Environment and Health

As family physicians, we provide holistic care for our patients. Since the beginning of our specialty, we have recognized the ways that families and communities affect the physical, mental, and spiritual health of our patients. It is now becoming clear that we also need to consider the health implications of the environment, not just our patient’s genetic makeup, personal actions, and interactions with the people and systems around them.

In the 1960s, multiple high-profile environmental accidents increased public awareness of the risks of toxic exposures. On June 22, 1969, the Cuyahoga River in Cleveland, Ohio, spontaneously burst into flames after years of industrial waste being dumped into the river. In response to this environmental disaster and press coverage of it, President Richard Nixon proposed a comprehensive program to address pollution and study the effects of contaminants on the environment in 1970.¹ This led to establishment of the Environmental Protection Agency (EPA), increased community awareness about the effects of pollution, and advancement of the scientific study of toxicology, environmental exposures, and occupational health.

For most patients, their family physician is their first point of contact with the health care system. Much of the time, identification of potential toxic exposures, initial testing and diagnosis, and patient education and risk reduction fall to primary care practices. Identification of toxic exposures is complicated. Determining the causative agent often involves awareness of group vulnerability and exposure risk as well as individual risk related to the location of the patient’s home, hobbies, or occupation. Family physicians should work with health departments and poison control centers to address individual patient exposures as well as public health concerns within the community. Physicians also need to be aware of reporting requirements for toxic exposures in their local jurisdictions.

This edition of FP Essentials addresses what family physicians need to know about the environment and health. Section One examines the roles of poison control centers, health departments, and family physicians in addressing toxic exposures. Section Two discusses heavy metal toxicity, including potential sources of exposure, symptoms of toxicity, and treatment of exposed patients. Section Three explores the causes and effects of water and soil contamination. Section Four reviews various endocrine-disrupting chemicals and their effects on health.

Although most of us received limited information about toxic substances as part of our medical education, we now encounter questions about exposures and their consequences for patient health on a regular basis. The information in this monograph will allow you to better guide your patients in this complex arena.

Ryan D. Kauffman, MD, FAAFP, CCFP, Associate Medical Editor
Family Medicine Physician
Erie Shores Family Health Team, Leamington, Ontario, Canada

Dhitinut (DT) Ratnapradipa, PhD, MPA, is a professor in the Department of Clinical Research and Public Health at Creighton University School of Medicine in Omaha, Nebraska. He also serves as program director for the master of public health program. Dr. Ratnapradipa has a secondary appointment in the Department of Family and Community Medicine. His area of focus is environmental health, and he previously served in state-level public health where he managed the state poison control program. Dr. Ratnapradipa served as clinical faculty at the Warren Alpert Medical School of Brown University in Providence, Rhode Island. He also served as graduate director and MD/MPH codirector of the concurrent degree program at Southern Illinois University School of Medicine in Springfield. He has authored more than 25 articles related to climate change and environmental and public health.

Amy L. McGaha, MD, MPH, FAAFP, is a professor in and chair of the Department of Family and Community Medicine at University of Nevada, Reno School of Medicine. Until recently, she was the Dr. Roland A. Kleeberger Endowed Chair of the Department of Family and Community Medicine at Creighton University School of Medicine. Dr. McGaha has served on the American Academy of Family Physicians (AAFP) Commission on Education and the Accreditation Council for Graduate Medical Education (ACGME) Family Medicine Milestones work group, which developed the first version of milestones for family medicine residency training. She has authored more than 20 publications on clinical topics in family medicine and interprofessional education.

The authors acknowledge the following individuals who provided research assistance: Danielle Hotalling, Martha Koenig, Kurt Parker, Megan Piotrowski, and Natasha Ratnapradipa.

Disclosure: It is the policy of the AAFP that all individuals in a position to control CME content disclose any relationships with ineligible companies upon nomination/invitation of participation. Disclosure documents are reviewed for potential relevant financial relationships. If relevant financial relationships are identified, mitigation strategies are agreed to prior to confirmation of participation. Only those participants who had no relevant financial relationships or who agreed to an identified mitigation process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

• Counsel patients regarding appropriate use of poison control centers.
• Counsel patients about the role of the local health department in preventing and addressing exposures to toxic substances.
• Recommend strategies for patients to avoid exposure to heavy metals.
• Determine which patients are at highest risk of heavy metal toxicity.
• Summarize potential sources of water and soil contamination.
• Describe organophosphate poisoning.
• Counsel patients about how to minimize exposure to endocrine-disrupting chemicals.
• Summarize the effects of various endocrine-disrupting chemicals in the body.