Pollution and Global Health – An Agenda for Prevention

Air pollution and its impact on cancer incidence, cancer care and cancer outcomes

Air pollution is an under-recognised global health threat linked to an increased risk of cancers and is due primarily to the burning of fossil fuels. This review provides a high-level overview of the associations between outdoor and indoor air pollution and cancer risk and outcomes. Outdoor air pollutants are largely due to the burning of fossil fuels from human activities, although there is growing data implicating outdoor pollution from wildfire smoke. Indoor air pollution is primarily caused by burning solid fuel sources such as wood, coal and charcoal for household cooking and heating. There is a growing number of pieces of evidence linking exposure to pollution and the risk of developing cancers. The strongest evidence is seen on the positive association of air pollution, particularly particulate matter 2.5 with lung cancer. Emerging data implicate exposure to pollutants in the development of breast, gastrointestinal and other cancers. The mechanisms underlying these associations include oxidative stress, inflammation and direct DNA damage facilitated by pollutant absorption and distribution in the body. References were identified through a PubMed search for articles published in 2000 to October 2024 using the terms 'air pollution' or 'pollutants' and 'carcinoma' or ''cancer'. Air pollution poses significant risks to health. Its health impacts, including cancer risks, are often underestimated. Hazardous pollutants have been studied in several epidemiological cohort studies. Despite the mounting evidence, air pollution is often overlooked in predictive cancer risk models and public health intervention.

Energy choices to health outcomes: A multidimensional analysis of risk in BRICS via PMG-ARDL approach

This article employs a Panel Mean Group Autoregressive Distributed Lag (PMG-ARDL) approach to investigate the interaction between carbon dioxide (CO2) emissions, Gross Domestic Product (GDP), fossil fuel, renewable energy consumption, trade, and their collective impact on life expectancy within the BRICS nations. The research reveals compelling findings. Notably, CO2 emissions and trade openness exhibit negative and statistically significant impact on life expectancy. In contrast, GDP per capita and renewable energy consumption are positive and significant determinants of longer life expectancy. The nuanced outcomes underscore the complex interplay of economic, environmental, and social factors within the BRICS nations. The effects found by PMG-ARDL and FMOLS are very comparable, except for the trade openness' coefficients, which is the inverse. These findings hold significant implications for policy interpretation and sustainable development strategies. As nations struggle to balance economic growth and environmental improvement with public health, tailored interventions targeting CO2 reduction, trade openness, renewable energy, and GDP growth can collectively contribute to longer life expectancy. In a broader context, this research contributes to the global discourse on sustainability, economic improvement, and health issue.

Perspective on using non-human primates in Exposome research

The physiological and pathological changes in the human body caused by environmental pressures are collectively referred to as the Exposome. Human society is facing escalating environmental pollution, leading to a rising prevalence of associated diseases, including respiratory diseases, cardiovascular diseases, neurological disorders, reproductive development disorders, among others. Vulnerable populations to the pathogenic effects of environmental pollution include those in the prenatal, infancy, and elderly stages of life. Conducting Exposome mechanistic research and proposing effective health interventions are urgent in addressing the current severe environmental pollution. In this review, we address the core issues and bottlenecks faced by current Exposome research, specifically focusing on the most toxic ultrafine nanoparticles. We summarize multiple research models being used in Exposome research. Especially, we discuss the limitations of rodent animal models in mimicking human physiopathological phenotypes, and prospect advantages and necessity of non-human primates in Exposome research based on their evolutionary relatedness, anatomical and physiological similarities to human. Finally, we declare the initiation of NHPE (Non-Human Primate Exposome) project for conducting Exposome research using non-human primates and provide insights into its feasibility and key areas of focus. SYNOPSIS: Non-human primate models hold unique advantages in human Exposome research.

Development and child health in a world of synthetic chemicals

Chemical pollution is one of today's most significant threats to the developmental potential of children worldwide. Maternal exposure to toxicants can perturb sensitive windows of fetal development, indirectly through promoting antenatal disorders, abnormal placental adaptation, or directly through maternal-fetal transport. Current evidence clearly shows that persistent organic chemicals promote hypertensive disorders of pregnancy, placental abnormalities, and fetal growth restriction, whereas findings are less consistent for phthalates and bisphenols. Prospective birth cohorts strongly support a link between adverse neurodevelopmental outcomes and prenatal exposure to flame retardants and organophosphate pesticides. Emerging evidence reveals a potential association between in utero exposure to bisphenols and childhood behavioral disorders, while childhood metabolic health is more consistently associated with postnatal exposure to phthalates and bisphenols. IMPACT: Synthesizes emerging evidence linking modern forms of chemical pollution to antenatal disorders, fetal growth restriction and childhood disorders. Highlights potential developmental impacts of emerging pollutants of concern now ubiquitous in our environment but without regulatory restrictions.

Community Perceptions on Health Risks Associated With Toxic Chemical Pollutants in Kwekwe City, Zimbabwe: A Qualitative Study

Globally, environmental pollution continues to be a significant public health problem, and according to the World Health Organisation, pollution-induced deaths account for 23% of deaths yearly, which could be prevented if people lived in healthier environments. Despite implementing multilateral agreements and international treaties such as the Bamako, Basel, Rotterdam, Minamata, and Stockholm conventions, the United Nations Sustainable Development Goals, and national laws, toxic pollutants remain a serious environmental and public health problem in low-income countries. In the specific context of Kwekwe City, an industrial and mining area in Zimbabwe, where environmental and pollution-induced health problems associated with industries have been widely reported, this study was conducted in close collaboration with the local community. The study aimed to assess community members' perceptions regarding health risks associated with potentially toxic elements and cyanide pollution in Kwekwe City. An explorative cross-sectional study was conducted with key stakeholders and industrial settlements' residents. Face-to-face interviews with key informants and focus group discussions with residents and workers were used to gather data. A thematic approach was utilised in data analysis. Study participants, who played a crucial role in the research process, perceived that industrial pollution principally linked to cyanide, mercury and chromium posed significant environmental and health risks. This participatory approach in risk perception assessment is critical in providing insight into the scope of the problem and formulating intervention strategies. However, given that qualitative study results lack generalisability and replicability, quantitative studies need to be undertaken to determine environmental levels of toxic chemical pollutants as a complementary and validative measure.

