The Changing Climate: Managing Health Impacts.

Concentrations of greenhouse gases continue to accumulate in the atmosphere at increasing rates, heating the Earth's surface and destabilizing climate. Health impacts from climate change may include increased morbidity and mortality from worsening cardiopulmonary health, worsening allergies, and greater risk of infectious disease and mental illness, including anxiety, depression, and posttraumatic stress disorder from extreme weather events. Family physicians should advise patients to minimize exposure to air pollution, which is potentiated by rising temperatures. Use of self-monitoring devices, tracking local weather information, and awareness of events such as wildfires can alert patients to poor ambient air quality. Vulnerable individuals should avoid intense outdoor exercise and stay indoors or wear protective N95 masks when air quality is in the harmful range. Physicians can teach patients to recognize early symptoms of heat illness and advise adequate hydration and cooling on hot days. Physicians should become aware of the signs and symptoms of vectorborne illnesses to ensure early treatment and limit spread. Physicians should be aware of the climate and health benefits of active transport and plant-based diets when counseling their patients. Physicians can have a positive impact on climate change awareness and policy by incorporating counseling, public health precepts, and advocacy into their practice.

System dynamics-based evaluation of interventions to promote appropriate waste disposal behaviors in low-income urban areas: A Baltimore case study.

Inappropriate waste disposal is a serious issue in many urban neighborhoods, exacerbating environmental, rodent, and public health problems. Governments all over the world have been developing interventions to reduce inappropriate waste disposal. A system dynamics model is proposed to quantify the impacts of interventions on residential waste related behavior. In contrast to other models of municipal solid waste management, the structure of our model is based on sociological and economic studies on how incentives and social norms interactively affect waste disposal behavior, and its parameterization is informed by field work. A case study of low-income urban neighborhoods in Baltimore, MD, USA is presented. The simulation results show the effects of individual interventions, and also identify positive interactions among some potential interventions, especially information and incentive-based policies, as well as their limitations. The model can help policy analysts identify the most promising intervention packages, and then field test those few, rather than having to pilot test all combinations. Sensitivity analyses demonstrate large uncertainties about behavioral responses to some interventions, showing where information from survey research and social experiments would improve policy making.

Multisite Assessment of Nursing Continuing Education Learning Needs Using an Electronic Tool.

A continued education needs assessment and associated education plan are required for organizations on the journey for American Nurses Credentialing Center Magnet® designation. Leveraging technology to support the assessment and analysis of continuing education needs was a new venture for a 12-hospital regional health system. The purpose of this performance improvement project was to design and conduct an enhanced process to increase the efficiency and effectiveness of gathering data on nurses' preferences and increase nurse satisfaction with the learner assessment portion of the process. Educators trialed the use of a standardized approach via an electronic survey tool to replace the highly variable processes previously used. Educators were able to view graphical summary of responses by category and setting, which substantially decreased analysis and action planning time for education implementation plans at the system, site, or setting level. Based on these findings, specific continuing education action plans were drafted for each category and classification of nurses.

Slowing global warming: benefits for patients and the planet.

Global warming will cause significant harm to the health of persons and their communities by compromising food and water supplies; increasing risks of morbidity and mortality from infectious diseases and heat stress; changing social determinants of health resulting from extreme weather events, rising sea levels, and expanding flood plains; and worsening air quality, resulting in additional morbidity and mortality from respiratory and cardiovascular diseases. Vulnerable populations such as children, older persons, persons living at or below the poverty level, and minorities will be affected earliest and greatest, but everyone likely will be affected at some point. Family physicians can help reduce greenhouse gas emissions, stabilize the climate, and reduce the risks of climate change while also directly improving the health of their patients. Health interventions that have a beneficial effect on climate change include encouraging patients to reduce the amount of red meat in their diets and to replace some vehicular transportation with walking or bicycling. Patients are more likely to make such lifestyle changes if their physician asks them to and leads by example. Medical offices and hospitals can become more energy efficient by recycling, purchasing wind-generated electricity, and turning off appliances, computers, and lights when not in use. Moreover, physicians can play an important role in improving air quality and reducing greenhouse gas emissions by advocating for enforcement of existing air quality regulations and working with local and national policy makers to further improve air quality standards, thereby improving the health of their patients and slowing global climate change.

