”) in the Gulf of Mexico was the largest offshore oil spill in US history.1 This event presented interlaced threats to local economies, fisheries, sensitive habitats and human health. From the oil spill’s start on April 20, 2010, to the near complete reopening of fishing waters on November 15, 2010, news coverage was extensive and generated greater reader interest than other leading news stories.2 Somewhat astonishingly, for the first 100 days, oil spill coverage accounted for 22% of the US newshole (space given to news content)2; 1 survey found that up to 50% to 60% of respondents followed the story “very closely.”2The present study explores the ways in which the safety of seafood for human consumption was presented amid other seafood-related risks in US print news media coverage of the oil spill. News coverage is a key source through which the public learns about health risks,3,4 particularly during heightened awareness situations. In assessing the messages about seafood safety, we address the dynamics and multiple potential functions5 of risk communication in print media. The news media as a social institution frequently stands apart from those that bear responsibility for the creation and management of risk and make risks perceptible to the public.3 Instead, the news media select among possible expert and lay sources, each which could have different interpretations of the issue at hand.6 To these sources, journalists contribute their own frames to create a story while also responding to deadlines, resource constraints, and sales pressures.3,7As a medium for risk communication in a politically sensitive contamination event such as the BP oil spill, news coverage faces potential extremes: downplaying food risk to avoid local economic fallout and therefore underinforming the public, focusing only on technical risk assessment and avoiding the many other interpretations of risk, or stigmatizing the domestic or regional seafood supply by highlighting dangers.8If long-range effects of media coverage are important, then the function of risk communication becomes more than the immediate avoidance of a hazard.5 Risk communication via the news media may also influence how the public understands direct and indirect causes of a risk issue. If the larger context of risk is highlighted, the various publics may pursue opportunities to engage in prevention via policy or structural means.9To assess (1) the newsworthiness of seafood safety, (2) factors potentially shaping public perception of risk, and (3) short- and long-term risk messaging about Gulf seafood safety, we examined coverage volume across various news outlets, the sources referenced in the stories, reference to cause, and depth of risk information provided in news coverage of the BP Deepwater Horizon Oil Spill. In particular, we examine how health messages presented in the news media reflect the complex interplay of economic, environmental, and health concerns. We address the following 4 questions: (1) How and where are human health threats of fish consumption being discussed as part of the oil spill news coverage?; (2) Do health risks associated with eating Gulf seafood appear alone or are they paired with other oil spill related risks?; (3) When an article includes a quote about seafood safety, who is the source and how does that source frame issues of seafood safety?; and finally (4) What parties are identified as responsible for ensuring seafood safety after the oil spill?The oil spill story is complex. Rather than a single narrative, it is perhaps better understood as numerous, intertwined news threads. These include issues such as the human tragedy of the explosion, ecological damage, future of the Gulf economy, energy policies, industrial regulation, cultural impacts, and the health consequences. In a report detailing the 3 main human health threats from the oil spill, seafood safety was identified along with direct oil contact and mental health issues.10 Consuming oil-contaminated seafood increases exposure to carcinogens known as polycyclic aromatic hydrocarbons (PAHs)11 or dispersants.12,13Seafood safety presents a unique dimension of risk communication in the oil spill. Many direct health threats associated with the oil spill are local, whereas the public health implications of seafood safety have both local and national impact. Though Gulf residents consume more seafood than the national average,14 Gulf seafood is sold and consumed throughout the United States. Ninety percent of the crawfish, 70% of shrimp, and 69% of oysters caught in the United States come from the US Gulf Coast fisheries.15 Some of the main Gulf seafood exports—shrimp, crab, and oysters—are more vulnerable to PAHs than other seafood because their systems are less able to clear these contaminants.11,16Certain types of seafood come predominantly from the Gulf, overall, but only 16% of the US seafood supply is sourced from the Gulf of Mexico.17 From a national perspective, consumers may assume information about the Gulf oil spill applies to most of their seafood, and this misunderstanding could change seafood purchasing accordingly. Alternatively, the attention to domestic seafood risk could cause consumers to lose sight of concerns about imported seafood, such as the risk of contamination with antimicrobial drugs,18 rather than making a more rational and informed calculus.Finally, the messages on seafood safety evolved over time moving from more to less uncertainty regarding actual rather than feared contamination with PAHs. According to 2 studies, ultimately the exposure risk posed to humans from oil- or dispersant-contaminated seafood in the Gulf was low.13 Readings from approximately 8000 seafood samples for 13 individual carcinogenic PAHs and a dispersant

were found in low concentrations or below the limits of quantitation. When detected, the concentrations were at least two orders of magnitude lower than the level of concern for human health risk.19^(p4)

Although the findings show minimal seafood contamination, the US Food and Drug Administration has been criticized for problematic exposure assessment in terms of underestimating human seafood consumption levels, not applying sufficient safety margins for children’s consumption, and overestimating body weight when considering exposure.11,16,20 The evolving nature of the data on seafood contamination and challenges to the assessment process underscore the uncertainty involved in terms of what messages could and should be communicated to whom at what point.From a public health perspective, the news media’s communication about seafood as a risky or healthy food source in the context of the oil spill is particularly relevant. Not only is the safety of Gulf seafood a standalone public health concern, but risk messages can also be detrimental if they disproportionately amplify concern and thus discourage consumption of seafood in general.21 Similarly, insufficient discussion of risk does not adequately inform consumers for their food choices. The quality of Gulf seafood is closely entwined with the economic and environmental future of the Gulf. Local reporting of seafood risk becomes a potentially delicate matter of gauging health and economic impacts. Finally, the extent to which these 3 risks (economic, environmental, and health) were reported as linked was of interest as the connections between environmental concerns and food systems concerns have not always been adequately addressed in the news media, missing an opportunity to detail the path from environmental problems to human health challenges.22     

Text Messaging to Communicate With Public Health Audiences: How the HIPAA Security Rule Affects Practice