Emerging contaminants: A One Health perspective

Environmental pollution is escalating due to rapid global development that often prioritizes human needs over planetary health. Despite global efforts to mitigate legacy pollutants, the continuous introduction of new substances remains a major threat to both people and the planet. In response, global initiatives are focusing on risk assessment and regulation of emerging contaminants, as demonstrated by the ongoing efforts to establish the UN's Intergovernmental Science-Policy Panel on Chemicals, Waste, and Pollution Prevention. This review identifies the sources and impacts of emerging contaminants on planetary health, emphasizing the importance of adopting a One Health approach. Strategies for monitoring and addressing these pollutants are discussed, underscoring the need for robust and socially equitable environmental policies at both regional and international levels. Urgent actions are needed to transition toward sustainable pollution management practices to safeguard our planet for future generations.

Pollutants, microbiota and immune system: frenemies within the gut

Pollution is a critical concern of modern society for its heterogeneous effects on human health, despite a widespread lack of awareness. Environmental pollutants promote several pathologies through different molecular mechanisms. Pollutants can affect the immune system and related pathways, perturbing its regulation and triggering pro-inflammatory responses. The exposure to several pollutants also leads to alterations in gut microbiota with a decreasing abundance of beneficial microbes, such as short-chain fatty acid-producing bacteria, and an overgrowth of pro-inflammatory species. The subsequent intestinal barrier dysfunction, together with oxidative stress and increased inflammatory responses, plays a role in the pathogenesis of gastrointestinal inflammatory diseases. Moreover, pollutants encourage the inflammation-dysplasia-carcinoma sequence through various mechanisms, such as oxidative stress, dysregulation of cellular signalling pathways, cell cycle impairment and genomic instability. In this narrative review, we will describe the interplay between pollutants, gut microbiota, and the immune system, focusing on their relationship with inflammatory bowel diseases and colorectal cancer. Understanding the biological mechanisms underlying the health-to-disease transition may allow the design of public health policies aimed at reducing the burden of disease related to pollutants.

Assessing the impact of water-sediment factors on water quality to guide river-connected lake water environment improvement

The substantial impacts of exogenous pollutants on lake water quality have been extensively reported. Water-sediment factors, which are essential for regulating water quality in river-connected lakes, have not been studied in depth under different hydrological conditions. This study has combined a 31-year water environmental dataset (1991-2021) regarding Dongting Lake and a vector autoregression model (VAR) in order to investigate the impulse response characteristics and contributions of water quality caused by water-sediment factors across different periods. Our analysis suggests that total nitrogen (TN) exhibited a significant increasing trend, whereas total phosphorus (TP) increased to 0.17 mg/L, and then decreased to 0.07 mg/L from 1991 to 2021. The inflow of suspended sediment discharge (SSD) decreased significantly during the study period, mainly because of the decrease in SSD in the three channels (TC). In the pre-Three Gorges Dam (TGD) period, water discharge (WD) and SSD were the Granger causes of TN and TP. In the post-TGD periods this relationship disappeared because of the construction of the TGD, which reduced the inflow of SSD and WD into the lake. Water quality indicators showed an instant response to the shock from themselves with high values, whereas the impulse response of the water quality to water-sediment factors exhibited lagged variations. This meant that the water quality indicators displayed a high impact by themselves across the different periods, with values varying from 67 % to 95 %. Water level (WL) and SSD were the predominant water-sediment factors for TP in the pre-TGD period, with the impact on TP changes accounting for 11 % and 9 %, respectively, whereas the contribution of SSD decreased to 2 % in the post-TGD period. WL was the most crucial water-sediment factor for CODMn during the different periods, with contributions varying from 17 % to 20 %. To improve the water quality of Dongting Lake, in addition to the implementation of strict controls on excessive external nutrient loading, regulating water-sediment factors according to the hydrological features of Dongting Lake during different periods is vital.

Environmental violence: a tool for planetary health research

From climate change to toxic pollution and the interactive effects of multiple pollution streams, human health is under siege. Human-produced environmental risks to health and wellbeing are high and contributing to patterns of global morbidity, mortality, economic inequality, displacement, and insecurity. The implications of human-produced environmental harms to global health are complex just as are their causes. The concept of environmental violence offers a potentially robust frame for engaging this issue. We argue that a more specified and structured framework and definition of environmental violence-focusing on human-produced harms by way of pollution emissions-is both timely and beneficial for engaging the complexities of global public health. To clarify why and how this is the case, we review the literature for publications that use the term environmental violence and we subsequently propose a specific definition focused on human-produced pollution along with a framework for tracking and analysing environmental violence and its constituent components. Finally, we discuss the potential value of our framework for research and policy making regarding human health.

Health risk management framework for heavy metals and cyanide in Kwekwe city of Zimbabwe: a mixed-method study protocol

BACKGROUND

According to WHO, in 2015, over 35% of ischaemic heart disease, the leading cause of death and disability worldwide, and about 42% of strokes, the second largest contributor to global mortality, could have been prevented by reducing or removing exposure to chemical pollutants. Heavy metal and cyanide pollution are prevalent in developing countries, especially in sub-Saharan Africa where the effects of industrial pollutants are more severe, partly due to poor regulation. In Zimbabwe, the mining industry alone contributed to 25% of occupational conditions and injuries in 2020. Therefore, to mitigate these problems, this study seeks to develop a health risk management framework for heavy metals and cyanide pollution in the industrial city of Kwekwe.

METHODS

The convergent parallel mixed-method study design will be utilised. Qualitative and quantitative data will be collected, analysed, and merged in order to inform the development of the risk framework. An analytical cross-sectional survey would be used to determine levels of heavy metals in surface water, soil, and vegetables. Free cyanide will be determined in surface water samples only. The phenomenological qualitative inquiry will be used to investigate health events and risks associated with potentially toxic pollutants (heavy metals and cyanide) to describe or interpret participants' lived experiences. The qualitative and quantitative results will be used to develop and validate the framework to manage identified health risks. For data analysis, statistical analysis will be used in the quantitative study, while thematic analysis will be used in the qualitative study. The study was approved by the University of Venda Ethics Committee (Registration Number FHS/22/PH/05/2306) and the Medical Research Council of Zimbabwe (Approval Number MRCZ/A/2944). All ethical principles will be adhered to throughout the study in accordance with the Helsinki Declaration.

DISCUSSION

While existing risk management frameworks have significantly contributed to human and environmental health protection, novel and comprehensive frameworks need to be developed to counter the ever-dynamic and evolving risks associated with chemical pollutants. If the management framework is successfully developed, it could offer an opportunity for the prevention and control of potentially toxic elements.

