[CPEO-BIF] ATSDR - Hazardous Substances and Public Health, Spring 2000, Part 1

[Emery Graham <egraham@ci.wilmington.de.us>]

FYI,

This article represents a change in paradigm re assessing the negative
impact of waste sites on local residents. It admits social science thinking
into the heretofore physical and natural science oriented waste site impact
assessment  paradigm.  It lets poor people, minorities, and waste site
proximate families have minds and worries that impact their physical
reality and behavioral reality. The context and consequences of site based
community education may be better understood as a result of these studies.

More important it suggests that psychosocial impact assessments may be
legitimate candidates for inclusion in brownfields assessment activity in
that the attitudes of waste site constituents may impact the content of
development related legislation, the selection of remediation approaches,
and even work environment of newly developed business.

Emery

The full article is also available at http://www.atsdr.cdc.gov/HEC/v10n1-1.html
  

Scientific Research Continues on the Psychological Responses to Toxic
Contamination 

Pamela Tucker, MD, ATSDR  

The basis of what is known about the psychological effects of environmental
contamination from hazardous substances began with the study of people's
reactions to natural disasters in the 1950s. Psychologists and clinicians
recognized that a small number of people exposed to various natural
disasters (e.g., fires, hurricanes, and floods) could develop psychological
sequelae from the stress such as major depression, chronic anxiety, and
post-traumatic stress disorder (PTSD). Current thought among disaster
relief workers holds that most people will suffer no or only transient
effects from the stress of a natural disaster (i.e., acute stress disorder
or, "people reacting normally to an abnormal situation") (1). 

There are important differences between psychological effects from actual
or perceived exposure to chemicals and those resulting from natural
disasters. Sociologists and psychologists performing field research in
communities near hazardous waste sites have pointed out that unlike a
natural disasterwhich has a discernible low point followed by a recovery
phase when life begins to return to "normal"life near a hazardous waste
site is a more nebulous and uncertain situation.  Environmental
contamination has no discernible starting point, no distinct low points,
may last for many years during the clean-up and remediation process, and,
in case of exposure, may result in latent health effects for those people
exposed to a hazardous substance (1). 

The slow onset and recovery from these situations may make adjustment to
them more difficult than a sudden, more tangible event such as a natural
disaster. Living near a hazardous waste site can breed uncertainty about
exposures and subsequent latent health effects (2) and spark social and
political turmoil (3, 4), all of which serve as additional stressors. Also,
exposures to neurotoxic chemicals can cause psychological changes, so it is
important to rule out exposures before declaring a health problem to be
solely psychologically based. 

The first quantitative scientific studies of the psychological stress
associated with environmental contamination were conducted about the Three
Mile Island (TMI) accident. Baum and colleagues (5) found indicators of
psychophysiological effects from stress in the people living near TMI when
compared with people in control groups. The psychological effects found in
many community members included elevated levels of psychological distress,
feelings of perceived threat, and subclinical anxiety and depression. The
physical signs of increased stress in the TMI group consisted of small
subclinical increases in blood pressure and higher than normal levels of
urinary cortisol and norepinephrine metabolites, which are indicators of
physical arousal due to psychological stress. This pattern of subclinical
psychological and physical symptoms of stress remained elevated for six
years after the incident and only returned to normal levels after 10 years
(6). 

Baum and colleagues looked for this same pattern of chronic stress in a
community located near a hazardous waste site. The findings were the same
(7). Baum and Fleming concluded that "distress and mental health outcomes
also represent major outcomes of environmental disasters."   

Further support for the findings at TMI comes from a group of researchers
in California who studied the towns affected by the Cantara loop railway
spill (8). The study looked at the physical, psychological,and
psychophysiological reactions of those who experienced exposure to metam
sodium as a result of the spill. Psychological assessments of the affected
residents showed increased worry and perceived decreases in social support.
Biological testing showed changes indicative of chronic stress. Testing
also showed greater occurrence of depression, anxiety, and somatic symptoms
in the exposed population versus the control population. Researchers felt
these outcomes were possibly connected to chronic arousal states. They
postulated that "physiological and psychosocial effects of the chemical
spill trauma precede long-term physiological manifestations." 