Text messaging is a powerful communication tool for public health purposes, particularly because of the potential to customize messages to meet individuals’ needs. However, using text messaging to send personal health information requires analysis of laws addressing the protection of electronic health information.The Health Insurance Portability and Accountability Act (HIPAA) Security Rule is written with flexibility to account for changing technologies. In practice, however, the rule leads to uncertainty about how to make text messaging policy decisions.Text messaging to send health information can be implemented in a public health setting through 2 possible approaches: restructuring text messages to remove personal health information and retaining limited personal health information in the message but conducting a risk analysis and satisfying other requirements to meet the HIPAA Security Rule.As public health professionals, one of our key roles is to provide credible, timely health information to the public. The explosion of new information channels over the past decade means that there are more opportunities to reach audiences, whether through traditional methods such as the television news or newspapers or through newer technologies such as the Internet and social media. Text messaging is another important communication channel that public health departments should consider, particularly for communities with less access to costlier technologies such as smartphones.Text messages are 140- to 160-character messages sent from cell phones or computers over wireless carrier networks to end users’ cell phones. Text messaging (also known as Short Message Service, or SMS) is an increasingly prevalent form of communication among all age groups.1 In 2011, 73% of adults with cell phones reported using texting, up from 65% in 2009.1 According to the cell phone industry, more than 2 trillion text messages were sent in the United States in 2011.2In 2008, recognizing the potential power of texting to reach a variety of audiences to improve health, the communications team at Public Health—Seattle & King County began a 5-year research-in-practice project to explore local audience needs and interests regarding text messaging from the department, along with the legal, financial, and logistical implications of adopting text messaging in a local public health setting. In the course of the research, multiple health applications were identified for text messaging, including public health emergency preparedness,3 smoking cessation programs,4,5 physical activity promotion,6,7 medicine adherence,8 and other health-related protection and promotion behaviors.9,10 Text messaging has also shown promise for vaccine uptake11 and appointment reminders.12–14A key theme of the texting for health literature is that text messages are valued when they are perceived as highly relevant, customized, and simple.15–18 In the context of provider–patient communication, a customized text message might include an individual’s health information, in which case senders must consider implications of the Security Rule promulgated under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Pub L No. 104-191).19Here we describe our analysis of the impact of the HIPAA Security Rule on sending text messages containing individuals’ health information. Our team of subject matter experts took 2 approaches to sending such messages. In the first approach, individuals’ health information was stripped from text messages to avoid triggering the Security Rule in the first place. The second approach, which addressed the issue of complying with the Security Rule when incorporating individual health information into messages, included conducting an in-depth analysis of risks inherent in texting personal health information.Our examples shed light on the complexities of implementing the federal Security Rule within a local health department context. Individual states also may have relevant laws that health departments will want to review. During our project, we reviewed Washington State laws and concluded that our risk analysis under the federal Security Rule provided an appropriate framework for Washington’s requirements. We offer recommendations for future policy work and suggestions that will make it more feasible for local health departments to use text messaging to reach their audiences.     

Social Media Adoption in Local Health Departments Nationwide

Objectives. We examined whether characteristics of local health departments (LHD) and their geographic region were associated with using Facebook and Twitter. We also examined the number of tweets per month for Twitter accounts as an indicator of social media use by LHDs.Methods. In 2012, we searched for Facebook and Twitter accounts for 2565 LHDs nationwide, and collected adoption date and number of connections for each account. Number of tweets sent indicated LHD use of social media. LHDs were classified as innovators, early adopters, or nonadopters. Characteristics of LHDs were compared across adoption categories, and we examined geographic characteristics, connections, and use.Results. Twenty-four percent of LHDs had Facebook, 8% had Twitter, and 7% had both. LHDs serving larger populations were more likely to be innovators, tweeted more often, and had more social media connections. Frequency of tweeting was not associated with adoption category. There were differences in adoption across geographic regions, with western states more likely to be innovators. Innovation was also higher in states where the state health department adopted social media.Conclusions. Social media has the potential to aid LHDs in disseminating information across the public health system. More evidence is needed to develop best practices for this emerging tool.Local health departments (LHDs) are charged with assuring their constituents receive 10 essential public health services.1 Among these services is Essential Service #3 (ES3): inform, educate, and empower people about health issues.1 The Public Health Accreditation Board has included communication with constituents about public health issues and health risks in a recently developed set of standards required of LHDs seeking accreditation.2 As of 2004, only 61% of LHDs were adequately addressing ES3.3One new communication tool that may aid LHDs in educating and informing their constituents and meeting accreditation standards is social media. Web-based social media sites, such as Facebook and Twitter, can facilitate direct, one-to-many communication with a large audience at little to no cost.4,5 Facebook accounts can be liked, and Twitter accounts can be followed by other users, including the general public, allowing individuals or organizations to receive and spread information posted by a source. A recent survey indicated that 65% of online adults in the United States, or half of all US adults, use social media.6 Facebook and Twitter are the most widely used social media platforms7; worldwide more than 845 million people use Facebook, whereas 140 million people are Twitter users.8 Each minute, 695 000 Facebook statuses are updated, and 98 000 tweets are sent.9In the United States, social media is used by many segments of the population. Although overall social media use among adults with Internet access is associated with age, it is independent of educational attainment, race/ethnicity, and health care access.10 Likewise, there are no significant differences in Twitter use by education or income; however, the use of Twitter is significantly higher among Black non-Hispanic Internet users (28%) compared with non-Hispanic White (12%) or Hispanic Internet users (14%).11 Twitter use is also significantly higher in young adults compared with older age groups and in urban and suburban locations compared with rural locations.Use of social media is emerging as a popular way to seek health information for the general public.12,13 For adult Internet users, the Internet is a primary source of health information, second only to health care providers; 80% of US Internet users (or 59% of US adults) have looked online for health information.14,15 Of adult social media users, 23% report following their friends’ personal health experiences or updates, 17% have used social media to remember or memorialize people with a specific health condition, and 15% have obtained health information from social media sites.15Social media platforms are also increasingly used by health care providers and public health organizations and practitioners to share information with each other during training16,17 and practice,18 and to reach consumers with health information.4,19–21 The World Health Organization has Facebook and Twitter accounts, as do the Centers for Disease Control and Prevention (CDC) and numerous health-related schools and departments, scientists, and health-focused news outlets.20 CDC has developed an online toolkit to aid public health practitioners in using social media to disseminate information and foster partnerships with consumers.5 Advocates of social media use in the health community believe social media outlets provide a place for dialogue with consumers,21 and a mechanism for real-time surveillance22 and rapid dissemination of time-sensitive health information.20,23 Challenges identified by health professionals include a lack of understanding of social media23 and the volume of information available online, which can confuse consumers.20Despite numerous barriers that often hinder the adoption of new technology in government organizations,4 studies indicate a majority of state health departments (60%–82%) are using at least 1 social media application.24,25 Those health departments using social media report using it daily to disseminate information on healthy behaviors and health conditions.25 In addition, in studies surveying a sample of LHDs nationwide, up to 30.9% reported having a Facebook page, whereas up to 47.0% reported using Twitter.26,27The adoption of Facebook and Twitter across the public health system constitutes a natural experiment providing insight into how technological innovations spread across this system. Given the potential of social media to reach a large segment of the adult population, many of whom are actively seeking health information online, it is important to better understand the adoption and use of this new tool by public health practitioners. To this end, we were the first that we know of to examine the adoption and use of Facebook and Twitter across all LHDs nationwide. Specifically, we examined whether characteristics of an LHD, and the state and region where it is located, were associated with adoption of social media. We also examined the number of followers or likes for each health department with a Facebook or Twitter account and whether followers and likes were associated with LHD characteristics. Finally, we examined the number of tweets per month for Twitter accounts as a general indicator of social media use by LHDs.     