Exposome, Molecular Pathways and One Health: The Invertebrate Caenorhabditis elegans

Due to its preferred habitats in the environment, the free-living nematode Caenorhabditis elegans has become a realistic target organism for pollutants, including manufactured nanoparticles. In the laboratory, the invertebrate animal model represents a cost-effective tool to investigate the molecular mechanisms of the biological response to nanomaterials. With an estimated number of 22,000 coding genes and short life span of 2-3 weeks, the small worm is a giant when it comes to characterization of molecular pathways, long-term low dose pollutant effects and vulnerable age-groups. Here, we review (i) flows of manufactured nanomaterials and exposition of C. elegans in the environment, (ii) the track record of C. elegans in biomedical research, and (iii) its potential to contribute to the investigation of the exposome and bridge nanotoxicology between higher organisms, including humans. The role of C. elegans in the one health concept is taken one step further by proposing methods to sample wild nematodes and their molecular characterization by single worm proteomics.

Predicting the impacts of chemical pollutants on animal groups

Chemical pollution is among the fastest-growing agents of global change. Synthetic chemicals with diverse modes-of-action are being detected in the tissues of wildlife and pervade entire food webs. Although such pollutants can elicit a range of sublethal effects on individual organisms, research on how chemical pollutants affect animal groups is severely lacking. Here we synthesise research from two related, but largely segregated fields - ecotoxicology and behavioural ecology - to examine pathways by which chemical contaminants could disrupt processes that govern the emergence, self-organisation, and collective function of animal groups. Our review provides a roadmap for prioritising the study of chemical pollutants within the context of sociality and highlights important methodological advancements for future research.

Study on Lung Injury Caused by Fine Particulate Matter and Intervention Effect of Rhodiola wallichiana

Objective

The objective of this study was to observe the protective effect of Rhodiola wallichiana drops in a rat model of fine particulate matter (PM2.5) lung injury.

Methods

Forty male Wistar rats were randomly divided into blank control (NC), normal saline (NS), PM2.5-infected (PM), and Rhodiola wallichiana (RW) groups. Rats in the NC group were not provided any interventions, whereas those in the NS and PM groups were administered normal saline and PM2.5 suspension by trachea drip once a week for four weeks. Rats in the RW group were intraperitoneally administered Rhodiola wallichiana for 14 days and then administered PM2.5 suspension by trachea drip 7 days after drug delivery. The levels of inflammatory factors such as interleukin-6, interleukin-1β, and tumor necrosis factor-alpha and oxidative stress biomarkers such as 8-hydroxy-2′-deoxyguanosine, 4-hydroxynonenal, and protein carbonyl content were determined in the serum and bronchoalveolar lavage fluid by ELISA. The level of 4-hydroxynonenal in the lung was also determined using Western blotting and immunohistochemical staining.

Results

Levels of inflammatory factors and oxidative stress biomarkers were all increased in the PM group but decreased in the RW group. Western blotting revealed increased 4-hydroxynonenal levels in the PM group but decreased levels in the RW group. Immunohistochemical staining also provided similar results.

Conclusion

Rhodiola wallichiana could protect rats from inflammation and oxidative stress injury caused by PM2.5.

Human health impacts of exposure to phthalate plasticizers: An overview of reviews

In this review of reviews, we overview the current global body of available evidence from structured reviews of epidemiological studies that explore human health outcomes associated with exposure to phthalates (chemical plasticisers commonly found in plastics). We found robust evidence for an association with lower semen quality, neurodevelopment and risk of childhood asthma, and moderate to robust evidence for impact on anogenital distance in boys. We identified moderate evidence for an association between phthalates/metabolites and low birthweight, endometriosis, decreased testosterone, ADHD, Type 2 diabetes and breast/uterine cancer. There was some evidence for other outcomes including anofourchette distance, fetal sex hormones, pre-term birth, lower antral follicle count, reduced oestrodiol, autism, obesity, thyroid function and hearing disorders. We found no reviews of epidemiological human studies on the impact of phthalates from recycled plastics on human health. We recommend that future research should use urine samples as exposure measures, consider confounders in analyses and measure impacts on female reproductive systems. Our findings align with emerging research indicating that health risks can occur at exposure levels below the "safe dose" levels set out by regulators, and are of particular concern given potential additive or synergistic "cocktail effects" of chemicals. This raises important policy and regulatory issues for identifying and controlling plastics and health related impacts and highlights a need for more research into substances of concern entering plastics waste streams via recycling.

Endocrine disruptors of sex hormone activities

Sex hormones, such as androgens, estrogens and progestins are naturally occurring compounds that tightly regulate endocrine systems in a variety of living organisms. Uncontrolled environmental exposure to these hormones or their biological and synthetic mimetics has been widely documented. Furthermore, water contaminants penetrate soil to affect flora, fauna and ultimately humans. Because endocrine systems evolved to respond to very small changes in hormone levels, the low levels found in the environment cannot be ignored. The combined actions of sex hormones with glucocorticoids and other nuclear receptors disruptors creates additional level of complexity including the newly described "dynamic assisted loading" mechanism. We reviewed the extensive literature pertaining to world-wide detection of these disruptors and created a detailed Table on the development and current status of methods used for their analysis.

Exposure to particulate matter: a brief review with a focus on cardiovascular effects, children, and research conducted in Turkey

Exposure to environmental particulate matter (PM), outdoor air pollution in particular, has long been associated with adverse health effects. Today, PM has widely been accepted as a systemic toxicant showing adverse effects beyond the lungs. There are numerous studies, from those in vitro to epidemiological ones, suggesting various direct and indirect PM toxicity mechanisms associated with cardiovascular risks, including inflammatory responses, oxidative stress, changes in blood pressure, autonomic regulation of heart rate, suppression of endothelium-dependent vasodilation, thrombogenesis, myocardial infarction, and fibrinolysis. In addition to these and other health risks, considerations about air quality standards should include individual differences, lifestyle, and vulnerable populations such as children. Urban air pollution has been a major environmental issue for Turkey, and this review will also address current situation, research, and measures taken in our country.

Tissue-Protective Effect of Erdosteine on Multiple-Organ Injuries Induced by Fine Particulate Matter

Background

Fine particulate matter (PM2.5) is the air pollutant that most threatens global public health. The purpose of this study was to observe the inflammatory and oxidative stress injury of multiple organs induced by PM2.5 in rats and to explore the tissue-protective effect of erdosteine.

