Confronting Environmental Racism

Characteristics of interventions that address racism in the United States and opportunities to integrate equity principles: a scoping review

BACKGROUND

As a driver of racial and health inequities, racism is deeply ingrained in the interconnected systems that affect health and well-being. Currently, no common frame is employed across researchers, interventionists, and funders to design, implement, and evaluate comprehensive interventions to address racism. Consequently, there is a need to examine the characteristics of interventions implemented in the United States that address racism across social and structural determinants of health and socio-ecological levels. Additionally, we utilized a Health Equity Action Research (HEART) framework to assess how interventions integrate equity principles.

METHODS

This scoping review examined the characteristics of multi-level interventions that addressed racism and appraised the interventions using a Health Equity Action Research frame. A comprehensive search strategy was conducted across nine electronic databases between 24 October 2022 through 15 November 2022. Records were included if they were available in English, discussed or evaluated a multi-level intervention or program conducted in the United States, and discussed or evaluated the intervention or program regarding the health and well-being of racialized and ethnically minoritized groups.

RESULTS

A total of 13,391 records were identified, of which 91 met the eligibility criteria and were included in the analysis. Most records reported the racialized group impacted by an intervention, of which the majority were racialized as African American or Black (n = 42) and Hispanic or Latino/a/x (n = 18). Eighty-one (89%) of interventions reported health outcomes and concentrated on the individual level. Most funders reported across the records, and 86 (51%) were a federal agency or department. A further 43 (25%) were private foundations, 12 (7%) were nonprofit organizations, 10 (6%) were private universities, and 4 (2%) were public universities. Regarding alignment with the HEART framework, 14% of interventions reported a mixed-methods approach, 45% reported community engagement, and less than 1% reported researcher self-reflection.

CONCLUSIONS

Most interventions prioritized people who are racialized as Black and report health outcomes. Since intervention designs, objectives, and methodological approaches vary, no standard frame defines racism and health equity. Applying the HEART framework offers a standard approach for interventionists and researchers to examine power, integrate community voice, and self-reflect to advance health equity.

The human health effects of unconventional oil and gas development (UOGD): A scoping review of epidemiologic studies

OBJECTIVE

Unconventional oil and gas development (UOGD, sometimes termed "fracking" or "hydraulic fracturing") is an industrial process to extract methane gas and/or oil deposits. Many chemicals used in UOGD have known adverse human health effects. Canada is a major producer of UOGD-derived gas with wells frequently located in and around rural and Indigenous communities. Our objective was to conduct a scoping review to identify the extent of research evidence assessing UOGD exposure-related health impacts, with an additional focus on Canadian studies.

METHODS

We included English- or French-language peer-reviewed epidemiologic studies (January 2000-December 2022) which measured exposure to UOGD chemicals directly or by proxy, and where health outcomes were plausibly caused by UOGD-related chemical exposure. Results synthesis was descriptive with results ordered by outcome and hierarchy of methodological approach.

SYNTHESIS

We identified 52 studies from nine jurisdictions. Only two were set in Canada. A majority (n = 27) used retrospective cohort and case-control designs. Almost half (n = 24) focused on birth outcomes, with a majority (n = 22) reporting one or more significant adverse associations of UOGD exposure with: low birthweight; small for gestational age; preterm birth; and one or more birth defects. Other studies identified adverse impacts including asthma (n = 7), respiratory (n = 13), cardiovascular (n = 6), childhood acute lymphocytic leukemia (n = 2), and all-cause mortality (n = 4).

CONCLUSION

There is a growing body of research, across different jurisdictions, reporting associations of UOGD with adverse health outcomes. Despite the rapid growth of UOGD, which is often located in remote, rural, and Indigenous communities, Canadian research on its effects on human health is remarkably sparse. There is a pressing need for additional evidence.

Sociodemographic inequities in the burden of carcinogenic industrial air emissions in the United States

BACKGROUND

Industrial facilities are not located uniformly across communities in the United States, but how the burden of exposure to carcinogenic air emissions may vary across population characteristics is unclear. We evaluated differences in carcinogenic industrial pollution among major sociodemographic groups in the United States and Puerto Rico.

METHODS

We evaluated cross-sectional associations of population characteristics including race and ethnicity, educational attainment, and poverty at the census tract level with point-source industrial emissions of 21 known human carcinogens using regulatory data from the US Environmental Protection Agency. Odds ratios and 95% confidence intervals comparing the highest emissions (tertile or quintile) to the referent group (zero emissions [ie, nonexposed]) for all sociodemographic characteristics were estimated using multinomial, population density-adjusted logistic regression models.

RESULTS

In 2018, approximately 7.4 million people lived in census tracts with nearly 12 million pounds of carcinogenic air releases. The odds of tracts having the greatest burden of benzene, 1,3-butadiene, ethylene oxide, formaldehyde, trichloroethylene, and nickel emissions compared with nonexposed were 10%-20% higher for African American populations, whereas White populations were up to 18% less likely to live in tracts with the highest emissions. Among Hispanic and Latino populations, odds were 16%-21% higher for benzene, 1,3-butadiene, and ethylene oxide. Populations experiencing poverty or with less than high school education were associated with up to 51% higher burden, irrespective of race and ethnicity.

CONCLUSIONS

Carcinogenic industrial emissions disproportionately impact African American and Hispanic and Latino populations and people with limited education or experiencing poverty thus representing a source of pollution that may contribute to observed cancer disparities.