Noise Levels Associated With New York City's Mass Transit Systems

Objectives. We measured noise levels associated with various forms of mass transit and compared them to exposure guidelines designed to protect against noise-induced hearing loss.Methods. We used noise dosimetry to measure time-integrated noise levels in a representative sample of New York City mass transit systems (subways, buses, ferries, tramway, and commuter railways) aboard transit vehicles and at vehicle boarding platforms or terminals during June and July 2007.Results. Of the transit types evaluated, subway cars and platforms had the highest associated equivalent continuous average (L_eq) and maximum noise levels. All transit types had L_eq levels appreciably above 70 A-weighted decibels, the threshold at which noise-induced hearing loss is considered possible.Conclusions. Mass transit noise exposure has the potential to exceed limits recommended by the World Health Organization and the US Environmental Protection Agency and thus cause noise-induced hearing loss among riders of all forms of mass transit given sufficient exposure durations. Environmental noise–control efforts in mass transit and, in cases in which controls are infeasible, the use of personal hearing protection would benefit the ridership''s hearing health.For the first time in history, more than half of the world''s population lives in cities, and it is projected that more than two thirds of the population will live in cities by 2030.¹ An important factor supporting the growth and viability of urban centers is mass transportation, which is rapidly expanding to keep pace with increasing demand. For example, in 2004 there were 95 subway systems worldwide; today there are 167, a 76% increase in only 5 years.² Although there are well-documented environmental and public health benefits associated with mass transit, interest in the health and safety effects of mass transit on urban communities is increasing.^3–5 A particular concern is the potential for mass transit to result in excessive exposure to noise.Noise exposure is a function of 2 main factors: (1) the frequency-weighted exposure level, measured in A-weighted decibels (dBA), and (2) the exposure duration. The causal association between chronic exposure to excessive noise and permanent, irreversible, noise-induced hearing loss (NIHL) is well known, as are the adverse social, psychological, and occupational effects associated with the condition. Nonauditory adverse health effects have also been reported,^6–8 and recent research suggests that excessive noise exposure may be linked to hypertension and ischemic heart disease, disruptions in stress hormones, and sleep disorders.^9–12There are no comprehensive national or international surveillance programs for hearing loss. Worldwide, more than 250 million people are estimated to suffer from hearing loss, of which at least 30 million cases represent NIHL.¹³ In the United States alone, between 3 to 10 million people are estimated to have NIHL.¹⁴ Hearing loss from all causes ranks among the top 10 most common serious health problems worldwide, and NIHL is the leading occupational disease in industrialized nations.^14,15 The limited data available suggest not only that NIHL prevalence and incidence rates are extraordinarily high but also that the associated costs are enormous.^16,17 Importantly, even though US occupational exposure regulations have been in place for decades, rates of NIHL-related workers'' compensation cases remain high. Therefore, nonoccupational sources of exposure are coming under scrutiny, including mass transit.The size of the population exposed to mass transit noise is of considerable magnitude. The US mass transit network, with an infrastructure encompassing subways, buses, commuter and light rail, ferry boats, trolleys, and tramways, is the largest in the world, with 9.7 billion passenger rides in 2006.¹⁸ There are 14 subway systems in the United States, with a combined daily ridership in excess of 10 million people.^19–21 Five of the US systems are more than 75 years old, and the largest, the New York City subway system, with over 4 million riders per weekday,²² is more than 100 years old. These older systems were designed before noise-control technologies were available. Worldwide, there are 2 subway systems with even greater ridership rates: Tokyo''s is the largest at 2.6 billion passenger rides per year, and Moscow''s is the second largest with 2.5 billion.^23,24In a recent sound-level pilot survey on subways,³ we noted levels that potentially exceeded the community exposure limits initially recommended by the US Environmental Protection Agency (EPA) in 1974 and confirmed by the World Health Organization (WHO) in 1998. WHO and EPA recommended daily allowable exposure times are 24 hours at 70 dBA, 8 hours at 75 dBA, 2.7 hours at 80 dBA, 0.9 hours at 85 dBA, and 0.3 hours at 90 dBA. Chronic exposures that exceed these allowable combinations of duration and noise level are expected to produce NIHL in some members of the exposed population.^25,26The amount of NIHL anticipated to result from specific noise-exposure levels can be predicted with a model published by the International Organization for Standardization.²⁷ This model allows users to estimate the amount of NIHL expected to result from chronic 8-hour equivalent continuous average (L_eq) noise exposures between 75 and 100 dBA or 24-hour L_eq exposures between 70 and 95 dBA. The model permits the estimation of median values of expected NIHL as well as values for the 0.05 to 0.95 fractiles among an exposed population for given exposure levels and durations. Based on the WHO and EPA recommendations, chronic exposure to 80.3 dBA for more than 160 minutes per day may be expected to produce hearing loss in some exposed individuals, and a 90.2-dBA level likewise may cause hearing loss with just 18 minutes of exposure per day.Few data involving dosimetry measurements of noise exposures associated with mass transit have been reported previously. In a study of the daily noise exposures experienced by 32 people in Madrid, Spain, Diaz et al.²⁸ measured noise levels associated with a variety of self-reported transportation exposures with noise dosimeters. Zheng et al.²⁹ conducted 24-hour noise dosimetry on 221 residents of Beijing, China, and assessed the noise levels associated with self-reported activities, including commuting. Nearly all other studies that have evaluated noise levels associated with subway equipment are decades old and based on sound level measurements rather than dosimetry. In 1931, Stanton conducted an unpublished noise-level survey of the New York City subways,³⁰ and in 1971, Harris and Aitken³¹ reported levels measured on specific New York City train line platforms and cars. A small sound level survey on a subway system in India was also recently reported.³²Our current study expanded on our pilot study of subway noise and assessed average noise levels on a variety of types of mass transit to further evaluate noise exposure among transit riders.     