Material/Methods

We randomly divided 40 male Wistar rats into a blank control group, a saline group, a PM2.5 exposure group, and an erdosteine intervention group. We assessed changes in organs tissue homogenate and biomarkers of inflammation and oxidative stress in serum and bronchoalveolar lavage fluid (BALF).

Results

(1) The expressions of IL-6, IL-1β, TNF-α, 8-OHdG, 4-HNE, and PCC in serum and BALF of the PM2.5 exposure group increased, but decreased after treatment with erdosteine, suggesting that erdosteine treatment attenuates inflammatory and oxidative stress injury. (2) The expression of γ-GCS in serum and lungs in the PM2.5 exposure group increased, but did not change significantly after treatment with erdosteine. This suggests that PM2.5 upregulates the level of γ-GCS, while erdosteine does not affect this protective response. (3) The expression of T-AOC in serum, lungs, spleens, and kidneys of the PM2.5 exposure group decreased, but increased after treatment with erdosteine. Our results suggest that PM2.5 can cause imbalance of oxidation/anti-oxidation in multiple organs, and erdosteine can alleviate this imbalance.

Conclusions

PM2.5 exposure can lead to inflammatory and oxidative stress damage in serum and organ tissues of rats. Erdosteine may be an effective anti-inflammatory and antioxidant that can reduce this injury.

Pilot-scale expanded assessment of inorganic and organic tapwater exposures and predicted effects in Puerto Rico, USA

A pilot-scale expanded target assessment of mixtures of inorganic and organic contaminants in point-of-consumption drinking water (tapwater, TW) was conducted in Puerto Rico (PR) to continue to inform TW exposures and corresponding estimations of cumulative human-health risks across the US. In August 2018, a spatial synoptic pilot assessment of than 524 organic and 37 inorganic chemicals was conducted in 14 locations (7 home; 7 commercial) across PR. A follow-up 3-day temporal assessment of TW variability was conducted in December 2018 at two of the synoptic locations (1 home, 1 commercial) and included daily pre- and post-flush samples. Concentrations of regulated and unregulated TW contaminants were used to calculate cumulative in vitro bioactivity ratios and Hazard Indices (HI) based on existing human-health benchmarks. Synoptic results confirmed that human exposures to inorganic and organic contaminant mixtures, which are rarely monitored together in drinking water at the point of consumption, occurred across PR and consisted of elevated concentrations of inorganic contaminants (e.g., lead, copper), disinfection byproducts (DBP), and to a lesser extent per/polyfluoroalkyl substances (PFAS) and phthalates. Exceedances of human-health benchmarks in every synoptic TW sample support further investigation of the potential cumulative risk to vulnerable populations in PR and emphasize the importance of continued broad characterization of drinking-water exposures at the tap with analytical capabilities that better represent the complexity of both inorganic and organic contaminant mixtures known to occur in ambient source waters. Such health-based monitoring data are essential to support public engagement in source water sustainability and treatment and to inform consumer point-of-use treatment decision making in PR and throughout the US.

Global distribution and coincidence of pollution, climate impacts, and health risk in the Anthropocene

Previous research demonstrates that low-income countries face higher risks than high-income countries from toxic pollution and climate change. However, the relationship between these two risks is little explored or tested, and efforts to address the risks are often independent and uncoordinated. We argue that the global risks from toxic pollution and climate change are highly correlated and should be jointly analyzed in order to inform and better target efforts to reduce or mitigate both risks. We provide such analysis for 176 countries and found a strong (r_s = -0.798;95%CI -0.852, -0.727) and significant (p<0.0001) relationship between the distribution of climate risk and toxic pollution. We also found that inequities in pollution production, economic status, and institutional readiness are interconnected and exacerbate risk for countries already in the highest risk categories for both toxic and non-toxic (greenhouse gas) pollution. The findings have policy implications, including the use of the proposed Target assessment to decide where best to address toxic and non-toxic pollution simultaneously, based on the need to minimize human suffering and maximize return on effort.

Moving towards green anaesthesia: Are patient safety and environmentally friendly practices compatible? A focus on single-use devices

OBJECTIVE

Discuss if the use of disposable or reusable medical devices leads to a difference in terms of hospital-acquired infection or bacterial contamination. Determine which solution is less expensive and has less environmental impact in terms of carbon footprint, energy and water consumption and amount of waste.

METHODS

We carried out a narrative review. Articles published in English and French from January 2000 to April 2020 were identified from PubMed.

RESULTS

We retrieved 81 articles, including 12 randomised controlled trial, 21 literature reviews, 13 descriptive studies, 6 experimental studies, 9 life-cycle studies, 6 cohort studies, 2 meta-analysis, 4 case reports and 8 other studies. It appears that pathogen transmission in the anaesthesia work area is mainly due to the lack of hand hygiene among the anaesthesia team. The benefit of single-use devices on infectious risk is based on weak scientific arguments, while reusable devices have benefits in terms of costs, water consumption, energy consumption, waste, and reducing greenhouse gas emissions.

CONCLUSION

Disposable medical devices and attire in the operating theatre do not mitigate the infectious risk to the patients but have a greater environmental, financial and social impact than the reusable ones. This study is the first step towards recommendations for more environmental-friendly practices in the operating theatre.

Pollution, Inflammation, and Vaccines: A Complex Crosstalk

The importance of pollution in determining human health is becoming increasingly clear, also given the dramatic consequences it has had on recent geopolitical events. Yet, the consequences of contamination are not always straightforward. In this paper, we will discuss the effects of different pollutants on different aspects of human health, in particular on the immune system and inflammation. Different environmental pollutants can have different effects on the immune system, which can then promote complex pathologies, such as autoimmune disorders and cancer. The interaction with the microbiota also further helps to determine the consequences of contamination on wellbeing. The pollution can affect vaccination efficacy, given the widespread effects of vaccination on immunity. At the same time, some vaccinations also can exert protective effects against some forms of pollution.