Petroleum scarcity and public health: considerations for local health departments.

Recognition of petroleum as a finite global resource has spurred increasing interest in the intersection between petroleum scarcity and public health. Local health departments represent a critical yet highly vulnerable component of the public health infrastructure. These frontline agencies currently face daunting resource constraints and rely heavily on petroleum for vital population-based health services. Against this backdrop, petroleum scarcity may necessitate reconfiguring local public health service approaches. We describe the anticipated impacts of petroleum scarcity on local health departments, recommend the use of the 10 Essential Public Health Services as a framework for examining attendant operational challenges and potential responses to them, and describe approaches that local health departments and their stakeholders could consider as part of timely planning efforts.

Peak oil, food systems, and public health.

Peak oil is the phenomenon whereby global oil supplies will peak, then decline, with extraction growing increasingly costly. Today's globalized industrial food system depends on oil for fueling farm machinery, producing pesticides, and transporting goods. Biofuels production links oil prices to food prices. We examined food system vulnerability to rising oil prices and the public health consequences. In the short term, high food prices harm food security and equity. Over time, high prices will force the entire food system to adapt. Strong preparation and advance investment may mitigate the extent of dislocation and hunger. Certain social and policy changes could smooth adaptation; public health has an essential role in promoting a proactive, smart, and equitable transition that increases resilience and enables adequate food for all.

Public health and medicine in an age of energy scarcity: the case of petroleum.

Petroleum supplies have heretofore been abundant and inexpensive, but the world petroleum production peak is imminent, and we are entering an unprecedented era of petroleum scarcity. This fact has had little impact on policies related to climate, energy, the built environment, transportation, food, health care, public health, and global health. Rising prices are likely to spur research and drive efficiency improvements, but such innovations may be unable to address an increasing gap between supply and demand. The resulting implications for health and the environment are explored in the articles we have selected as additional contributions in this special issue. Uncertainty about the timing of the peak, the shape of the production curve, and decline rates should not delay action. The time for quick, decisive, comprehensive action is now.

From health care to home community: an Aboriginal community-based ABI transition strategy.

PRIMARY OBJECTIVE: To explore the barriers and enablers surrounding the transition from health care to home community settings for Aboriginal clients recovering from acquired brain injuries (ABI) in northwestern Ontario. RESEARCH DESIGN: Participatory research design using qualitative methods. METHODS: Focus groups conducted with clients with ABI, their caregivers and hospital and community health-care workers. The Framework Method of analysis was used to uncover emerging themes. FINDINGS: Six main categories emerged: ABI diagnosis accuracy, acute service delivery and hospital care, transition from hospital to homecare services, transition from hospital to community services, participant suggestions to improve service delivery and transition, and views on traditional healing methods during recovery. DISCUSSION: A lack of awareness, education and resources were acknowledged as key challenges to successful transitioning by clients and healthcare providers. Geographical isolation of the communities was highlighted as a barrier to accessibility of services and programmes, but the community was also regarded as an important source of social support. The development of educational and screening tools and needs assessments of remote communities were identified to be strategies that may improve transitions. CONCLUSIONS: Findings demonstrate that the structure of rehabilitation and discharge processes for Aboriginal clients living on reserves or in remote communities are of great concern and warrants further research.

The evidence base for effectiveness of preparedness training: a retrospective analysis.