Incidence and Prevalence of Systemic Lupus Erythematosus Among Arab and Chaldean Americans in Southeastern Michigan: The Michigan Lupus Epidemiology and Surveillance Program

Objectives. We assessed the burden of systemic lupus erythematosus (SLE) among Arab and Chaldean Americans residing in southeast Michigan.Methods. For those meeting SLE criteria from the Michigan Lupus Epidemiology and Surveillance Registry, we determined Arab or Chaldean ethnicity by links with demographic data from birth certificates and with a database of Arab and Chaldean names. We compared prevalence and incidence of SLE for Arab and Chaldean Americans with estimates for non-Arab and non-Chaldean American Whites and Blacks.Results. We classified 54 individuals with SLE as Arab and Chaldean Americans. The age-adjusted incidence and prevalence estimates for Arab and Chaldean Americans were 7.6 and 62.6 per 100 000, respectively. Arab and Chaldean Americans had a 2.1-fold excess SLE incidence compared with non-Arab and non-Chaldean American Whites. Arab and Chaldean American women had both significantly higher incidence rates (5.0-fold increase) and prevalence estimates (7.4-fold increase) than did Arab and Chaldean American men.Conclusions. Recognizing that Arab and Chaldean Americans experience different disease burdens from Whites is a first step toward earlier diagnosis and designing targeted interventions. Better methods of assigning ethnicity would improve research in this population.Population-based registries of systemic lupus erythematosus (SLE) cases have expanded the epidemiological knowledge about SLE. In addition to producing overall incidence and prevalence estimates, registries allow further investigation of the disease burden among various racial and ethnic groups.1–3 The Michigan Lupus Epidemiology and Surveillance (MILES) program, a collaboration between the Centers for Disease Control and Prevention, the Michigan Department of Community Health, and the University of Michigan, developed a population-based registry for 2 southeastern Michigan counties—Wayne and Washtenaw—comprising approximately a quarter of the Michigan population and including the cities of Detroit and Ann Arbor in the catchment area.1Michigan has the second largest Arab and Chaldean American population in the United States after California.4 Chaldeans are Eastern Rite Catholics from Iraq; they speak a form of Aramaic rather than Arabic.5 Although many Arab and Chaldean immigrants first came to Michigan in search of better economic opportunities, their numbers continue to rise with the influx of refugees,5 and individuals from these ethnic groups now represent a significant portion of the Michigan population. The 2000 US Census estimated that approximately 151 493 Arab and Chaldean Americans reside in Michigan6; however, because Arab and Chaldean Americans are not federally recognized minority groups, obtaining accurate population estimates proves difficult, often leading to underestimates. Within the state of Michigan, Wayne County has the highest percentage of Arab and Chaldean Americans, and Washtenaw County has the fourth highest.4 Although Arab and Chaldean Americans constitute noteworthy minority groups in Michigan, only limited health data specific to these populations exist.7Previous research addressing SLE among Arabs or Chaldeans has focused primarily on clinical and immunological manifestations of the disease for those living in Arab countries.8–13 To date, no research has looked at the burden of rheumatic or autoimmune diseases in Arab or Chaldean Americans.14 We used the MILES registry, a large population-based public health surveillance registry, and a novel methodology to assess incidence and prevalence estimates of SLE among Arab and Chaldean Americans living in the United States.     

Assessment of the Distribution of Toxic Release Inventory Facilities in Metropolitan Charleston: An Environmental Justice Case Study