The GEOHealth Hub for Eastern Africa: Contributions and Lessons Learned

Externalities, such as air pollution and increased occupational hazards, resulting from global trends in climate change, rapid industrialization, and rapidly increasing populations are raising global concerns about the associated health risks. The Global Environmental and Occupational Health Hub for Eastern Africa was established to address some of these problems at national and regional levels through focused training and applied research that would yield evidence supporting policies and investments to mitigate risks of increasing environmental threats throughout the Eastern African region. Emphasis has been placed on air pollution, a leading risk factor for global mortality, accounting for over 7 million premature deaths or 8.7% of the 2017 global mortality burden. Despite the enormous disease burden that air pollution causes, global investment in air pollution monitoring and research capacity building in low-middle and middle-income countries have been inadequate. This study outlines the activities the Hub has undertaken in planning for and carrying out its initial capacity building and building its primary research programs and identifies central lessons that can inform other large global research partnerships.

A Clustering Framework to Reveal the Structural Effect Mechanisms of Natural and Social Factors on PM2.5 Concentrations in China

Understanding the mechanisms of various factors that affect PM2.5 can assist in the development of scientific measures to improve air quality. Nevertheless, existing research has concentrated on exploring local effect mechanisms, while structural effect mechanisms at regional or national scales have scarcely been analysed. Consequently, this study presents an analytical framework for elucidating the structural effect mechanisms of associated factors on PM2.5. Geographically and temporally weighted regression was used to explore the local effect mechanisms. This was followed by spatial clustering analysis to reveal these mechanisms by detecting their aggregation patterns. In the analysis, datasets for annual mean PM2.5 and socio-economic factors in China from 1999 to 2016 were employed. Urban population, gross industrial output, and sulphur dioxide emissions were identified as factors affecting changes in PM2.5 concentrations. These three factors had both negative and positive effects, while the gross industrial output had the largest coefficient variation degree. Three geographically related factors exhibited different impacts on PM2.5 concentrations in most of mainland China. These factors were the urban population roughly west of the Heihe-Tengchong line, gross industrial output primarily in southwestern China, and sulphur dioxide emissions primarily in southern China.

High-Throughput UHPLC-MS/MS Measurement of Per- and Poly-Fluorinated Alkyl Substances in Human Serum

Per- and poly-fluorinated alkyl substances (PFASs) are a large group of synthetic surfactant chemicals with widespread uses in food packaging and textile manufacturing and as the main constituent of aqueous film-forming firefighting foams. PFASs are highly persistent in the environment, and human exposures are extensive with these chemicals detectable in the blood of almost all adult Americans. PFASs exhibit a range of toxic effects in preclinical models. In humans, PFAS exposure has been associated with lower birth weights, decreased immune responses, cancer and impaired fertility and elevated circulating cholesterol levels. We have developed a sensitive high-throughput method for quantification of representative PFAS in human serum and plasma for biomonitoring and epidemiological studies of human health effects of PFAS exposure. The method combines robust and reproducible 96-well plate format sample preparation with ultra-performance liquid chromatography-tandem mass spectrometry. The method was developed, validated and used for targeted measurements of eight short-/long-chain PFAS analytes in human serum. Targeted analytes were measured in 50 microliters of sample using mass-labeled internal standards. Mean spiked recoveries (n = 10) of target analytes for three tiers quality control (QC-low, QC-medium, QC-high) samples ranged from 70 to 127% with 2-14% relative standard deviation (RSD). The average spiked recoveries (n = 10) of surrogates were 79-115% with 8-12% RSD for QC-low, 90-123% with 7-12% RSD for QC-medium and 82-114% with 9-15% RSD for QC-high. The limit of detection for the target compounds was 0.05-0.04 ng/mL. The method was used to reveal regional differences in PFAS exposures in Kentucky residents receiving care at the University of Kentucky Hospitals.

Short-term exposure to ambient air quality of the most polluted Indian cities due to lockdown amid SARS-CoV-2

Air pollution has happened to be one of the mounting alarms to be concerned with in many Indian cities. COVID-19 epidemic endow with a unique opportunity to report the degree of air quality improvement due to the nationwide lockdown in 10 most polluted cities across the country. National Air Quality Index (NAQI) based on continuous monitoring records of seven criteria pollutants (i.e. common air pollutants with known health impacts e.g. PM₁₀, PM_2.5, CO, NO₂, SO₂, NH₃ and O₃) for a total of 59 stations across the cities, satellite image derived Aerosol Optical Depth (AOD) and few statistical tools are employed to derive the outcomes. NAQI results convey that 8 cities out of the 10 air quality restored to good to satisfactory category during the lockdown period. Within week+1 of the lockdown period, PM₁₀ and PM_2.5 concentrations have suppressed below the permissible limit in all cities. CO and NO₂ have reduced to about -30% and -57% respectively during the lockdown period. Diurnal concentrations of PM₁₀ and PM_2.5 have dropped drastically on the very 4th day of lockdown and become consistent with minor hourly vacillation. In April 2020 the AOD amount was reduced to about 36% and 18% in contrast to April 2018 and April 2019 respectively. This add-on reporting of the possible recovery extent in air quality may help to guide alternative policy intervention in form of short term lockdown so as to testify whether this type of unconventional policy decisions may be put forward to attain a green environment. Because, despite numerous restoration plans, air pollution levels have risen unabated in these cities. However, detailed inventory needs to be focused on identifying the localized pollution hotspots (i.e. source contribution).

The global and national burden of chronic kidney disease attributable to ambient fine particulate matter air pollution: a modelling study

Introduction

We aimed to integrate all available epidemiological evidence to characterise an exposure-response model of ambient fine particulate matter (PM2.5) and the risk of chronic kidney disease (CKD) across the spectrum of PM2.5 concentrations experienced by humans. We then estimated the global and national burden of CKD attributable to PM2.5.

Methods

We collected data from prior studies on the association of PM2.5 with CKD and used an integrative meta-regression approach to build non-linear exposure-response models of the risk of CKD associated with PM2.5 exposure. We then estimated the 2017 global and national incidence, prevalence, disability-adjusted life-years (DALYs) and deaths due to CKD attributable to PM2.5 in 194 countries and territories. Burden estimates were generated by linkage of risk estimates to Global Burden of Disease study datasets.

Results

The exposure-response function exhibited evidence of an increase in risk with increasing PM2.5 concentrations, where the rate of risk increase gradually attenuated at higher PM2.5 concentrations. Globally, in 2017, there were 3 284 358.2 (95% UI 2 800 710.5 to 3 747 046.1) incident and 122 409 460.2 (108 142 312.2 to 136 424 137.9) prevalent cases of CKD attributable to PM2.5, and 6 593 134.6 (5 705 180.4 to 7 479 818.4) DALYs and 211 019.2 (184 292.5 to 236 520.4) deaths due to CKD attributable to PM2.5. The burden was disproportionately borne by low income and lower middle income countries and exhibited substantial geographic variability, even among countries with similar levels of sociodemographic development. Globally, 72.8% of prevalent cases of CKD attributable to PM2.5 and 74.2% of DALYs due to CKD attributable to PM2.5 were due to concentrations above 10 µg/m3, the WHO air quality guidelines.

