Our Health and the Environment
Are health professionals properly educated to provide us with the
care we need?
Abstract………. 1
Introduction: How Does Air Pollution Directly Harm Us and Why? ………..1
What is the Importance of Environmental Education in Medical Programs? .............5
Why Are These Concerns So Difficult to Diagnose? ………..….5
Current Data on Environmental Core Curriculum in Worldwide Medicine ………….7
Moving Forward: Potential Solutions ………….. 9
Conclusion …………….…11
Bibliography ………………..12
As human beings continue to have momentous impacts on the environment and its resources,
core education seems to be the best device for providing the public with medical professionals
that understand the ramifications human actions and behavior patterns that influence their
health and environment. This project focuses on the present current core curriculum of medical
professionals in different regions of the world, and if they meet the standards to ensure proper
diagnosis of environmental-related health concerns. Working with The Public Health Coalition,
a nonprofit focused on environmental studies in downtown Haifa, Israel, has allowed for an
opportunity to gain insight into the core education of medical professionals worldwide, and
provides a backdrop for the organization of new curricula and the challenges of their
implementation.
Abstract
The purpose of this research is to outline the effects that air pollution has within public health,
which raises the question of how public health officials prepare to deal with this phenomena
within their own education. Consequently, I will investigate the core curriculum of top medical
schools in Israel, Europe, and the United States in order to isolate the importance of
environmental influences on public health and the education that medical professionals receive
upon completion of their specific program. The undeniable correlation between environmental
health and public health is suspected to be compromised in the core curriculum of medical
students worldwide, which adversely affects the primary care that patients receive. In order to
develop an inclusive understanding of the education that medical students receive in respect to
environmental health, I will individually examine each program's core courses and electives
and conclude whether or not the standards are exhaustive. The schools selected display a
prominent influence in their respected countries, in addition to being representative of the
regions this paper is focused on.
Introduction: How Does Air Pollution Directly Harm Us and Why?
By taking a step back and defining how detrimental air pollution is to human health, we can
begin to grasp the importance of medical professionals and what they face when confronted
with medical complications due to air pollution. Air pollution is a serious issue, and there are
many ways that air pollution can directly and indirectly harm people. The most three common
ways are by inhalation, ingestion, and amalgamation.
The primary path for air pollutants to enter the human body is via the respiratory system. By the
simple act of breathing, harmful particles and droplets reach the lungs and other organs. Most
particulates bind with the alveoli, which are the sacs where oxygen and carbon dioxide are
exchanged, which overtime causes scarring to the tissue. Likewise, when blood is pumped
through the body, the toxins progress further, and vital organs are exposed to the chemicals
that damage the body.1
However, these pollutants are not just restricted to the atmosphere. Air toxins can deposit on
many natural surfaces including the soil and water. When the natural environment absorbs
these pollutants, they move up the food chain, they grow in concentration and become more
dangerous to humans.
Thirdly, when we make contact with contaminated soil, dust, or water, we absorb many of the
same toxins that are suspended in the air. Thus, these harmful chemicals may enter the cells
and tissue of a person through diffusion and osmosis. 2 These methods of bodily entry are
virtually unavoidable as long as there is pollution in our environment, and thus emphasize the
importance of the awareness of primary care physicians, who we see on a regular basis for
non-life threatening health complications.
Many of these complications are cases that primary care physicians often treat. Various
examples of short-term effects include irritation to the eyes, nose and throat, and upper
respiratory infections such as bronchitis and pneumonia. Additionally, exposure can cause
headaches, nausea, and allergic reactions to the air. Long-term health effects can include
chronic respiratory disease, lung cancer, heart disease, and even damage to the brain, nerves,
liver, or kidneys. Continual exposure to air pollution affects the lungs of growing children and
may aggravate or complicate medical conditions in the elderly, which is difficult to diagnose
when there has been no previous medical instruction on environmental pollution, as these
symptoms can easily be misread as other illnesses.
Here are five examples of how damaging air pollution can be.
1) The "Smog Disaster" in London in 1952, four thousand people died in a few days due
to the high concentrations of pollution within the air.3
2) 1997 Southeast Asian Haze Disaster In this catastrophe, much of the surrounding
forest was destroyed. The impacts of the haze included decreased quality of life,
decreased biodiversity, and atmospheric damage. Particulate matter was the main
pollutant constituent and increased acute health problems such as asthma, respiratory
infection, and eye and skin irritation in all affected countries. Fire related damages,
including restricted air travel costs, totaled over 4.5 billion US dollars.4
3) The Pollution Disaster in Bhopal, India played host to one such local disaster in 1984,
when the Union Carbide plant released massive amounts of methyl isocyanate into the
air. Because the gas was denser than air, it spread around the surrounding
communities. Over 3,000 people were killed in the 6 hours of leakage, and over 500,000
people were exposed.5
4)
The Yokkaichi Asthma Outbreak occurred in the city of Yokkaichi in Mie Prefecture,
Japan between 1960 and 1972. The burning of petroleum and crude oil released large
quantities of sulfur oxide that caused severe smog, resulting in severe cases of chronic
obstructive pulmonary disease, chronic bronchitis, pulmonary emphysema, and
bronchial asthma among the local inhabitants. The generally accepted sources of the
sulfur oxide pollution were petro-chemical processing facilities and refineries that were
built in the area between 1957 and 1973.6
5) The Haifa Bay Air Quality The main sources of air pollution in Israel are energy
production, transportation and industry. Since these are largely concentrated in the
coastal plain, the highest levels of pollution have been detected in this area. Natural
conditions for pollution dispersion in the atmosphere of the coastal area are not
favorable and, until recently, relatively high concentrations of sulfur dioxide (SO2),
emitted for the most part by power plants and oil refineries, have been recorded in the
Ashdod and Haifa Bay areas. Intense industrial activities as well as the natural
atmosphere are problematic in terms of air pollution.
In all five of these cases, primary care physicians were relied upon to treat affected individuals.
Since these events encompass catastrophes as well as chronic environmental problems, it
supports the claim that doctors, not just environmental experts, need to be trained to respond
to the public need in relation to environmental pollution and its implications on environmental
health.
What is the Importance of Environmental Education in Medical Programs?
The rigor of a medical professional’s education is something that is championed worldwide,
and is hard to compare to other academic endeavors. Pursuing a comprehensive education, in
regards to medicine, is a critical step in treatment and diagnosis within public health. In regards
to education, it is imperative that it’s comprehensive in regards to environmental dangers,
including pollution.
Globally, air pollution is a major environmental risk to health. It is proven that by reducing air