Objectives. We assessed spatial disparities in the distribution of Toxic Release Inventory (TRI) facilities in Charleston, SC.Methods. We used spatial methods and regression to assess burden disparities in the study area at the block and census-tract levels by race/ethnicity and socioeconomic status (SES).Results. Results revealed an inverse relationship between distance to TRI facilities and race/ethnicity and SES at the block and census-tract levels. Results of regression analyses showed a positive association between presence of TRI facilities and high percentage non-White and a negative association between number of TRI facilities and high SES.Conclusions. There are burden disparities in the distribution of TRI facilities in Charleston at the block and census-tract level by race/ethnicity and SES. Additional research is needed to understand cumulative risk in the region.Toxic Waste and Race in America, published in 1987, was the first comprehensive national report to demonstrate that many people-of-color communities and disadvantaged populations are differentially burdened by environmental hazards and unhealthy land uses1 These burden disparities lead to exposure disparities, increased health risks, and environmental health disparities.1–3 Community activists, health advocates, researchers, and public health practitioners are working to address environmental injustice, which is driven by differential power and privilege embedded in how we zone, plan, develop, and regulate.2,3 Environmental injustice is linked to the historic pattern of exploitation, commodification, and devaluation of place, space, and people, which leads to the production of unhealthy geographies and environmental disparities.2,3 The environmental justice movement is a social movement that includes activists and advocates struggling for the health of communities affected by disparities in burden, exposure, and environmental health. Since the 1987 report, researchers in environmental justice science (the academic arm of the environmental justice movement) have shown that these disparities continue to exist.1Low-income populations and populations of color continue to live in communities that suffer from the exposure and burden of environmental hazards.1–7 These hazards may include noxious land uses such as incinerators and landfills,8 Superfund sites,9 Toxic Release Inventory (TRI) facilities,4–10 sewer and water treatment plants,5,6 and other locally unwanted land uses.11 This disproportionate burden results in increased exposure to harmful environmental conditions for affected communities. Constant exposure to these harmful conditions results in negative health outcomes, stressed communities, and reduction in quality of life and neighborhood sustainability.2,12As noted in many studies, people of color and poor populations exposed to environmental hazards show increased health risks that are heavily influenced by many social factors, including racism and classism, segregation, socioeconomic status (SES), and inequities in zoning and planning.1–7,11–16 Studies have also shown that socioeconomic vulnerability contributes to increased health disparities and variation in community health,17,18 which further enhance the long-term effects of environmental injustice. Along with increased environmental exposure, communities overburdened by environmental hazards are also affected by associated psychosocial stressors.2,12,14 Such stressors, coupled with inadequate health-promoting infrastructure (e.g., supermarkets, parks, open spaces, medical facilities), reduce the community’s ability to defend against the adverse health consequences of their differential burden and exposure.2,12,14Environmental injustice and related disparities continue to plague much of the southern United States, especially in port communities such as New Orleans, Louisiana; Savannah, Georgia; and Charleston, South Carolina. In South Carolina, limited work has been performed to assess and address burden disparities associated with the distribution of environmental hazards and unhealthy land uses. The Port of Charleston, with its 3 port terminals on the Charleston peninsula and another port terminal on the Wando River, is currently the fourth largest port in the country and the busiest in the southeastern United States.19 In 2000, it brought in more than 5% of total US imports.20 The port has a tremendous impact on the local and state economy, as it generates $3.5 billion a year for the Charleston area and $23 billion statewide. The South Carolina State Ports Authority plans to build a new marine container terminal on the Cooper River (on the site of the former Charleston Navy Base in North Charleston) that will open in 2017.21,22Charleston has also become a major port of call for cruise liners, the volume of which tripled in only 3 years.23 This development may contribute to increased air and water pollution in nearby communities. Furthermore, the Charleston region is undergoing rapid urbanization.23 Metropolitan Charleston is among the top 100 fastest-growing metro areas in the United States, and population expansion could lead to more use of chemicals. The region has several chemical plants, a coal-fired plant, a paper mill, Superfund sites, an incinerator site, brownfields, and 2 major wastewater treatment plants that discharge into Charleston Harbor, with additional upstream discharges into the Ashley, Wando, and Cooper rivers. The region also has a large amount of car traffic on Interstate 26. Local pollution emissions are also caused by diesel truck traffic, rail traffic, and cargo ship traffic related to the movement of goods in the region, leading to air quality problems in heavily trafficked areas.The Low Country Alliance for Model Communities (LAMC) is a community-based organization concerned about the differential burden of environmental hazards and unhealthy land use in the Charleston Metropolitan Statistical Area (MSA), particularly North Charleston.24 LAMC organized in 2005 to address environmental justice and health issues in LAMC communities and develop partnerships in South Carolina to revitalize LAMC neighborhoods and other disadvantaged neighborhoods in the region. LAMC created a community–university partnership with the University of South Carolina and other stakeholders to study and address environmental justice and health issues in the region.24 This study is part of a larger effort of the partnership to assess burden disparities associated with TRI facilities and other locally unwanted land uses in this region with significant port traffic.We assessed spatial disparities in the distribution of TRI facilities in Charleston as part of a community-driven research program to assess the cumulative burden and impact of industrial facilities and unhealthy land use in the Charleston region. We aimed to ascertain whether the racial and SES composition of census tracts with a TRI facility differs from the composition of those that do not have a TRI facility. Examination of the effects of differences in distance from a TRI facility can help determine whether these populations may have potentially higher risks of exposure and negative health outcomes. With this knowledge, LAMC will be able to engage local policymakers in the mitigation of environmental injustice and revitalization of poor and disadvantaged neighborhoods in the Charleston MSA. Furthermore, because there is limited literature on the distribution of TRI facilities in traditional southern US port cities, this research may help environmental justice groups in these communities to develop their own assessment of the spatial distribution and burden of toxic facilities.     

Race/Ethnicity,Residential Segregation,and Exposure to Ambient Air Pollution: The Multi-Ethnic Study of Atherosclerosis (MESA)