Conclusion

The global burden of CKD attributable to PM2.5 is substantial, varies by geography and is disproportionally borne by disadvantaged countries. Most of the burden is associated with PM2.5 levels above the WHO guidelines, suggesting that achieving those targets may yield reduction in CKD burden.

Diabetes Minimally Mediated the Association Between PM2.5 Air Pollution and Kidney Outcomes

Epidemiologic observations suggest that exposure to ambient fine particulate matter (PM_2.5) is associated with increased risk of chronic kidney disease (CKD) and diabetes, a causal driver of CKD. We evaluated whether diabetes mediates the association between PM_2.5 and CKD. A cohort of 2,444,157 United States veterans were followed over a median 8.5 years. Environmental Protection Agency data provided PM_2.5 exposure levels_. Regression models assessed associations and their proportion mediated. A 10 µg/m³ increase in PM_2.5 was associated with increased odds of having a diabetes diagnosis (odds ratio: 1.18, 95% CI: 1.06–1.32), use of diabetes medication (1.22, 1.07–1.39), and increased risk of incident eGFR <60 ml/min/1.73 m² (hazard ratio:1.20, 95% CI: 1.13–1.29), incident CKD (1.28, 1.18–1.39), ≥30% decline in eGFR (1.23, 1.15–1.33), and end-stage renal disease (ESRD) or ≥50% decline in eGFR (1.17, 1.05–1.30). Diabetes mediated 4.7% (4.3–5.7%) of the association of PM_2.5 with incident eGFR <60 ml/min/1.73 m², 4.8% (4.2–5.8%) with incident CKD, 5.8% (5.0–7.0%) with ≥30% decline in eGFR, and 17.0% (13.1–20.4%) with ESRD or ≥50% decline in eGFR. Diabetes minimally mediated the association between PM_2.5 and kidney outcomes. The findings will help inform more accurate estimates of the burden of diabetes and burden of kidney disease attributable to PM_2.5 pollution.

Metallothionein 2A gene polymorphisms in relation to diseases and trace element levels in humans

Human metallothioneins are a superfamily of low molecular weight intracellular proteins, whose synthesis can be induced by essential elements (primarily Zn and Cu), toxic elements and chemical agents, and stress-producing conditions. Of the four known isoforms in the human body MT2 is the most common. The expression of metallothioneins is encoded by a multigene family of linked genes and can be influenced by single nucleotide polymorphisms (SNPs) in these genes. To date, 24 SNPs in the MT2A gene have been identified with the incidence of about 1 % in various population groups, and three of them were shown to affect physiological and pathophysiological processes. This review summarises current knowledge about these three SNPs in the MT2A gene and their associations with element concentrations in the body of healthy and diseased persons. The most investigated SNP is rs28366003 (MT2A -5 A/G). Reports associate it with longevity, cancer (breast, prostate, laryngeal, and in paranasal sinuses), and chronic renal disease. The second most investigated SNP, rs10636 (MT2A +838G/C), is associated with breast cancer, cardiovascular disease, and type 2 diabetes. Both are also associated with several metal/metalloid concentrations in the organism. The third SNP, rs1610216 (MT2A -209A/G), has been studied for association with type 2 diabetes, cardiomyopathy, hyperglycaemia, and Zn concentrations. Metallothionein concentrations and MT2A polymorphisms have a potential to be used as biomarkers of metal exposure and clinical markers of a number of chronic diseases. This potential needs to be studied and verified in a large number of well-defined groups of participants (several hundreds and thousands) with a focus on particular physiological or pathological condition and taking into consideration other contributing factors, such as environmental exposure and individual genetic and epigenetic makeup.

Principles of problem-based learning for training and professional practice in ecotoxicology

Problem-based learning (PBL) is a protagonist of constructivism widely used successfully in higher education. PBL is a learner-centered instructional and curricular approach that can use real problems for the development of the teaching and learning process. On the other hand, the complexity of knowledge of Ecotoxicology, as well as the importance of this field for Environmental Health and society demand reflections and proposals for the training of professionals who work in this field. Therefore, in accordance with the principles of PBL, this strategy can effectively contribute to the training and professional practice of ecotoxicologists. We report herein the importance of the principles of PBL for the training of ecotoxicologists, including the discussion of a case study using fish biomarkers for the development of this teaching strategy. Teaching ecotoxicology through PBL principles allowed students to develop several advantages for Ecotoxicology training through the discussion of an authentic, real life problem that engaged them in its discussion, functioning as a stimulus for learning. The students were able to develop laboratory skills, group work competences, understand basic concepts and fundamentals of Ecotoxicology and become empowered regarding skills and competences for future practice.

Hydroquinone exposure alters the morphology of lymphoid organs in vaccinated C57Bl/6 mice

The influenza is a common viral infection that can be fatal, especially in high-risk groups such as children, pregnant women, elderly, and immune-deficient individuals. Vaccination is the most efficient approach to prevent the spreading of viral infection and promote individual and public health. In contrast, exposure to environmental pollutants such as cigarette smoke reduces the efficacy of vaccination. We investigated whether chronic exposure to hydroquinone (HQ), the most abundant compound of the tobacco particulate phase, could impair the adaptive immune responses elicited by influenza vaccination. For this, adult male C57BL/6 mice were daily exposed to either nebulized HQ or PBS for 1 h for a total of eight weeks. At weeks 6 and 8, the mice were primed and boosted with the trivalent influenza vaccine via IM respectively. Although the HQ exposure did not alter the body weight of the mice and the biochemical and hematological parameters, the pollutant increased the oxidative stress in splenocytes of immunized animals, modified the morphology of spleen follicles, and augmented the size of their lymph nodes. The lymphoid organs of HQ-exposed mice presented a similar number of vaccine-specific IgG-secreting cells, titers of vaccine-specific total IgG, and respective subclasses. Transcriptome studies with HQ, benzene, or cigarette smoke exposure were also analyzed. The genes up-regulated upon pollutant exposure were associated with neutrophil migration and were shown to be co-expressed with antibody-secreting cell genes. Therefore, these findings suggest that HQ exposure may trigger an immune-compensatory mechanism that enhances the humoral responses induced by influenza vaccination.