Results of other recent studies further suggest that the experience of
exposure to hazardous substances and the resulting psychological changes
might result in adverse physical and psychological health effects. For
example, in 1994, epidemiologists at the University of Texas investigated
the physical and subsequent psychological effects found in a community that
had been exposed to a toxic cloud of hydrogen fluoride (9).These
researchers first investigated and documented both the short- and long-term
physical health effects found in persons exposed to hydrogen fluoride
vapors. They then evaluated the psychological effects of these exposures in
this population and found that a linear relationship existed between the
degree of gas exposure and the level of psychological distress. Specific
findings included increased anxiety and somatic concerns.

The critical factors and underlying causes that result in these types of
effects from stress are still not understood. The research done at TMI and
at the toxic waste sites and spills conclude that the effects may be

largely related to event characteristics and the individual responses. The
responses can range from little concern to extreme agitation. Individual
reactions are affected by many factors, including the event itself (e.g.,
did exposures and injuries occur?); the imagery associated with the
episode; media coverage; and the individual's circumstances (e.g., were
they or someone they knew injured or affected?), his or her perception of
the situation, appraisal of the degree of threat, and perceived sense of
control over the circumstances.

There are still many questions to be answered about the psychological
responses people have to toxic contamination: How do special populations
like children and the elderly respond? How common is the chronic stress
response such as that seen in the TMI and such events? What are the effects
of this chronic stress on a person's health? If these questions are
answered, the psychological effects and the extent of these effects from
real or perceived exposure to toxins can be more accurately defined and
adequate preventive strategies developed to help to mitigate the
psychosocial stresses of hazardous substances in our environment.

ATSDR is taking first steps to address the psychological effects associated
with exposure or possible exposure to hazardous substances through its
Psychological Effects Program. As part of this Program, ATSDR recently
published the Report of the Expert Panel Workshop on the Psychological
Responses to Hazardous Substances. 

References 

Agency for Toxic Substances and Disease Registry. Report of the expert
panel workshop on the psychological responses to hazardous substances.
1999. Department of Health and Human Services, Atlanta. 
Vyner HM. Invisible trauma: psychosocial effects of invisible environmental
contaminants. Lexington, Massachu-setts: D.C. Heath; 1988. 
Couch SR, Kroll-Smith JS. Patterns of victimization and the chronic
technological disaster. In: Viano EC, editor. The victimology handbook. New
York: Garland Publishers; 1991. 
Edelstein, MR. Contaminated communities: the social and psychological
impact of residential toxic exposure. Boulder (Colorado): Westview Press;
1988. 
Baum A, Fleming I, Israel A, O'Keeffe MK. Symptoms of chronic stress
following a natural disaster and discovery of a human-made hazard. Environ
Behav 1992 May;24(3): 347-67. 
Baum A, Fleming I, Davidson LM. Natural disaster and technological
catastrophe. Environ Behav 1983 May; 15(3):333-54. 
Baum A, Fleming I. Implications of psychological research on stress and
technological accidents. Am Psychol 1993;48(6):665-72. 
Bowler RM, Megler D, Huel G, Cone JE. Psychological, psychosocial, and
psychophysiological sequelae in a community affected by a railroad chemical
disaster. J Trauma Stress 1994;7(4):1-24. 
Dayal HH, Baranowski T, Yi-hwei L, Morris R. Hazardous chemicals:
psychological dimensions of the health sequelae of a community exposure in
Texas. J Epidemiol Community Health 1994;48:560-8. 

[Table of Contents] 

ATSDR's Psychological Effects Program Addresses Stress-Related Health Concerns 

Pam Tucker, MD, ATSDR  

According to scientific and medical literature, people react in
psychologically unique ways to exposures to hazardous substances. Since the
discovery of toxic leachate in the basements of houses near Love Canal in
the 1970s, psychologists, psychiatrists, and social scientists have studied
the psychological responses in people exposed to hazardous substances
because of technological breakdowns. 

The psychological and social responses to possible exposure to
environmental hazards have many similarities to those seen in natural
disasters and emergencies. For both, event-related stress leads to
transient disturbances in many people and serious disorders, such as
anxiety and depression, in a few. In other words, "normal people reacting
normally to an abnormal situation." However, chronic stress can be
associated with life living near a hazardous waste site and can be
accompanied by "long-lasting elevations in blood pressure, evidence of
changes in immune-system function, persisting symptoms of post-traumatic
stress disorder (e.g., hyperarousal, frequent and bother-some intrusive
thoughts about the accident, and avoidance of reminders of it)" (1). These
possible health consequences, as well as others, and how stress contributes
to them still need further study. 

