“Acknowledging the complexities of the ecosystem into which synthetic chemicals are released is an important first step toward an integrated public health approach.”10

Medical training is still carried out largely from a paradigm that focuses on illness and the individual, and the relationship between environment and health has a limited place within that schema.

“[Health professionals] are in a position to advise health authorities on how to identify and reduce health risks associated with environmental exposures and to stimulate decision-makers to take appropriate action.”
World Health Organization

Medical opinion has an important impact on policy-makers, and physicians can be vocal leaders in support of progressive policy development and review of issues.

Tools and Implications for Physicians

Photograph courtesy of Health Canada.

Clearly, then, the most effective strategies for improving children’s environmental health are those that educate, influence and mobilize communities concerning the urgency of this agenda. As community leaders, physicians can inspire change in behaviour and attitude not just among their own patients, but also within the broad reaches of our society. As individuals and as a collective, physicians can make contributions that will depend on the environmental health issue at hand, but might be summarized into three vital functions.

1. Awareness and Advice

Canadian physicians do encounter and are concerned about environmental health problems in their practices.6 They routinely provide advice on prevention, and this extends to counselling parents on ways to avoid environmental exposures so as to give their children the best possible start in life. Of necessity, therefore, physicians translate scientific information on environmental health risks for their patients and thereby raise awareness of the realities of these issues.

Health Canada surveys indicate that Canadians rely substantially on their doctor’s advice regarding prevention of health risks from the environment, as they consider physicians a highly credible source of such information.7,8  In so doing, physicians empower their patients to take actions for themselves.

Canadian physicians recognize at the same time, however, that they are restricted by both a self-perceived lack of knowledge in the field of environmental health and by the deficiency of accessible resources to improve that knowledge.9 Medical training is still carried out largely from a paradigm that focuses on illness and the individual, and the relationship between environment and health has a limited place within that schema.

This perspective is unlikely to adequately prepare medical graduates for understanding the inextricable links between humans and their environment. One of the fundamental tools for physicians engaging in primary prevention is comprehensive training in ecosystem health at the earliest stage possible, which can foster an appreciation for the far-reaching and often unpredictable reverberations from even subtle alterations to natural systems.

The Faculty of Medicine and Dentistry at University of Western Ontario is unique in Canada, and among only a handful of medical schools in the world, to have incorporated an Ecosystem Health Program into its curriculum. Instituted in 1997, this program provides medical training that allows future physicians to fully appreciate the interdependence between human and ecosystem health. The program’s web pages include case studies and eco-concepts that illustrate its broad approach to the study of health within a global ecosystem.

Human and ecosystem health issues are explored in two additional online resources geared to medical and health professionals. These include the Global Health Network’s Supercourse lecture “Health and Environment in Sustainable Development”11 and “Human Health and Global Environmental Change,” a course offered by the Center for Health and the Global Environment of Harvard Medical School.

Resources for physicians to educate themselves about environmental health issues are rapidly improving. The Environmental Health Committee of the Ontario College of Family Physicians, in conjunction with the International Joint Commission, recently released Environmental Health in Family Medicine, a comprehensive curriculum for physicians to expand their knowledge of environmental health issues from a clinical perspective. The Resources unit in this web resource identifies a number of other opportunities for physicians to enhance their knowledge of environmental health issues.

Armed with this knowledge, physicians can identify links between an individual’s lifestyle and ecosystem health and the health of future generations. For example, researchers warn that our “disinfection obsession,” the use of antimicrobial products and improper use of antibiotics, is leading to selection for antibiotic resistant strains of bacteria that has implications for treating bacterial disease in the future.12 

More people need to appreciate that pesticides used anywhere become pesticides everywhere, and that many pesticides threaten children’s neurological development. Physicians can point out to patients that driving high polluting, low fuel efficiency cars such as sport utility vehicles (SUVs) not only has implications for their child’s or their own respiratory health, but also directly contributes to climate change and alterations in our global weather and disease patterns. Along with the expected health messages about reducing respiratory health effects, the OMA Smog advisory cautions on the behavioural changes necessary for society as a whole to improve air quality for all.

The examples are seemingly endless.

We should also give patients an appreciation of the dangers of complacency. If we as a society maintain a narrow, reductionist worldview, we are doomed to fail in our efforts to improve children’s environmental health. We must make smarter choices as consumers, cast electoral votes more wisely, and lobby school officials and all levels of government more vigourously.

