Pesticides initiative: basic training for health care providers.

Getting the U.S. health care world to adopt the tenets of the recently launched Pesticides Initiative may be a rough sell, according to participants at a June 2003 national forum to further the effort, held in Washington, D.C. Doctors and nurses have only so much time for continuing education, and competing educational priorities limit the interest in and knowledge of several environmental health issues. But the initiative is a campaign that the forum's 100-plus participants are committed to promoting, because they agree upon the importance of incorporating environmental health into primary care education and practice.

The U.S. Environmental Protection Agency (EPA) and the National Environmental Education & Training Foundation (NEETF), in collaboration with the Department of Health and Human Services, the Department of Agriculture, and the Department of Labor, developed the 10-year Pesticides Initiative. Unveiled last summer, the initiative will help bring basic training in environmental health to medical and nursing education by fostering curriculum development, faculty leadership, and incentives for teaching on the subjects of environmental health and pesticides. "The front line of health care is about being an educator, particularly with issues like the environment," asserts NEETF president Kevin Coyle.

A Call for Education

According to the 2001 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System, pesticides are one of the substances most frequently involved in poisonings, with more than 90,000 incidents reported for 2001. Although fatal pesticide poisoning is rare among the general population, with only 17 deaths reported in 2001, initiative advocates contend that many exposures are not tracked. There is also still the question of what the effects of low-level exposures might be, especially cumulatively. Children are of primary concern, as they are among the most vulnerable populations. Theories abound that pesticides may contribute to increasing rates of asthma, obesity, autism, and other diseases, as well as to subtle but serious dysfunction and adult-onset conditions such as Parkinson disease.

The goal of the initiative is to improve the way primary health care providers assess and respond to potential pesticide exposure cases in their daily practice. The Pesticides Initiative calls for all primary health care providers to acquire basic knowledge of the health effects of pesticides and the treatments and preventive strategies used to address those effects.

The Pesticides Initiative is "an excellent model to apply to other environmental health issues," says Leyla Erk McCurdy, senior director of NEETF. The implementation of the initiative will not only help primary health care providers address pesticides, but also, Coyle says, "practitioners and educators will have a larger understanding to address other kinds of exposures within the environment." For example, skills acquired to take medical histories from patients may be applied to diagnose and treat other environmentally induced health problems.

The First Line of Defense

General practitioners and nurses are the initiative's primary audience, because they are usually the first point of contact for patients, and they treat the most patients who may have been exposed to pesticides, says James Roberts, an assistant professor of pediatrics at the Medical University of South Carolina in Charleston. These caregivers need to know how to handle issues of identifying and treating pesticide and other environmental exposures.

"We have to raise awareness and acknowledge we're not going to ban pesticides tomorrow," says Katherine Kirkland, executive director of the Association of Occupational and Environmental Clinics. "[Pesticides are] going to be out there, and we need to bring practitioners, nurses, physicians, and others into thinking about [them]."

Currently, however, the vast majority of patients are seen by physicians who have no training in occupational or environmental medicine, says NIEHS director Kenneth Olden. "We can't prevent disease unless we deal with the issue of the environment," he says. Much work lies ahead to fill this knowledge gap.

The forum worked to build support for the initiative from stakeholders, create a national vision for environmental health outreach to health care providers, and develop a nationwide network of health care providers committed to incorporating environmental health into primary care education and practice. Specifically, participants developed strategies to help ensure that information on pesticides would be used by caregivers and would infiltrate the medical and nursing community.

Forum participants included representatives from health care provider organizations, credentialing bodies, academia, government agencies, primary care providers, and more. Many pledged to encourage implementation of the initiative by working with their professional associations, decision-making authorities, and practice settings to integrate pesticide-related content into curriculum and practice. For example, several individuals committed to seeking endorsements from national professional associations of the initiative's companion booklets--National Pesticide Competency Guidelines for Medical & Nursing Education and National Pesticide Practice Skills Guidelines for Medical & Nursing Practice, both published in January 2003 by NEETF.

Selling the Message

"Ken Olden's message is a great message: The future of medicine in this country and [other] developed nations is about understanding the interactions between environmental factors, behaviors, and genetics," says Daniel Goldstein, director of medical toxicology for Monsanto. "And that's the message that resonates with deans, with public officials, with people who make broader curriculum decisions. If you're going to [sell the idea of pesticide education], you really need to be selling a much broader program in environmental health. Pesticides can serve as the best-developed model of that."

Pesticide education alone may not interest caregivers, educators, and other concerned parties in incorporating environmental health into training and practice, Kirkland agrees. "What we need to do is integrate it into a bigger occupational and environmental program."

"A lot of this stuff will never trickle down unless we change marketing approaches," adds Amy Liebman, an environmental health specialist with the Migrant Clinician Network. She suggests emulating marketing strategies employed by other industries, such as pharmaceutical companies, which successfully target doctors through free samples, mailings, and other means to educate them about new products and get them to prescribe their drugs.

Forum participants generated specific recommendations for education and practice settings and for the development of resources and tools. Examples included pursuing consumer-based promotion of environmental health/pesticides messaging in tandem with caregiver continuing education, initiating discussion and coverage of the issue with leading physician and nursing societies, and creating educational opportunities through credentialing bodies and professional societies that influence providers' continuing education.

Shelley Davis, coexecutive director of the Farmworker Justice Fund, says there are gaps in the data on nationwide pesticide exposures that make addressing related health issues difficult. For example, clinical diagnostic tests are limited, as are efforts to track such exposures on a broader scale. "We really don't have good tools to identify when [exposures and poisonings] occur," says Davis. The health care community should advocate for better data and more accessible diagnostic tests.

"Some places could do a better job of integrating risk reduction into public health programs such as Head Start [which fosters healthy development in low-income children with the ultimate goal of preparing them for school] and other large programs that are the foundation of public health," says Patricia Butterfield, director of occupational health nursing at the University of Washington School of Nursing, who represented the American Association of Colleges of Nursing. "Sometimes a modest change in the provision of materials can help families make simple and commonsense decisions about risk reduction"--for example, choosing less toxic products or taking off their shoes before going into the home to prevent tracking pesticides in from the outdoors.

Besides working at the grassroots level, health care providers need to function as advocates for environmental health issues on many fronts. "We should also be concerned about the environmental justice and ethical issues related to pesticides and environmental health issues," says Bonnie Rogers, an associate professor of nursing and public health at the University of North Carolina School of Public Health. For example, exposures are worse in inner cities (where more pesticides may be used inside the home to control cockroaches and other vermin) and in migrant farm communities.

Following Up

Although the forum succeeded in obtaining commitments from important players--such as key nursing and occupational health associations--greater commitments need to be secured from pesticide manufacturers, Davis says: "We need to look to industry groups to be responsible stewards of their products." No such commitments were secured at the meeting, but Goldstein says industry generally supports the Pesticides Initiative.

NEETF will conduct a six-month follow-up survey to assess the progress that participants make on their commitments and the short-term goals of the forum. Forum leaders expect full implementation of the initiative will be a long-term national effort. A conference report will be available in the fall of 2003.

As Olden summed, when it comes to educating physicians and other primary health care providers about the environment, the NIEHS and like-minded institutions haven't had the impact they should have had. Full implementation of the Pesticides Initiative will reverse that trend, its promoters contend.

For More Information

National Strategies for Health Care Providers: Pesticides Initiative http://www.neetf.org/health/ providers/index.shtm