The Psychological Effects Program was developed by the Agency for Toxic
Substances and Disease Registry's (ATSDR's) Division of Health Education
and Promotion (DHEP) to address these possible stress-related health
concerns that may occur in communities near hazardous waste sites or in
communities that are exposed to a hazardous substance. 

The Psychological Effects Program has the following four phases:

Phase 1-define current science and practice; 
Phase 2-develop an action plan; 
Phase 3-implement a public health action plan; 
Phase 4-build capacity and evaluation efforts. 

In September 1995, the Program took its first step when ATSDR co-sponsored
with Emory University and the Connecticut Department of Health, an Expert
Panel Workshop on the Psychological Responses to Hazardous Substances (2).
Workshop participants included affected community members and social,
psychological, and neurological scientists. The participants were asked to
discuss an integrated approach to addressing the neurobiological,
psychological, and social health effects found in communities near
hazardous waste sites or following a chemical spill. They explored and
examined what is known about how communities and individuals respond
socially and psychologically to hazardous substances and the possible
effects of those responses on their health. 

The workshop used the holistic biopsychosocial model as its underpinning
philosophy. As opposed to the Cartesian dualistic model, which defines the
body as separate from the mind, this model assumes an intertwined,
inseparable entity that looks at a combination of biological,
sociocultural, and psychological factors as they interact and affect a
person's psychosocial and physical health. Therefore, not only were
physical factors (e.g., hazardous substances and their potential impact on
the nervous system) and the physiology of stress discussed, but also how
psychological coping skills and social influences operating at Superfund
sites can affect the health of both individuals and communities.

The workshop consisted of three panels and three sets of issues: Panel One,
Biomedical and Psychophysiological Effects, examined the possible
biological effects on the public's health related to the chronic stress in
communities near hazardous waste sites, as well as how to perform
neurobehavioral testing to determine if any observed neurological effects
are caused by chemical or stress effects on the nervous system. Panel Two,
Community and Social Science Perspectives, discussed how people respond
psychologically to exposures to hazardous waste and the influence of social
and cultural factors on community reactions. Panel Three, Protecting and
Promoting Psychosocial Health, began developing a framework for appropriate
public health strategies. Following is a more indepth discussion of panel
findings. 
Panel One: Biomedical and Psychophysiological Effects

Stress reactions have been studied in both individuals and communities near
hazardous waste sites, but the study of the full effect on the public's
health, in terms of specific disease outcomes, is still in the very early
stages. There is, however, much that is known about psychological stress
and how it affects health. Psychological stress causes both psychological
changes that can be measured by self-reports and objective tests as well as
physical changes, such as increased blood pressure, heart rate, and
biochemical parameters (e.g., changes in stress hormones). 

Panel One was charged with reviewing and discussing how health care
providers can clinically examine an exposed individual to determine if
health effects are the result of exposure to neurotoxic chemicals or from
stress. They found that careful history-taking is essential to ensure
differentiation of exposure to neurotoxic chemicals and/or the development
of stress-related health effects. 

Panel Two: Community and Social Science Perspectives

There are many reasons why psychosocial responses to hazardous substances
are unique. Unlike the damage and injury caused by a natural disaster, many
toxic substances are invisible to the senses, which results in feelings of
uncertainty about exposure and its extent. As well, because chemically
related health outcomes can be often delayed, there is difficulty in
relating past exposure to subsequent disease. Kroll-Smith and Couch have
stated that perhaps a primary reason technological disasters, as opposed to
natural disasters, diminish the long-term psychosocial health of victims is
because technological disasters, such toxic spills or releases, contaminate
(i.e., poison an environment) rather than visibly damage (3), crippling a
sense of long-term safety. They further state that this view is complicated
by the perception held by the individual experiencing the disaster and that
the individual's "behavior is shaped less by statistical probabilities of
danger than by the subjectively lived experiences of living under
objectively ambiguous circumstances (3).

Panel Two also emphasized the importance of the individual response (as did
all three panels) by outlining the unique aspects of the psychological and
social responses to toxic exposures and the reasons behind those responses.
Each person affected by a hazardous exposure develops his or her own
beliefs about the nature of the resultant harm. These beliefs develop from
the available facts, pre-existing opinions, cultural factors, sensory
clues, and beliefs of leaders and others in the community. Panel
participants determined that the viewpoint of the exposed person is crucial
to understanding the diverse reactions that can occur in affected
communities, that community members must be seen as experts on their
community, and that the majority of responses people have to toxic
substances are normal. 

