ACOEM President's Message E stands for Environmental

[Guest guest]

The “Es†in ACOEM

The “E†in ACOEM stands for “Environmentalâ€: The American College of

Occupational and Environmental Medicine. However, in recent years it could as

easily have stood for “Emergency Preparedness.â€

In this column we will talk about the environmental health mission of ACOEM,

what it means for physicians whose day-to-day practice is mostly concerned

with occupational health and how the recent emphasis on emergency preparedness

became, in large part, a redirection of the energy that was originally

intended to go into environmental health.

Conceptually, occupational health is a subset of environmental health. Like

indoor air quality and housing problems, occupational health concerns itself

with conditions in the “built environment,†that is, the world created by

people. Occupational health and environmental health deal with the same range of

hazards, largely the same chemical exposures, and apply the same

intellectual tools (epidemiology, toxicology, exposure assessment, and

methodology). As

academic fields, they differ mostly in scale, exposure levels, and the

population at risk (whether the generally healthier working population or the

general population, which includes more vulnerable groups).

However, in practice occupational and environmental health are separate

fields. The web of job requirements and responsibilities, regulations,

credentials, regulatory agencies, technology, and professional licensure

requirements

in which occupational and environmental medicine is embedded tend to keep us

focused on occupational health and to marginalize our role in environmental

health. There is also no reimbursement mechanism for environmental disease

cases, as there is for workers’ compensation. So, many ACOEM members view

occupational medicine as their “day job†and environmental medicine as an

add on.

Historically, occupational physicians tended to be called in on problems

involving air quality and hazardous waste, where the chemical regimen tended to

be similar to the workplace. General preventive medicine and (medical) public

health specialists tended to be called in on issues involving water and food

safety because their core expertise was public health protection and more

often involved infectious disease. This is changing with consolidation of

responsibilities among consultants and medical directors, increasing litigation,

concern over consumer protection and liability issues, globalization and

responsibility for foreign operations, improved training of occupational

physicians in public health generally, and the threat of emerging infections in

the

workplace.

Today, environmental health and occupational health go together like coffee

and milk. You can drink your coffee (environmental health) without milk

(occupational health) and your milk without coffee. Most of us in ACOEM take a

caffe latte, in which the occupational medicine practice takes up most of our

time and environmental health issues are in the overall mix.

In the late 1990s, ACOEM began a big push for big-E environmental education

and training. E-Content was incorporated into the Millennium Series and other

ACOEM programming. The plan was to make the E a central feature of ACOEM’s

agenda for the future. What happened? Another E came along and pushed it

aside.

The ACOEM leadership was aware of issues emerging in emergency preparedness,

particularly the risk of terrorism, by 1999. In its conferences and courses,

ACOEM developed emergency preparedness programming on an urgent basis and

slotted it into sessions and venues that were originally intended for

environmental medicine. Subsequently, emergency preparedness has taken center

stage

and this priority pushed our environmental health programming interests to

issues of intentional environmental threats. Now the time has come to revisit

environmental health priorities in their own right.

So, what should ACOEM do now in environmental health? What will offer value

to its members and prepare them for new duties? The short answer is: a lot.

This is an open frontier for occupational physicians to expand their practice

and usefulness to the community, one which draws on their existing expertise

and capacity. So why would we not want to do it?

We don’t need to do everything in the broad field of environmental health and

we don’t need to duplicate the specific public health expertise of our

colleagues in general preventive medicine. Rather, we need to identify those

areas of environmental health science that we do and learn how to do them

better.

(There is a Special Committee on Revising the ACOEM Occupational Medicine

Competencies that is doing just that this year.)

In my personal opinion, what occupational physicians need to master (as

opposed to understand) includes the workplace environment, the relationship

between releases inside and beyond the plant boundary, a rather thorough

knowledge

of air quality issues, cross-training on how the same chemicals we deal with

in the workplace are significant in environmental exposures, infectious

hazards with emphasis on zoonoses (a major driver of emerging infections in the

modern world), public health protection as practiced in facilities management

(food, water, sanitation), and life-cycle issues of hazardous chemicals of

importance in industry, including waste. Obviously, additional, highly specific

knowledge is required for anyone working in a sensitive industry, such as

oil and gas.

What about environmental issues outside the traditional realm of “

environmental health?†There is a broad range of health issues that involve

ecosystem

disturbance unrelated to pollution and chemical exposure that we must deal

with. They include global climate change, stratospheric ozone depletion,

ecosystem encroachment and exposure to zoonotic infections, control of diseases

dependent on parasite life cycles (e.g., malaria), and so forth. These issues

have not been part of mainstream environmental and occupational health in North

America, at least not recently, but we are beginning to pay attention. At

SOTAC five years ago, a team from the University of Western Ontario presented a

well-attended session on ecosystem and human health. At this year’s Western

Occupational Health Conference, an excellent session on the ecology of Lake

Tahoe gave attendees an outstanding, and enjoyable, introduction into the

intricacies of limnology (the science of lakes). We do not, as occupational and

environmental physicians, need to cross train as ecologists. We do need to know

the basics so that when an issue is brought to us by a client or our employer

we can come up to speed quickly.

Occupational and environmental medicine is nothing if not adaptable. Many

challenges we will face in the future are environmental as much as occupational.

Environmental health, realistically circumscribed, is part of our field of

practice and we need to be ready for it.

Tee L. Guidotti, MD, MPH, FACOEM

ACOEM President