OBJECTIVES: In 2007, the Centers for Disease Control and Prevention (CDC) commissioned an Evidence-Based Gaps Collaboration Group to consider whether past experience could help guide future efforts to educate and train public health workers in responding to emergencies and disasters. METHODS: The Group searched the peer-reviewed literature for preparedness training articles meeting three criteria: publication during the period when CDC's Centers for Public Health Preparedness were fully operational, content relevant to emergency response operations, and content particular to the emergency response roles of public health professionals. Articles underwent both quantitative and qualitative analyses. RESULTS: The search identified 163 articles covering the topics of leadership and command structure (18.4%), information and communications (14.1%), organizational systems (78.5%), and others (23.9%). The number of reports was substantial, but their usefulness for trainers and educators was rated only "fair" to "good." Thematic analysis of 137 articles found that organizational topics far outnumbered leadership, command structure, and communications topics. Disconnects among critical participants--including trainers, policy makers, and public health agencies--were noted. Generalizable evaluations were rare. CONCLUSIONS: Reviews of progress in preparedness training for the public health workforce should be repeated in the future. Governmental investment in training for preparedness should continue. Future training programs should be grounded in policy and practice needs, and evaluations should be based on performance improvement.

Emergency preparedness: addressing a residency training gap.

As the importance of physician involvement and leadership in crisis preparedness is recognized, the literature suggests that few physicians are adequately trained to practice effectively in a large-scale crisis situation. A logical method for addressing the emergency preparedness training deficiency identified across several medical specialties is to include disaster and emergency preparedness training in residency curricula. In this article, the authors outline the development and implementation of an emergency preparedness curriculum for the Johns Hopkins General Preventive Medicine Residency (JHGPMR) from 2004 to 2006. The curriculum consists of two components. The first was developed for the academic year in the JHGPMR and includes didactic lectures, practical exercises to apply new knowledge, and an opportunity to integrate the knowledge and skills in a real-world exercise. The second, developed for the practicum year of the residency, includes Web-based lectures and online content and culminates in a tabletop preparedness exercise. Topics for both components include weapons of mass destruction, risk communication and personal preparedness, aspects of local emergency response planning, and mental health and psychological aspects of terrorism. On the basis of the emergency preparedness training gap that has been identified in the literature, and the success of the three-year experience in implementing a preparedness training curriculum in the JHGPMR, the authors recommend incorporation of competency-based emergency preparedness training for residencies of all specialties, and offer insights into how the described curriculum could be adapted for use in other residency settings.

Global environmental change: what can health care providers and the environmental health community do about it now?

The debate about whether global environmental change is real is now over; in its wake is the realization that it is happening more rapidly than predicted. These changes constitute a profound challenge to human health, both as a direct threat and as a promoter of other risks. We call on health care providers to inform themselves about these issues and to become agents of change in their communities. It is our responsibility as clinicians to educate patients and their communities on the connections between regressive policies, unsustainable behaviors, global environmental changes, and threats to health and security. We call on professional organizations to assist in educating their members about these issues, in helping clinicians practice behavior change with their patients, and in adding their voices to this issue in our statehouses and Congress. We call for the development of carbon and other environmental-labeling of consumer products so individuals can make informed choices; we also call for the rapid implementation of policies that provide tangible economic incentives for choosing environmentally sustainable products and services. We urge the environmental health community to take up the challenge of developing a global environmental health index that will incorporate human health into available "planetary health" metrics and that can be used as a policy tool to evaluate the impact of interventions and document spatial and temporal shifts in the healthfulness of local areas. Finally, we urge our political, business, public health, and academic leaders to heed these environmental warnings and quickly develop regulatory and policy solutions so that the health of populations and the integrity of their environments will be ensured for future generations.

Understanding radiologic and nuclear terrorism as public health threats: preparedness and response perspectives.

Terrorism dates back to antiquity, but our understanding of it as a public health threat is still in its nascent stages. Focusing on radiation and nuclear terrorism, we apply a public health perspective to explore relevant physical health and psychosocial impacts, the evolving national response infrastructure created to address terrorism, and the potential roles of nuclear medicine professionals in preparing for and responding to radiologic and nuclear terrorism.

Establishing evidence-informed core intervention competencies in psychological first aid for public health personnel.