Panel Three: Protecting and Promoting Psychosocial Health

The psychological research done on natural disasters and emergencies has
resulted in the development of specific issues to be addressed. In the case
of technological disasters, "the management of hazards, formulation of
regulations and guidelines for siting of potential hazards, construction of
environmental impact assessments, interpretation of responses following
accidents, and determination of post-accident damages" should, perhaps,
also be considered within this context (1). Panel Three participants were
asked to provide an overview of 1) what is known and not known about the
effectiveness of previous prevention strategies in affected communities; 2)
the most effective methods for preventing and mitigating stress-related
problems in communities near hazardous waste sites; and 3) methods for
increasing public and professional capacity to respond to psychological
issues related to hazardous waste sites. They based their suggestions for
solutions on their own past experiences with disaster relief work. 

The Panel members formulated the following suggestions for solutions:

Conduct a community needs assessment to ensure the community desires are
heard, 
Apply disaster mental health concepts to guide interventions, 
Implement relief work strategies used for natural disasters, and  
Work to ensure citizens have as much control as possible over their situation. 

Furthermore, Panel 3 emphasized the importance of community education
regarding the normality of psychosocial stress related to hazardous
substance exposure.

With the close of the workshop and the printing of the proceedings, Phase 1
of the completed. This is a first step in providing communities the
necessary information to help them cope with the stress of hazardous
substance exposure. In addition, as a result of the workshop, ATSDR is
developing a training handbook for health care providers, social workers,
and others to help them in their work with affected communities. (See the
next article for an update on the recent accomplishments of the
Psychological Effects Program.)

A limited number of published workshop proceedings, Report of the Expert
Panel Workshop on the Psychological Responses to Hazardous Substances, are
available for distribution. Please contact the ATSDR Information Center at
1-888- 42ATSDR for more information on how to obtain a copy of the report. 

References

1.  Baum A, Fleming I. Implications of psychological research on stress and
technological accidents. Am Psychol 1993;48(6):665-72. 

2.  Agency for Toxic Substances and Disease Registry, Report of the expert
panel workshop on the psychological responses to hazardous substances,
Division of Health Education and Promotion, Atlanta. U.S. Department of
Health and Human Services, 1999.

3.  Kroll-Smith JS, Couch SR. What is a disaster? An ecological-symbolic
approach to resolving the definitional debate. Int J Mass Emergencies and
Disasters 1991 Nov;9(3):355-66. 

[Table of Contents] 

ATSDR's Psychological Effects Program Activities 

1996 

Developed projects with communities to help them deal with temporary or
permanent relocation due to environmental contamination by hazardous
substances and provided training for social workers involved in the
relocation of hundreds of Gulf Coast residents during the methyl parathion
response. 

1997 

Developed a training module and provided training for public health
professionals to raise awareness and ability to respond to the
psychological and social responses of communities affected by hazardous
substances. 
Held, in cooperation with the Wisconsin Department of Health and the
residents of Douglas County, Wisconsin, a workshop on Emergencies in
Douglas County: Assessing Community Needs for the Future, in response to
the Burlington Northern railroad spill. The workshop provided ways to
improve emergency responses in the case of a future spill. Convened the
second expert panel workshop on psychological responses to exposure to
hazardous substances, The Feasibility of Measuring Stress Related to
Hazardous Waste, in Atlanta, Georgia.  Provided workshops to assist
communities with the chronic psychological effects of hazardous substances,
when requested by the community. 

1998 

Worked with the Missouri Department of Health and the Office of Regional
Operations (ATSDR) to develop a needs assessment on a community's needs and
desires for assistance with psychological effects. 

1999

Began a joint initiative, ATSDR-EPA Initiative Regarding Community Stress
Related to Hazardous Substances, involving ATSDR and the U.S. Environmental
Protection Agency (EPA) to train EPA personnel to increase their awareness
and ability to respond to community stress related to hazardous exposures.
Two trainings have already been held. The initiative will also pilot public
health responses in three sites over the next three years. Currently,
initiative representatives are participating in a relocation in New Jersey,
in a community-support network, which includes social workers to assist in
both permanent and temporary relocations. Another project is ongoing with
the Keystone community in Pennsylvania. 
Published the Report of the Expert Panel Workshop on the Psychological
Responses to Hazardous Substances. 

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