pollution levels, the global burden of disease from respiratory infections, heart disease, and
lung cancer is reduced. It is proven that the lower the air pollution levels are in a certain region,
the healthier the respiratory and cardiovascular systems of the residents will be. According to
the World Health Organization (WHO), urban outdoor air pollution is estimated to cause 1.3
million deaths worldwide per year, while indoor air pollution is estimated to cause
approximately 2 million premature deaths mostly in developing countries. Almost half of these
deaths are due to pneumonia in children under 5 years of age.7
Since exposure to air pollutants is largely beyond the control of individuals and requires action
by public authorities at the national, regional and even international levels, it is imperative to
educate our primary care physicians and health workers about this imminent risk to make
certain that when medical attention is needed, it is delivered in an efficient and accurate
manner. Policy change can take years, sometimes decades, to be successful.
Why Are These Concerns So Difficult to Diagnose?
Because people are exposed to so many mixtures of potentially dangerous pollutants, it is
often hard to know exactly which pollutants are responsible for causing sickness. Also,
because a combination of different pollutants can intensify the problem, it is often difficult to
isolate those pollutants that are at fault. This is a serious problem that a systematic diagnosis
encounters, which is a strategy that is heavily relied upon by medical professionals,
specifically, those involved in primary care.
As previously stated, air pollution can affect our health in many ways with both short-term and
long-term effects. Since certain individuals are much more sensitive to pollutants than are
others, misdiagnosis is a problem that is often faced by medical professionals, as the same
complication can display itself in a variety of ways depending on the person affected. This
particularly affects young children and elderly people, in addition to people with health
problems such as asthma, heart and lung disease.
As defined by the Natural Resources Defense Council, the extent to which an individual is
harmed by air pollution usually depends on the total exposure to the damaging chemicals, i.e.,
the duration of exposure and the concentration of the chemicals must be taken into account.8
These variables are volatile and can change rapidly given the outlying circumstances of the
location that a person resides or travels to. When medical professionals lack accurate data or
quantitative information about the air a person is breathing, the diagnosis can be based off of
false information, and prolong a patient’s suffering. Since people often visit primary care
professionals first, and not professionals in other areas such as public health, it is important to
consider what the education these doctors have. Just because diagnosis can be elusive
doesn’t mean it should not be taught in a medical programme.
Below is the current report on pertaining to the top medical schools in the world. As you can
see, a vast majority of the schools are located in the United States and Europe. Universities
that are given this honor are examined in many dimensions, including their curriculum.
Interestingly, many of these schools are lacking the environmental aspect in their clinical core
courses, yet still seem to appear annually as the top universities for clinical medicine.
The Number of Universities in the top 50 of the Times Education List
by Country
12
USA
1
UK
1
Germany
Switzerland
30
Israel
Other
12
http://www.guardian.co.uk/news/datablog/2012/mar/15/top-100universities-times-higher-education
Current Data on Environmental Core Curriculum in Worldwide Medicine
From this research, it is evident that our primary care physicians, no matter what area of the
world they are attending, place little emphasis on environmental toxicology in regards to their
core and elective courses, although some universities have incorporated this subject in their
material. Of the 25 schools that were surveyed, only 6 definite courses were offered; however
not all of these courses were in the primary care tracts and were offered in broader subjects
such as public health. Additionally, none of these courses were required in the program, unless
the individual were to do independent research in the realm of environmental health, and the
majority belonged in the elective category. In the Europe and the USA, out of the twenty
schools researched, only 20% had some type of environmental health course, however none of
them were required and all were elective courses. In Israel, Bar Ilan University was the only
school with intent to educated clinical physicians about environmental concerns, stating that
“the curriculum will focus not only on patient care, but also on healthy lifestyles, with specific
regard to environmental factors”.
It is important to consider the tuition and funding that these schools receive, since it directly
correlates to the ability to provide students with the most up to date and comprehensive
information. For example, Harvard University’s tuition, a whopping $47,500, provides students
with an extensive list of electives in regards to primary care. In 2012, Harvard University is
number one in the top 100 list of most reputable universities as it did last year, according to
data put together by The Times Higher Education and Thomson. Although Harvard is near the
most expensive on the list, it provides a comprehensive primary care education in respect to
environmental health. However, there are more expensive medical schools that do not
incorporate these topics, and perhaps do not allocate their funds to this subject matter.
As you can see below, the distribution of environmental courses varies from region to region,
but nonetheless is lacking in number.
Moving Forward: Potential Solutions for a Comprehensive Environmental Health
Education
It is evident that one of the first steps to improve clinical health education is via advocacy and
funding to public medical schools. Once acquired, faculty can implement core courses that are
required for primary care physician students to take with their other courses. Using the few
courses provided in select programs, we can develop a comprehensive model to begin the
reformation and integration of an environmentally aware primary care program.
One of the main goals in doing so is to prevent misdiagnosis and effectively dealing with
environmental exposure. It is imperative that all primary care physicians are knowledgeable
about the scientific basis of medicine, including its most recent developments in the areas of
pollution and air quality. Likewise, it is equally important that medical students understand the
importance of physical, psychological and social aspects of patient care. Misdiagnosis can
prolong the patients suffering, and additionally deteriorate the trust between the patient and
physician. The best way to avoid this is to be sure the course is multidisciplinary in terms that
posses the capacity for inquiry so that physicians can continue learning, teaching, and
researching to prepare them fully for their roles as doctors that may encounter environmental
health hazards.
Even though many students agree that a comprehensive education is imperative for success,
many times the medical student is busy fulfilling other requirements or pursuing other research,
and anything that is not required is work that is put off for when the individual has completed
their core courses. After graduation, and physicians begin residency, their schedules become
more and more demanding and the free time to research and learn about external health
concerns, such as the environment and its impact on health, becomes nearly impossible. It is
for this reason that a core course, not an elective course, should be required for every primary
care physician with the following learning objectives. This way, the knowledge is required for
them to graduate and we can ensure that students will be familiar with environmental concerns.
The following points are the proposed objectives for this universal core course:

Students should be competent in occupational and environmental history. This can be
achieved through studying methods and resources for exposure assessment, for
example, administering monitoring tests appropriate to specific exposure and basic
concepts of environmental assessment.

Students should learn about the toxicology of important environmental toxins, such as
ozone and particulates. Students should learn how to develop differential diagnoses
that include occupational and environmental exposures.

Students learn about preventive strategies, including basics like personal protection and
safety precautions. They should also have extensive knowledge pertaining to
government regulations and reporting requirements that are relevant to physicians.

Students should research local environmental concerns where they plan to do their
residency. Since environmental concerns are not the same in every region, this is a
strategy to acclimate themselves to the diagnoses they are likely to encounter.

Students should read scholarly articles, attend lectures, and research the latest
developments in the environmental health sector so they are ensured to be educated
on the latest medical breakthroughs and findings.

Students should be exposed to case studies and complete patient examinations that
expose them to potential symptoms of environmental exposure under the direction of
medical professionals with experience in this area. The purpose of this is to expose
students to the variety of symptoms and different reactions to pollutants and
environmental complications that can be easily misread, so they can provide an
accurate diagnosis during residency.
The essential problem is that every university in the USA, Europe, and Israel has a
comprehensive course list in environmental studies; however they are not incorporated in
primary healthcare. This can easily be overlooked; its mere existence can be enough for
academic professionals to assume that it is taken by the students who need it in their
respected programs. The vast majority of these schools have accomplished faculty and leading
research institutes in environmental health, but the courses offered in these divisions are
separate from the medical schools and therefore, little to no communication between the two
institutes is facilitated. However, since these 25 universities are already established in
environmental research outside of the medical school, with some restructuring and synthesis, it
will be beneficial to incorporate the environmental education within the respected medical
institutes.
Conclusion
These findings support that our primary care physicians need a more comprehensive education
in respect to environmental health, since these concerns are multiplying and intensifying
exponentially. The public relies on primary care physicians to improve their health and well
being, it should be of the upmost importance that the education of these individuals is allencompassing. It is imperative to educate our primary care physicians and health workers
about this imminent risk to make certain that when medical attention is needed, it is delivered in
an efficient and accurate manner. As previously stated, policy change and educational reform
can take years, sometimes decades, to be successful, and it is a critical step to collectively
improve diagnoses worldwide to ensure healthy wellbeing for years to come.
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Natural Resources Defense Council
40 West 20th Street New York, NY 10011