Objectives. We described the associations of ambient air pollution exposure with race/ethnicity and racial residential segregation.Methods. We studied 5921 White, Black, Hispanic, and Chinese adults across 6 US cities between 2000 and 2002. Household-level fine particulate matter (PM_2.5) and nitrogen oxides (NO_X) were estimated for 2000. Neighborhood racial composition and residential segregation were estimated using US census tract data for 2000.Results. Participants in neighborhoods with more than 60% Hispanic populations were exposed to 8% higher PM_2.5 and 31% higher NO_X concentrations compared with those in neighborhoods with less than 25% Hispanic populations. Participants in neighborhoods with more than 60% White populations were exposed to 5% lower PM_2.5 and 18% lower NO_X concentrations compared with those in neighborhoods with less than 25% of the population identifying as White. Neighborhoods with Whites underrepresented or with Hispanics overrepresented were exposed to higher PM_2.5 and NO_X concentrations. No differences were observed for other racial/ethnic groups.Conclusions. Living in majority White neighborhoods was associated with lower air pollution exposures, and living in majority Hispanic neighborhoods was associated with higher air pollution exposures. This new information highlighted the importance of measuring neighborhood-level segregation in the environmental justice literature.In the United States, race/ethnicity is highly correlated with residential location, with Whites and minorities often living segregated from one another.1,2 Differential residential location can result in important racial/ethnic differences in environmental exposures, such as air pollution.1,3–6 Epidemiological studies have consistently shown increased risk for morbidity and mortality from cardiovascular7–10 and respiratory diseases (chronic obstructive pulmonary disease, asthma, and lung cancer)8,11–14 associated with exposure to ambient air pollution, including exposure to fine particulate matter (particles < 2.5 μm in aerodynamic diameter [PM_2.5]) and nitrogen oxides (NO_X; sum of nitric oxide, nitrogen dioxide, nitrous acid, and nitric acid).15–21 Predominantly minority areas are more likely to have22,23 or be more proximal4,24,25 to hazardous sites or air pollution sources, including point sources and roadway traffic. However, few studies have investigated how individual- or household-level exposure estimates are associated with race/ethnicity.In addition to proximity to pollution sources, poor enforcement of environmental regulations in minority communities and inadequate response to community complaints may also contribute to higher exposure to environmental hazards in minority communities.1 These institutional factors reflect physical, political, social, and economic characteristics of neighborhoods that are often correlated with their racial/ethnic composition and the level of racial residential segregation. For these reasons, measures of neighborhood racial/ethnic composition and racial residential segregation may be associated with environmental exposures independently of the individual race/ethnicity of residents. Despite the importance of contextual information for advancing research for environmental justice, few studies have simultaneously examined how neighborhood characteristics and the race/ethnicity of study participants are related to environmental exposures or examined racial residential segregation as it relates to air pollution exposure.6,26Also, most studies have compared exposure among Whites and Blacks with few studies including other races/ethnicities.4,24,27–29 Our objective in this study was to describe associations of exposure to ambient air pollution, estimated by annual average PM_2.5 and NO_X concentrations at the household level, with race/ethnicity, neighborhood racial/ethnic composition, and racial/ethnic residential segregation in White, Black, Hispanic and Chinese adults who participated in the Multi-Ethnic Study of Atherosclerosis (MESA) in 6 US communities.     

Psychological First Aid: A Consensus-Derived,Empirically Supported, Competency-Based Training Model

Surges in demand for professional mental health services occasioned by disasters represent a major public health challenge. To build response capacity, numerous psychological first aid (PFA) training models for professional and lay audiences have been developed that, although often concurring on broad intervention aims, have not systematically addressed pedagogical elements necessary for optimal learning or teaching. We describe a competency-based model of PFA training developed under the auspices of the Centers for Disease Control and Prevention and the Association of Schools of Public Health. We explain the approach used for developing and refining the competency set and summarize the observable knowledge, skills, and attitudes underlying the 6 core competency domains. We discuss the strategies for model dissemination, validation, and adoption in professional and lay communities.The beginning of the 21st century has seen considerable attention devoted to improving emergency response capabilities at the national, state, and local levels of the US public health emergency preparedness system. A daunting challenge has been planning for the disproportionally high volume of psychological (vs physical) casualties that attend natural, technological, and intentional hazards.1–7 Evidence suggests that many disaster survivors fail to receive the care they need8 and that care deprivation under such circumstances is associated with mental health morbidity and increased rates of suicide.9,10 The difficulty of managing disaster-occasioned surges of demand for mental and behavioral health services is further compounded by the shortage of able and willing responders.11–14An increasingly popular idea for enhancing surge capacity during disaster scenarios is to develop cadres of potential responders trained in mental and behavioral health management, including psychological first aid (PFA).15–19 The American Red Cross20 and the World Health Organization21 provide PFA training programs, and the National Child Traumatic Stress Network and National Center for PTSD (posttraumatic stress disorder) distribute PFA field operations manuals for both general audiences and specific fields. Specialized PFA curricula have been developed for people working with the homeless,22 those working in nursing homes,23 Medical Reserve Corps volunteers,24 faith and lay community leaders,15,16,25,26 and public health workers.27Despite the virtual cottage industry of PFA training activities and previous efforts to identify core competencies16,26–28 and trauma intervention principles,29 current PFA training programs have significant shortcomings, including variability of content, format, and emphasis (with little motivation for standardization); learning objectives and outcomes defined in nonobservable constructs that preclude meaningful measurement; little external accountability for quality; and no in-depth analysis of the pedagogical principles for optimal learning and teaching of PFA competencies. The result is a dearth of qualified PFA-trained responders available for call-up during public health emergencies11,13,30 and no widely accepted model for training public health workers in PFA competencies.We describe the development of a PFA training curriculum based on sound pedagogical principles applicable to a broad range of learners, including midtier public health professionals and lay community members. The product is a component competency set of the Public Health Preparedness and Response Core Competency Model,31 a proposed national standard of behaviorally based, observable skills for the workforce to prepare for and respond to all-hazards scenarios. The project was conducted as part of a larger effort by 14 Preparedness and Emergency Response Learning Centers (PERLCs) in accredited schools of public health. These centers, funded by the Centers for Disease Control and Prevention (CDC), aim to develop knowledge, skills, and attitudes (KSA) content for each of the competency statements in the model.32 The project could serve as a basis for enhancing consistency in preparedness training curricula and fulfilling mandates in the Pandemic and All-Hazards Preparedness Act 2006.33     

Walking Associated With Public Transit: Moving Toward Increased Physical Activity in the United States

