In addition to patient concerns about exposure to natural and man-made hazards, environmental factors are important in many common illnesses and injuries in primary care. Most of them manifest in the tissues in direct contact with the outside world including skin and mucus membranes, respiratory tract, and gastrointestinal tract, but internal organs like brain, bone marrow, liver, and kidney are targets for blood-borne chemical and biologic toxins. With the exception of infectious diseases, the role of most environmental hazards is not always obvious and consideration of environmental factors may be key in the evaluation and management of common syndromes like wheezing, fever, and anemia.
As with most other diagnostic problems in primary care, a careful history is often the clue to an environmentally induced problem. A thorough history should include consideration of both current and past exposures in the home, workplace, and community. The Agency for Toxic Substances and Disease Registry of the Centers for Disease Control (ATSDR/CDC) has an online lesson in taking an exposure history; https://www.atsdr.cdc.gov/csem/csem.asp?csem=33&po=0. A self-administered version of the environmental exposure history recommended is available as a fillable Adobe PDF and can be found at https://www.atsdr.cdc.gov/csem/exphistory/docs/CSEMExposHist-26-29.pdf. Another case study in this series particularly relevant to primary care is Environmental Triggers of Asthma https://www.atsdr.cdc.gov/csem/csem.asp?csem=32&po=13 which has as an appendix of an Asthma Triggers Exposure History form. ATSDR has other environmental health training for primary care https://www.atsdr.cdc.gov/emes/health_professionals/index.html and partners with other medical specialty organizations https://www.atsdr.cdc.gov/emes/partners.html.
The scientific basis of environmental medicine is often derived from epidemiologic studies correlating clusters of disease with the presence of a chemical, physical, or biologic agent in a select population which then becomes the basis for further epidemiologic investigation and empirical testing in disease models before declaration of that agent as a health hazard. This is particularly problematic in the common diseases seen in primary care which are often multifactorial in etiology. Federal regulatory agencies like the FDA and EPA require a consensus of evidence which is often debated in a public forum. Positively identifying environmental health hazards is often a difficult process and subject to sociopolitical as well as scientific controversy. Many patients are ironically more concerned with environmental factors beyond their control and may inappropriately estimate the role of “pollution” or “additives” as either greater or lesser than the likely probability of causation of or contribution to their current health conditions.
As with many issues in primary care, we can ask our patients to partner with us in both investigating and mitigating health hazards in their personal environments. Fortunately, reasonable steps to avoid, remove, or minimize environmental hazards are often easily and inexpensively performed. Licensing of commercial environmental assessment and remediation providers varies greatly by locality. Community environmental health issues are a public health responsibility. Your local health department may be helpful in recommending allied environmental professionals.
Many environmental health educational resources for our patients and their families can be found at the websites listed below:
ATSDR/CDC https://www.atsdr.cdc.gov/emes/public/index.html
Environmental Protection Agency (EPA) https://www.epa.gov/environmental-topics/health-topics
Occupational Safety and Health Administration (OSHA) https://www.osha.gov/SLTC/index.html
Food and Drug Administration (FDA) https://www.fda.gov/
National Institute for Environmental Health and Safety (NIEHS) https://www.niehs.nih.gov/health/topics/index.cfm
National Environmental Education Foundation https://www.neefusa.org/
Environmental Science https://www.environmentalscience.org/
Charles A. Sneiderman, MD, PhD, DABFP
Medical Director, Culmore Clinic
Falls Church, VA
csneiderman@culmoreclinic.org
Published on 8/7/19