A full-scale public health response to disasters must attend to both the physical and mental health needs of affected communities. Public health preparedness efforts can be greatly expanded to address the latter set of needs, particularly in light of the high ratio of psychological to physical casualties that often rapidly overwhelms existing mental health response resources in a large-scale emergency. Psychological first aid--the provision of basic psychological care in the short term aftermath of a traumatic event--is a mental health response skill set that public health personnel can readily acquire with proper training. The application of psychological first aid by public health workers can significantly augment front-line community-based mental health responses during the crisis phase of an event. To help achieve this augmented response, we have developed a set of psychological first aid intervention competencies for public health personnel. These competencies, empirically grounded and based on best practice models and consensus statements from leading mental health organizations, represent a necessary step for developing a public health workforce that can better respond to the psychological needs of impacted populations in disasters.

Expanding disaster mental health response: a conceptual training framework for public health professionals.

The available research literature suggests that in disasters, individuals presenting acutely with psychologically-related complaints tend to outnumber those presenting with physical symptoms directly stemming from the injury-causing agent or event. This acute "mental health surge" can rapidly overwhelm existing community mental health resources, especially in the context of terrorism. Training professionals from outside the traditional mental health workforce in basic psychological crisis intervention may promote more efficient use of mental health services through a gatekeeper process of early intervention and appropriate referrals to mental health specialists. With their experience in patient and client services at the community level, public health professionals represent a cohort well-suited for training in and delivery of acute mental health services in disasters. In this paper, we outline a conceptual model and rationale for training public health professionals in basic crisis-oriented mental health functions (psychological first aid) in order to augment community-based mental health services for affected populations in a disaster.

The Road Map to Preparedness: a competency-based approach to all-hazards emergency readiness training for the public health workforce.

Facing limited time and budgetary resources, state and local health departments need a practical, competency-based training approach to meet the all-hazards readiness requirements of their employees. The Road Map to Preparedness is a training tool designed to assist health departments in providing comprehensive, agency-tailored readiness instruction to their employees. This tool uses an incentive-based, game-like, experiential learning approach to meet the Centers for Disease Control and Prevention's nine core competencies for all public health workers while facilitating public health employees' understanding and acceptance of their emergency response roles. A corresponding evaluation tool, the Road Map to Preparedness Evaluation, yields metrically-driven assessments of public health employee readiness competencies. Since its pilot in 2003, the Road Map to Preparedness has met with enthusiastic response from participating health departments in the mid-Atlantic region. In addition to its public health impact, the Road Map offers future promise as a tool to assist organizational emergency response training in private sector and non-public health first-responder agency settings.

Applying risk perception theory to public health workforce preparedness training.

Since 9/11, public health has seen a progressive culture change toward a 24/7 emergency response organizational model. This transition entails new expectations for public health workers, including (1) a readiness and willingness to report to duty in emergencies and (2) an ability to effectively communicate risk to an anxious public about terrorism or naturally occurring disasters. To date, however, research on readiness education for health department workers has focused little attention upon the risk perceptions that may influence their willingness to report to duty during disasters, as well as their ability to provide effective emergency risk communication to the public. Here, we apply risk perception factors to explore the potential barriers and remedies to effective public health workforce emergency response.

The practice community meets the ivory tower: a health department/academic partnership to improve public health preparedness.

When the local health department of Montgomery County, Maryland, was chosen to participate in Project Public Health Ready and was charged with the daunting task of providing a comprehensive emergency preparedness plan, training all 600 employees to carry out that plan, and conducting exercises to demonstrate the department's competency, it realized it couldn't do it alone. The department sought the assistance of the Johns Hopkins Bloomberg School of Public Health. The first challenge for these unlikely partners, one a bastion of research and the other firmly immersed in the practice world of public health, was to figure out how to work together. This article describes the development of their partnership; outlines the preparedness plan, training, and exercises that resulted from the partnership; summarizes the challenges and benefits for each entity; and enumerates lessons learned that could be useful to other public health entities planning to undertake similar partnerships.