Objectives. We assessed changes in transit-associated walking in the United States from 2001 to 2009 and documented their importance to public health.Methods. We examined transit walk times using the National Household Travel Survey, a telephone survey administered by the US Department of Transportation to examine travel behavior in the United States.Results. People are more likely to transit walk if they are from lower income households, are non-White, and live in large urban areas with access to rail systems. Transit walkers in large urban areas with a rail system were 72% more likely to transit walk 30 minutes or more per day than were those without a rail system. From 2001 to 2009, the estimated number of transit walkers rose from 7.5 million to 9.6 million (a 28% increase); those whose transit-associated walking time was 30 minutes or more increased from approximately 2.6 million to 3.4 million (a 31% increase).Conclusions. Transit walking contributes to meeting physical activity recommendations. Study results may contribute to transportation-related health impact assessment studies evaluating the impact of proposed transit systems on physical activity, potentially influencing transportation planning decisions.The health benefits of physical activity have been well documented;1–4 still, only 64.5% of Americans are physically active, and 25.4% do not participate in leisure time physical activity at all.5 Inadequate physical activity contributes to numerous health problems, causing an estimated 200 000 annual deaths in the United States and significantly increasing medical costs.6 In contrast, average annual medical expenditures are 32% lower among physically able adults who get regular exercise than the expenditures of those who lead a sedentary lifestyle.7The US Department of Health and Human Services created guidelines to describe the amount and type of physical activity most likely to provide health benefits. The 2008 Physical Activity Guidelines for Americans recommended that adults get at least 150 minutes of aerobic physical activity per week.8 The guidelines also recommended that physical activity be moderate in intensity, such as brisk walking, and last at least 10 consecutive minutes. Morabia and Costanza9 demonstrated the health value of brisk walking for as little as 15 minutes per day or slow walking 30 minutes per day in preventing weight gain on the basis of caloric expenditures. Because most public transit trips begin or end with walking,10–13 public transit use can be an important opportunity to add physical activity into one’s day. Additional research has shown that walking to or from public transit, “transit walking,” may help people meet physical activity recommendations.10,14–17The community environment can affect whether and how community members engage in physical activity.18 The way communities are built has an impact on the viability of public transit and the safety of its users and influences whether healthy choices, such as walking, are easy or difficult.17,19,20 Socioeconomic factors, such as household income levels21 and employment status,22 also strongly influence the viability of public transit for community members. Whatever the forces driving people to use public transit, a growing body of evidence has suggested that its use benefits community public health and directly benefits the personal health of transit users. Previous research has found links between the use of public transit and physical activity,10 lower body mass index (defined as weight in kilograms divided by the square of height in meters),1,23,24 and travel safety.25The Centers for Disease Control and Prevention and the National Center for Environmental Health have formally recognized the health impact of transportation systems. Consequently, they developed transportation recommendations that promote travel choices to improve health, such as those that include opportunities for physical activity.26 Current demographic and economic trends (i.e., aging population, rising fuel prices, increasing health and environmental concerns, rising medical care costs) are increasing the value of public transportation–related health benefits27; however, little is known about how these current trends influence physical activity. Examining the influence of current demographic and economic trends on transportation patterns is vital for informing community design and transportation decisions.The purposes of this study were to estimate the daily level of physical activity attained by Americans solely through transit walking, to describe the demographic and socioeconomic characteristics of transit walkers, to determine transit-walker and environmental factors that influence transit walking, to help predict those who will achieve 30 minutes or more of physical activity solely by walking to or from public transit, and to assess changes in transit walking over time.     

Neighborhood Disparities in Access to Healthy Foods and Their Effects on Environmental Justice

Environmental justice is concerned with an equitable distribution of environmental burdens. These burdens comprise immediate health hazards as well as subtle inequities, such as limited access to healthy foods.We reviewed the literature on neighborhood disparities in access to fast-food outlets and convenience stores. Low-income neighborhoods offered greater access to food sources that promote unhealthy eating. The distribution of fast-food outlets and convenience stores differed by the racial/ethnic characteristics of the neighborhood.Further research is needed to address the limitations of current studies, identify effective policy actions to achieve environmental justice, and evaluate intervention strategies to promote lifelong healthy eating habits, optimum health, and vibrant communities.ENVIRONMENTAL JUSTICE HAS been defined as

fair treatment and meaningful involvement of all people regardless of race, ethnicity, income, national origin, or educational level in the development, implementation, and enforcement of environmental laws, regulations, and policies.^1(p1)

Fair treatment signifies that “no population, due to policy or economic disempowerment, is forced to bear a disproportionate exposure to and burden of harmful environmental conditions.”^1(p1) The concept of environmental justice, which has its roots in the fight against toxic landfills in economically distressed areas, can be similarly applied to the inequitable distribution of unhealthy food sources across socioeconomic and ethnic strata.1 The neighborhood environment can help promote and sustain beneficial lifestyle patterns or can contribute to the development of unhealthy behaviors, resulting in chronic health problems among residents.2–4 The higher prevalence of obesity among low-income and minority populations has been related to their limited access to healthy foods5–18 and to a higher density of fast-food outlets and convenience stores where they live.9,19–21 These environmental barriers to healthy living represent a significant challenge to ethnic minorities and underserved populations and violate the principle of fair treatment.Several studies have investigated disparities in the distribution of neighborhood vegetation,22,23 the proximity of residences to playgrounds,24 and the accessibility of supermarkets and grocery stores,25,26 but fewer have examined access to fast-food outlets and convenience stores as a function of neighborhood racial and socioeconomic demographics. To our knowledge, our review is the first to expand the focus of environmental justice from environmental hazards and toxic exposures to issues of the food environment by examining research on socioeconomic, ethnic, and racial disparities in neighborhood access to fast-food outlets and convenience stores.     

