Health and the Environment in North Carolina

Outdoor Air Quality

In 2008, it was estimated that approximately 127 million people living in the United States were exposed to air containing pollutants that exceeded the National Air Quality Standards [6]. Consequently, outdoor air quality, which has been linked to premature deaths, cancer, and long-term damage to the respiratory and cardiovascular systems, is a major topic in this issue of the NCMJ. Most people are aware that bad air quality can lead to respiratory diseases such as asthma, but an additional critical aspect of air pollution is its effects on the heart. In fact, it is cardiovascular disease which causes the most morbidity, mortality, and cost of any medical condition related to air pollution [7]. The well-established causal associations between active and passive smoking with heart disease and stroke support the plausibility of an adverse effect of air pollution, including particulate matter, on the cardiovascular system. Collectively, a number of scientific studies suggest that air pollution may accelerate the development of coronary atherosclerosis and worsen its sequelae. As Dr. Wayne Cascio, acting director of the National Health and Environmental Research Lab for the EPA, writes, some of these effects may occur over time, as with acceleration of the progression of atherosclerosis, while others occur rather abruptly, as with the triggering of an arrhythmia or myocardial infarction by acute inflammatory responses, altered platelet adhesiveness, or perhaps vascular endothelial dysfunction [7]. This is particularly a problem in areas dealing with wildfires.

In addition to respiratory and cardiovascular disease, there are a number of unexpected health effects from pollution and particulates in the air that have been linked to other health conditions including depression, osteoporosis, and even autism, which Dr. David Peden, director of the Center for Environmental Medicine at the University of North Carolina at Chapel Hill (UNC-CH), addresses in a sidebar article [8].

Surface and Ground Water Quality

High-quality water is also a critical factor for health and the environment, as contamination by infectious agents or chemicals can cause a variety of illnesses. Protecting our water sources and minimizing exposure to contaminated water are important aspects of water quality in North Carolina that are addressed in this issue. Most significantly, a review by Drs. Julia Kravchenko and H. Kim Lyerly of the Environmental Health Scholars Program at Duke University describes the reported health risks associated with exposure to water that may have been contaminated by coal ash [9]. Additional challenges to water quality in North Carolina include contamination due to a variety of environmental exposures including lead, chemicals such as GenX, and contaminants from concentrated animal feeding operations (CAFOs). An original resarch article describing the poor health outcomes for a variety of conditions found in communities in proximity to CAFOs was generated by Dr. Kravchenko and colleagues at Duke [10]. In an accompanying article, Dr. Virginia Guidry of the NIEHS and colleagues discuss the concept of environmental justice, present the impact of large-scale hog production as an example of environmental injustice in North Carolina, and make suggestions for how clinicians can address environmental injustices affecting their patients [11].

Toxic Substances and Hazardous Waste

The specific assessment of toxic substances such as hazardous waste features significantly in this issue. For example, there is a need for enacting a health-based standard for lead in drinking water to improve children's health even though there is no safe level of exposure to lead, especially for children, who may suffer lifelong developmental defects. As Dr. Jennifer Hoponick Redmon of the Research Triangle Institute (RTI) and colleagues write [12], a health-based drinking water standard has never been set. In 2017, a study by RTI International tested participating North Carolina child care centers and schools for lead in the water and found that 3 out of 4 tap water samples contained lead above the 0.1 parts per billion laboratory detection limit, yet few (< 1%) of these samples exceeded the EPA's treatment-based action level of 15 parts per billion [12]. The questions of what is an acceptable level of lead in drinking water and what are the policies needed to implement this type of monitoring remain. In this issue, Drs. Ann Chelminski and Kim Gaetz of the North Carolina Department of Health and Human Services also run the numbers on trends in lead poisoning prevention among North Carolina children aged 6 and younger [13].

The term “contaminant of emerging concern,” or CEC, describes a collection of chemical compounds found in water sources in recent years that may cause adverse effects to human health and aquatic life. One such contaminant that has emerged to be of importance to North Carolina residents is GenX, based on potential pollution from the Chemours Plant at the Cape Fear River and the surrounding water supplies. In a sidebar about GenX, Dr. Stanley Meiburg of the Graduate Program of Sustainabilty at Wake Forest University writes that sampling beginning in 2012 detected GenX in surface water in the Cape Fear River and the North Carolina Department of Environmental Quality (NCDEQ) later detected GenX in groundwater and well water near the Chemours facility [14].

Emerging contaminants result from products we depend on, but there is a lot we don't know know about their effects. Meiburg asks readers to consider an important question [14]: “How much risk, in exchange for what benefits and under conditions of uncertainty, are we willing to tolerate?”

Homes and Communities

The homes and communities that are affected by environmental hazards create an opportunity to address environmental justice issues. Clinicians with a better understanding of how the environment affects their patients' health are better poised to recognize symptoms and conditions associated with known sources of pollution [11].

Several authors in this issue focus on hog production not because it is the only source of environmental injustice in North Carolina, but because it impacts vulnerable populations disparately. As Guidry et al. write, “Low-income communities and communities of color can be disproportionately exposed to environmental pollution compared to higher-income, white communities [11].” Their hope, and the hope of many authors in this issue, is that as clinicians receive better education and training about environmental issues, they will be able to better engage with patients and communities around the impacts of CAFOs and other environmental injustices [11].

Infrastructure and Surveillance

The need for environmental monitoring to detect environmental hazards is addressed in several articles in this issue, including a review of the Clean Smokestacks Act. Drs. Kravchenko and Lyerly of Duke and Bill Ross, former secretary of the NC Department of Environment and Natural Resources, write about the impact of this policy on improving environmental conditions in North Carolina including the reduction in mortality from respiratory disease and cardiovascular disease [15]. In addition, there has been a Medical Advocates for Healthy Air (MAHA) initiative to reduce idling and diesel exhaust fumes caused by construction. Rachel McIntosh-Kastrinsky, manager at MAHA, and Dr. Tom Zweng, formerly of Novant Health, write about how hospital systems are working together to improve air quality to protect both patients and workers from construction pollution [16].

In another article, McIntosh-Kastrinsky highlights Dr. Bob Parr's efforts to track pollution using individual air quality monitors and describes the potential impact of these types of activities on the health of patients [17].

Global and Environmental Health

Populations across the United States are vulnerable to and experiencing health effects from changes to climate, and North Carolina is no exception. Health professionals are vital to identifying and treating such impacts, but also to serving as trusted authorities in educating and acting to protect communities against climate health threats. Dr. Greg Kearney of East Carolina University provides an original article on this topic titled Climate Change and Public Health through the Lens of Rural, Eastern North Carolina [18]. Also in the theme of global and environmental health, the impact of climate change on North Carolina's health, particularly regarding natural disasters, is described by Lauren Thie, environmental program consultant at the North Carolina Division of Public Health, and Kimberly Thigpen Tart, health science policy analyst at the NIEHS [19]. In a sidebar article, Dr. Margaret Sugg of Appalachian State University describes how extreme heat events are some of the most dangerous climate-change-related disasters and how they affect health in ways one might not expect [20].