Women exposure to household air pollution after an improved cookstove program in rural San Luis Potosi, Mexico

The state government of San Luis Potosí (SLP), Mexico implemented an improved cookstove (ICS) program in rural areas. As part of the comprehensive program evaluation, we compared fine particulate material (PM_2.5) concentrations in kitchens and patios in treated (TH), and non-treated households (NTH), and analyzed pollutant levels according to patterns of fuels and devices use reported by the women. A panel study was conducted in 728 households (357 TH and 371 NTH) in three regions of SLP including two sampling rounds in 2015-16. Data on exposure determinants, ICS conditions and cooking practices were collected. Daily PM_2.5 in kitchen and patio was measured in a subsample. The average treatment effect was estimated using the double difference method. We constructed a mixed linear model to estimate PM_2.5 levels for the entire study sample and obtained personal exposure according to time-activity logs. NTH had lower socioeconomic status compared to TH. The average daily PM_2.5 concentrations in NTH compared to TH were 155.2 and 92.6 μg/m³ for kitchen and 35.4 and 39.8 μg/m³ for patio, respectively. PM_2.5 levels showed significant regional differences but no significant treatment effect. In many cases, the ICS was added to previous open fire and LPG use (stacking). The household size, kitchen ventilation, relative humidity, temperature and the ratio of indoor/outdoor PM_2.5 concentration were significant predictors of kitchen PM_2.5 levels. The daily PM_2.5 personal exposure was significantly reduced using ICS in good conditions or LPG (57 μg/m³) compared to the traditional open fire (86 μg/m³). This study strengthens the evidence on the potential daily PM_2.5 exposure reduction for women using an ICS in good conditions or LPG, displacing the polluting open fire. Comprehensive strategies tailored to the sociocultural context of the communities are needed to implement clean energy programs that achieve adoption and sustained use of ICS or LPG.

Proatherogenic Importance of Carbamylation-induced Protein Damage and Type 2 Diabetes Mellitus: A Systematic Review

INTRODUCTION & BACKGROUND

Protein carbamylation is a non-enzymatic and irreversible posttranslational process. It affects functions of numerous enzymes, hormones and receptors playing several roles in diabetes pathogenesis by changing their native structures. Detrimental consequences of oxidative protein damage comprise, but are not limited to glyoxidation, lipoxidation and carbonylation reactions. Since the carbamylated plasma proteins are strongly related to the glycemic control parameters of diabetes, they may have an additive value and emerge as potential biomarkers for the follow up, prognosis and treatment of diabetes mellitus.

METHODS & RESULTS

To conduct our systematic review, we used PubMed and Semantic Scholar, and used 'Protein carbamylation and diabetes' and 'Protein carbamylation and atherosclerosis' as keywords and looked into about five hundred manuscripts. Manuscripts that are not in English were excluded as well as manuscripts that did not mention carbamylation to maintain the focus of the present article. Similar to glycation, carbamylation is able to alter functions of plasma proteins and their interactions with endothelial cells and has been shown to be involved in the development of atherosclerosis.

CONCLUSION

At this stage, it seems clear that protein carbamylation leads to worse clinical outcomes. To improve patient care, but maybe more importantly to improve healthcare-prevention, we believe the next stage involves understanding how exactly protein carbamylation leads to worse outcomes and when and in what group of people anti-carbamylation therapies must be employed.

THE EXPOSOME IN HUMAN EVOLUTION: FROM DUST TO DIESEL

Global exposures to air pollution and cigarette smoke are novel in human evolutionary history and are associated with about 16 million premature deaths per year. We investigate the history of the human exposome for relationships between novel environmental toxins and genetic changes during human evolution in six phases. Phase I: With increased walking on savannas, early human ancestors inhaled crustal dust, fecal aerosols, and spores; carrion scavenging introduced new infectious pathogens. Phase II: Domestic fire exposed early Homo to novel toxins from smoke and cooking. Phases III and IV: Neolithic to preindustrial Homo sapiens incurred infectious pathogens from domestic animals and dense communities with limited sanitation. Phase V: Industrialization introduced novel toxins from fossil fuels, industrial chemicals, and tobacco at the same time infectious pathogens were diminishing. Thereby, pathogen-driven causes of mortality were replaced by chronic diseases driven by sterile inflammogens, exogenous and endogenous. Phase VI: Considers future health during global warming with increased air pollution and infections. We hypothesize that adaptation to some ancient toxins persists in genetic variations associated with inflammation and longevity.

Improving and Expanding Estimates of the Global Burden of Disease Due to Environmental Health Risk Factors

BACKGROUND

The Global Burden of Disease (GBD) study, coordinated by the Institute for Health Metrics and Evaluation (IHME), produces influential, data-driven estimates of the burden of disease and premature death due to major risk factors. Expanded quantification of disease due to environmental health (EH) risk factors, including climate change, will enhance accuracy of GBD estimates, which will contribute to developing cost-effective policies that promote prevention and achieving Sustainable Development Goals.

OBJECTIVES

We review key aspects of the GBD for the EH community and introduce the Global Burden of Disease-Pollution and Health Initiative (GBD-PHI), which aims to work with IHME and the GBD study to improve estimates of disease burden attributable to EH risk factors and to develop an innovative approach to estimating climate-related disease burden-both current and projected.

METHODS

We discuss strategies for improving GBD quantification of specific EH risk factors, including air pollution, lead, and climate change. We highlight key methodological challenges, including new EH risk factors, notably evidence rating and global exposure assessment.

DISCUSSION

A number of issues present challenges to the scope and accuracy of current GBD estimates for EH risk factors. For air pollution, minimal data exist on the exposure-risk relationships associated with high levels of pollution; epidemiological studies in high pollution regions should be a research priority. For lead, the GBD's current methods do not fully account for lead's impact on neurodevelopment; innovative methods to account for subclinical effects are needed. Decisions on inclusion of additional EH risk-outcome pairs need to be guided by findings of systematic reviews, the size of exposed populations, feasibility of global exposure estimates, and predicted trends in exposures and diseases. Neurotoxicants, endocrine-disrupting chemicals, and climate-related factors should be high priorities for incorporation into upcoming iterations of the GBD study. Enhancing the scope and methods will improve the GBD's estimates and better guide prevention policy. https://doi.org/10.1289/EHP5496.