2. Vigilance

It was an astute, attentive physician who recognized the pediatric cases of bloody diarrhea and severe abdominal cramps from Walkerton as signals of a larger problem.13 Alongside that traditional role on the frontlines of public health, family physicians can also play an important role in helping to document the range of adverse effects from such population or community-level exposures. In the aftermath of the 1997 fire at Plastimet Inc. in Hamilton, family physicians and academics documented the resultant health effects among firefighters and community residents.14 

Physician vigilance is enhanced by learning to take a thorough exposure history, a skill that is critical for establishing the diagnosis of environmentally related problems, which are often associated with subclinical effects and generalized symptoms.15 The data generated by such efforts are vital to assessing community-wide health status and to conducting long-term surveillance regarding potential environmental health risks.16

Being attuned to the potential for environmental health problems in children can reap important dividends. For example, it is often assumed that with lead removed from gasoline, children are no longer at risk of exposure and the harmful effects of lead. Indeed, blood lead levels have dropped considerably since the 1980s, largely in step with the declining use of leaded gasoline. However, there continues to be a sizeable proportion of children with blood levels at or close to the “threshold” level of 0.5 micromoles/L (10 mcg/dL).

In addition, there are numerous new, unsuspected and virtually unregulated sources of lead to which children can easily be exposed.17 The effects on neurodevelopment of low-level exposure to lead are irreversible and most significant in children under three. There is strong speculation that there may be no “safe” level of exposure to lead for children. Averting the cognitive and behavioural impairments that appear in young children from low-level lead exposure is a profound potential contribution of ongoing physician vigilance.

The Canadian Handbook on Health Impact Assessment is a publication of Health Canada’s Office of Environmental Health Assessment. It is designed “to assist health professionals with little or no experience in environmental impact assessment (EIA) in providing health advice to an EIA process.”  Volume 3 addresses roles for the health practitioner and suggests that policy-makers are aware that clinicians and others can provide valuable perspective on the impacts of developmental projects in different communities.

3. Advocacy

Being an advocate for his or her patients’ health is central among a physician’s duties. Taking on the all-important and far broader challenge of being an advocate for public environmental health is a natural extension of that obligation.18 Medical opinion has an important impact on policy-makers, and physicians can be vocal leaders in support of progressive policy development and review of issues. There are a number of precedents that demonstrate the power of a medical voice on issues of environment and health.

The testimony of Dr. Kelly Martin (on behalf of CAPE) before the House of Commons Standing Committee on the Environment and Sustainable Development conveyed the concerns Canadian physicians have about pesticide regulation in Canada. Martin’s statement had substantial influence and was liberally cited in the Standing Committee’s subsequent report, "Pesticides, Making the Right Choice for the Protection of Health and The Environment."

This report was founded on the principle that protection of health, particularly children’s health, is the central consideration in formulating pesticide legislation, and it recommended urgent action, including awareness-building, followed by reduction and eventual phase-out of the cosmetic use of pesticides.19 How these recommendations are carried out remains to be seen, but the report certainly stands as a strong statement for a precautionary approach to pesticide regulation in Canada.

Similarly, the Ontario Medical Association’s Position Paper on the Health Effects of Ground-Level Ozone, Acid Aerosols and Particulate Matter garnered wide media attention and raised awareness of the enormous health problems and costs associated with air pollution. This document also incorporates a comprehensive set of recommendations by which physicians, industry and government can increase awareness of the problem and reduce air emissions.

Dr. Philip Landrigan, Professor of Pediatrics and Director of the Center for Children's Health and the Environment, The Mount Sinai School of Medicine in the United States, has been a pioneer in promoting the children’s environmental health agenda through research and policy work. See for example, his testimony before the US House of Representatives entitled, “Disease of Environmental Origin in American Children: Prospects for Research and Prevention.”

Forming partnerships and coalitions between medical and environmental groups and other health organizations with similar goals is an effective strategy that can be mutually beneficial. For example, the Environmental Health Committee of the Ontario College of Family Physicians and the Canadian Environmental Law Association recently collaborated to examine Canadian standard-setting regimes and children’s health. This project resulted in substantial community outreach and a major report that has been widely cited and utilized by other groups to further the children’s environmental health agenda in Canada.

CAPE is endeavouring to strengthen its own activities both by looking to our American counterparts, and by working with a broad collective of organizations in Canada that have interest in protecting children’s environmental health. The Environment and Health Program of the US-based Physicians for Social Responsibility (PSR) has an exemplary history of awareness campaigns, lobbying and activism for pollution prevention and precautionary measures at the community level and beyond. Their Legislative Action Center is a superb, interactive resource with quick links to information and relevant elected officials on several environmental issues.

PSR has been a world leader on raising awareness of “problems that pose a particular threat to a sustainable global future: contamination of the environment by persistent toxic pollutants and the health effects of global climate change.”20   The former issue, which combines substantial scientific uncertainty with the potential for widespread exposure and troubling health effects, demands a precautionary approach if we are to protect children from such exposures and health effects and preserve our ecosystem at the same time. In their 1997 POPs resolution, PSR pushed for strong and immediate global action to ban and reduce POPs in the environment globally. The recent international treaty to ban the “dirty dozen” POPs is an important step towards that goal.

As one observer has suggested, the road of the physician advocate is not an even one, but it is one that must be traveled by more clinicians if there is to be a return to “a climate of reasoned and thoughtful discussion” on the topic of protecting children’s environmental health.21 The journey is greatly enhanced by support, networking and information-sharing among colleagues, and the destination is certainly worthy of the effort.

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