A Review of Disaster-Related Carbon Monoxide Poisoning: Surveillance,Epidemiology, and Opportunities for Prevention

Objectives. We conducted a systematic literature review to better understand aspects of disaster-related carbon monoxide (CO) poisoning surveillance and determine potentially effective prevention strategies.Methods. This review included information from 28 journal articles on disaster-related CO poisoning cases occurring between 1991 and 2009 in the United States.Results. We identified 362 incidents and 1888 disaster-related CO poisoning cases, including 75 fatalities. Fatalities occurred primarily among persons who were aged 18 years or older (88%) and male (79%). Hispanics and Asians accounted for 20% and 14% of fatal cases and 21% and 7% of nonfatal cases, respectively. Generators were the primary exposure source for 83% of fatal and 54% of nonfatal cases; 67% of these fatal cases were caused by indoor generator placement. Charcoal grills were a major source of exposure during winter storms. Most fatalities (94%) occurred at home. Nearly 89% of fatal and 53% of nonfatal cases occurred within 3 days of disaster onset.Conclusions. Public health prevention efforts could benefit from emphasizing predisaster risk communication and tailoring interventions for racial, ethnic, and linguistic minorities. These findings highlight the need for surveillance and CO-related information as components of disaster preparedness, response, and prevention.Carbon monoxide (CO) poisoning is a leading cause of poisoning in the United States. Unintentional, non–fire-related (UNFR) CO poisoning results in more than 20 000 emergency department (ED) visits, more than 2000 hospitalizations, and nearly 450 deaths annually.1–3 Health effects of CO exposure can range from viral-like symptoms such as fatigue, dizziness, headache, confusion, and nausea to more severe symptoms such as disorientation, unconsciousness, long-term neurologic disabilities, coma, cardiorespiratory failure, and death.1,4–6 CO is a colorless, odorless, and tasteless nonirritant gas that is imperceptible to human senses.7 Furthermore, CO exposure is often underdiagnosed or misdiagnosed as a result of the nonspecificity of the clinical effects.8,9 Both of these factors make exposure to CO a serious health concern because individuals can be severely or fatally poisoned before even realizing that they have been exposed. UNFR carbon monoxide exposure occurs year-round, with a usual seasonal peak during the winter season, and has been reported to be a leading cause of mortality and morbidity in postdisaster situations when engagement in high-risk behaviors is more common (e.g., improper placement of generators, use of charcoal grills indoors).1,2,10 Power outages during disasters or postdisaster cleanup and recovery have been found to be primarily responsible for a large number of fatal and nonfatal disaster-related CO exposures.10 It is important to identify and characterize high-risk populations and circumstances leading to disaster-related CO exposures to better target public health interventions and health messaging.For this study, we reviewed disaster-related CO poisoning articles in scientific journals that included cases occurring between 1991 and 2009 in the United States. The objective was to better understand the aspects of disaster-related CO poisoning surveillance, characterize the populations at risk, and determine potentially effective prevention strategies.     

The Next Public Health Revolution: Public Health Information Fusion and Social Networks

Social, political, and economic disruptions caused by natural and human-caused public health emergencies have catalyzed public health efforts to expand the scope of biosurveillance and increase the timeliness, quality, and comprehensiveness of disease detection, alerting, response, and prediction. Unfortunately, efforts to acquire, render, and visualize the diversity of health intelligence information are hindered by its wide distribution across disparate fields, multiple levels of government, and the complex interagency environment. Achieving this new level of situation awareness within public health will require a fundamental cultural shift in methods of acquiring, analyzing, and disseminating information. The notion of information “fusion” may provide opportunities to expand data access, analysis, and information exchange to better inform public health action.Internet-based technologies (e.g., social-networking Web sites, wikis, and blogs) have led to an explosion in social networks that harness the “wisdom of crowds,” giving Internet users convenient instant access to information and communities.¹ These new tools and novel information sources are also becoming ubiquitous in our increasingly wired (and wireless) society, such that members of the general public can readily disseminate their own interpretations of public health events outside a public health context or scientific framework. As these developments make clear, an information revolution is overdue in public health, particularly in epidemiology and surveillance (i.e., biosurveillance), where there is an increasing need to develop, “fuse,” and share critical health information for decision-making across numerous fields, communities, professions, organizations, institutions, and health systems. Public health epidemiology and surveillance that are conducted through an electronic medium (chiefly the Internet)—termed “infodemiology” and “infoveillance,” respectively—present good opportunities for practice and research.¹ Public health also confronts an increasing proliferation of novel electronic surveillance approaches and multiple legacy data systems amid growing concerns about appropriateness of data release, data validity, and costs versus benefits.^2,3 Although more information now exists electronically than ever before, there is no guarantee that electronic information can be successfully exchanged; in addition, the exchange of electronic information can still be constrained by organizational boundaries erected in response to technical, legal, and privacy concerns.⁴In recent years, it has become evident that public health events can threaten our national security. Bioterrorism poses an obvious threat to health and life, but any public health event might weaken public confidence in a government''s ability to respond to emergencies, undermine a nation''s social order, catalyze regional instability, or cause adverse economic impact, including trade restrictions.⁵ The worldwide response to the 2009 pandemic influenza (H1N1) outbreak was a prime example of the need for rapid exchange of public health information.⁶ Similar recent examples include the SARS (severe acute respiratory distress syndrome) epidemic that spread from China in early 2003 in a matter of days and was associated with local transmission in 4 additional countries, with an economic impact of at least $50 billion⁷; the largest US foodborne disease outbreak of Salmonella Saintpaul in history, with an estimated $100 million loss to the tomato industry in 2008; and an outbreak of foot-and-mouth disease in Great Britain in 2001, with a tourism industry loss of £2.7 to £3.2 billion and a loss to agriculture and the food industry of £3.1 billion (equivalent to 0.2% of Great Britain''s gross domestic product).⁸ A typical pandemic of influenza in the United States is estimated to result in 89 000 to 207 000 deaths and economic costs of $71.3 to $166.5 billion, excluding disruptions to commerce and society.⁹To identify novel risks and address extant threats, the United States must implement a nationwide biosurveillance capability that connects domestic and international surveillance systems to provide early warning and ongoing characterization of disease outbreaks in near–real time.¹⁰ Comprehensive biosurveillance ideally would use multiple modalities of information collection, analysis, and dissemination, as well as secure yet flexible information architecture. In addition, strengthening existing surveillance networks and infrastructure, enhancing clinician awareness and participation in biosurveillance, and strengthening laboratory diagnostic capabilities and capacity would result in potential threats being recognized as soon as possible. Integration of routine surveillance information with other potential indicator sources (e.g., health care, veterinary care, agriculture, meteorology, environmental protection, and intelligence) may provide a more comprehensive picture of community health and environmental threats.