Prenatal air pollution and childhood IQ: Preliminary evidence of effect modification by folate

OBJECTIVES

Animal studies suggest that air pollution is neurotoxic to a developing fetus, but evidence in humans is limited. We tested the hypothesis that higher air pollution is associated with lower child IQ and that effects vary by maternal and child characteristics, including prenatal nutrition.

METHODS

We used prospective data collected from the Conditions Affecting Neurocognitive Development and Learning in Early Childhood study. Outdoor pollutant exposure during pregnancy was predicted at geocoded home addresses using a validated national universal kriging model that combines ground-based monitoring data with an extensive database of land-use covariates. Distance to nearest major roadway was also used as a proxy for traffic-related pollution. Our primary outcome was full-scale IQ measured at age 4-6. In regression models, we adjusted for multiple determinants of child neurodevelopment and assessed interactions between air pollutants and child sex, race, socioeconomic status, reported nutrition, and maternal plasma folate in second trimester.

RESULTS

In our analytic sample (N = 1005) full-scale IQ averaged 2.5 points (95% CI: 0.1, 4.8) lower per 5 μg/m³ higher prenatal PM₁₀, while no associations with nitrogen dioxide or road proximity were observed. Associations between PM₁₀ and IQ were modified by maternal plasma folate (p_interaction = 0.07). In the lowest folate quartile, IQ decreased 6.8 points (95% CI: 1.4, 12.3) per 5-unit increase in PM₁₀; no associations were observed in higher quartiles.

CONCLUSIONS

Our findings strengthen evidence that air pollution impairs fetal neurodevelopment and suggest a potentially important role of maternal folate in modifying these effects.

Assessing heavy metal pollution in paddy soil from coal mining area, Anhui, China

Heavy metal pollution in agricultural soil has negative impact on crop quality and eventually on human health. A total of 24 top soil samples were collected from paddy field near the Zhangji Coal Mine in Huainan City, Anhui Province. Seven heavy metals (Cu, Zn, As, Cr, Cd, Pb, and Ni) were selected to evaluate the pollution status through total content and chemical speciation, geo-accumulation index (I_geo), and risk assessment code (RAC) and investigate leaching behavior of heavy metals under simulated rainfall. The results of present study indicated that mining activities were responsible for elevated Cu and Cd in surrounding paddy soil. Based on the results of chemical speciation, most heavy metals were associated with the residual fraction, and the environmental risk of heavy metals in soil was sequenced as Pb > Cd > Ni > As > Zn > Cu > Cr. It revealed that Pb in soil would pose a higher environmental risk due to its higher reducible fraction, then followed by Cd, Ni, As, and Zn, which would pose a medium risk. The result of simulated rainfall leaching analysis showed that heavy metals could be categorized into two groups: concentrations of Cu, Ni, Cd, Zn, and Cr in the leachates displayed a continuous decrease tendency with the increase in accumulative simulated rain volume; whereas leachable tendency of As and Pb was enhanced with increasing leaching time and rain volume. Generally, the leaching percentage of heavy metals followed the sequence of As > Zn > Ni > Cd > Cr > Cu > Pb. More attention should be paid to the higher environmental risk of Pb and higher leaching percentage of As with regard to ecosystem safety and human health.

Association between Outdoor Air Pollution and Childhood Leukemia: A Systematic Review and Dose-Response Meta-Analysis

BACKGROUND

A causal link between outdoor air pollution and childhood leukemia has been proposed, but some older studies suffer from methodological drawbacks. To the best of our knowledge, no systematic reviews have summarized the most recently published evidence and no analyses have examined the dose-response relation.

OBJECTIVE

We investigated the extent to which outdoor air pollution, especially as resulting from traffic-related contaminants, affects the risk of childhood leukemia.

METHODS

We searched all case-control and cohort studies that have investigated the risk of childhood leukemia in relation to exposure either to motorized traffic and related contaminants, based on various traffic-related metrics (number of vehicles in the closest roads, road density, and distance from major roads), or to measured or modeled levels of air contaminants such as benzene, nitrogen dioxide, 1,3-butadiene, and particulate matter. We carried out a meta-analysis of all eligible studies, including nine studies published since the last systematic review and, when possible, we fit a dose-response curve using a restricted cubic spline regression model.

RESULTS

We found 29 studies eligible to be included in our review. In the dose-response analysis, we found little association between disease risk and traffic indicators near the child's residence for most of the exposure range, with an indication of a possible excess risk only at the highest levels. In contrast, benzene exposure was positively and approximately linearly associated with risk of childhood leukemia, particularly for acute myeloid leukemia, among children under 6 y of age, and when exposure assessment at the time of diagnosis was used. Exposure to nitrogen dioxide showed little association with leukemia risk except at the highest levels.

DISCUSSION

Overall, the epidemiologic literature appears to support an association between benzene and childhood leukemia risk, with no indication of any threshold effect. A role for other measured and unmeasured pollutants from motorized traffic is also possible. https://doi.org/10.1289/EHP4381.

Air pollution and kidney disease: review of current evidence

Along with amazing technological advances, the industrial revolution of the mid-19th century introduced new sources of pollution. By the mid-20th century, the effects of these changes were beginning to be felt around the world. Among these changes, health problems due to environmental air pollution are increasingly recognized. At the beginning, respiratory and cardiovascular diseases were emphasized. However, accumulated data indicate that every organ system in the body may be involved, and the kidney is no exception. Although research on air pollution and kidney damage is recent, there is now scientific evidence that air pollution harms the kidney. In this holistic review, we have summarized the epidemiology, disease states and mechanisms of air pollution and kidney damage.

Lead Exposure in Low and Middle-Income Countries: Perspectives and Lessons on Patterns, Injustices, Economics, and Politics

Lead exposure is a legacy issue that continues to affect vulnerable population groups globally, but particularly in low and middle-income countries (LMICS). We take a multi-disciplinary approach to examine the patterns of lead exposure in these countries, discuss the underlying injustices and socio-political causes, and the economic costs that are associated with exposure. We conclude with some lessons we drew from our discussion of lead across the disciplines and advocate for a number of approaches to solving this ongoing issue. These include (i) biomonitoring that could be integrated into existing health surveys or public health programs targeting young children; (ii) greater civic engagement to push for solutions; and, (iii) environmental control policies that represent a continuum of local, context-specific to broad, national-level, and even global approaches.