Measuring Local-Area Racial Segregation for Medicare Hospital Admissions

Importance

Considerable racial segregation exists in US hospitals that cannot be explained by where patients live. Approaches to measuring such segregation are limited.

Objective

To measure how and where sorting of older Black patients to different hospitals occurs within the same health care market.

Design, Setting, and Participants

This retrospective cross-sectional study used 2019 Medicare claims data linked to geographic data. Hospital zip code markets were based on driving time. The local hospital segregation (LHS) index was defined as the difference between the racial composition of a hospital's admissions and the racial composition of the hospital's market. Assessed admissions were among US Medicare fee-for-service enrollees aged 65 or older living in the 48 contiguous states with at least 1 hospitalization in 2019 at a hospital with at least 200 hospitalizations. Data were analyzed from November 2022 to January 2024.

Exposure

Degree of residential segregation, ownership status, region, teaching hospital designation, and disproportionate share hospital status.

Main Outcomes and Measures

The LHS index by hospital and a regional LHS index by hospital referral region.

Results

In the sample of 1991 acute care hospitals, 4 870 252 patients (mean [SD] age, 77.7 [8.3] years; 2 822 006 [56.0%] female) were treated, including 11 435 American Indian or Alaska Native patients (0.2%), 129 376 Asian patients (2.6%), 597 564 Black patients (11.9%), 395 397 Hispanic patients (7.8), and 3 818 371 White patients (75.8%). In the sample, half of hospitalizations among Black patients occurred at 235 hospitals (11.8% of all hospitals); 878 hospitals (34.4%) exhibited a negative LHS score (ie, admitted fewer Black patients relative to their market area) while 1113 hospitals (45.0%) exhibited a positive LHS (ie, admitted more Black patients relative to their market area); of all hospitals, 79.4% exhibited racial admission patterns significantly different from their market. Hospital-level LHS was positively associated with government hospital status (coefficient, 0.24; 95% CI, 0.10 to 0.38), while New York, New York; Chicago, Illinois; and Detroit, Michigan, hospital referral regions exhibited the highest regional LHS measures, with hospital referral region LHS scores of 0.12, 0.16, and 0.21, respectively.

Conclusions and Relevance

In this cross-sectional study, a novel measure of LHS was developed to quantify the extent to which hospitals were admitting a representative proportion of Black patients relative to their market areas. A better understanding of hospital choice within neighborhoods would help to reduce racial inequities in health outcomes.

Broadening the Environmental Lens to Include Social and Structural Determinants of Women's Health Disparities

BACKGROUND

Due to the physical, metabolic, and hormonal changes before, during, and after pregnancy, women-defined here as people assigned female at birth-are particularly susceptible to environmental insults. Racism, a driving force of social determinants of health, exacerbates this susceptibility by affecting exposure to both chemical and nonchemical stressors to create women's health disparities.

OBJECTIVES

To better understand and address social and structural determinants of women's health disparities, the National Institute of Environmental Health Sciences (NIEHS) hosted a workshop focused on the environmental impacts on women's health disparities and reproductive health in April 2022. This commentary summarizes foundational research and unique insights shared by workshop participants, who emphasized the need to broaden the definition of the environment to include upstream social and structural determinants of health. We also summarize current challenges and recommendations, as discussed by workshop participants, to address women's environmental and reproductive health disparities.

DISCUSSION

The challenges related to women's health equity, as identified by workshop attendees, included developing research approaches to better capture the social and structural environment in both human and animal studies, integrating environmental health principles into clinical care, and implementing more inclusive publishing and funding approaches. Workshop participants discussed recommendations in each of these areas that encourage interdisciplinary collaboration among researchers, clinicians, funders, publishers, and community members. https://doi.org/10.1289/EHP12996.

Toward Advancing Precision Environmental Health: Developing a Customized Exposure Burden Score to PFAS Mixtures to Enable Equitable Comparisons Across Population Subgroups, Using Mixture Item Response Theory

Quantifying a person's cumulative exposure burden to per- and polyfluoroalkyl substances (PFAS) mixtures is important for risk assessment, biomonitoring, and reporting of results to participants. However, different people may be exposed to different sets of PFASs due to heterogeneity in the exposure sources and patterns. Applying a single measurement model for the entire population (e.g., by summing concentrations of all PFAS analytes) assumes that each PFAS analyte is equally informative to PFAS exposure burden for all individuals. This assumption may not hold if PFAS exposure sources systematically differ within the population. However, the sociodemographic, dietary, and behavioral characteristics that underlie systematic exposure differences may not be known, or may be due to a combination of these factors. Therefore, we used mixture item response theory, an unsupervised psychometrics and data science method, to develop a customized PFAS exposure burden scoring algorithm. This scoring algorithm ensures that PFAS burden scores can be equitably compared across population subgroups. We applied our methods to PFAS biomonitoring data from the United States National Health and Nutrition Examination Survey (2013-2018). Using mixture item response theory, we found that participants with higher household incomes had higher PFAS burden scores. Asian Americans had significantly higher PFAS burden compared with non-Hispanic Whites and other race/ethnicity groups. However, some disparities were masked when using summed PFAS concentrations as the exposure metric. This work demonstrates that our summary PFAS burden metric, accounting for sources of exposure variation, may be a more fair and informative estimate of PFAS exposure.

Toward Language Justice in Environmental Health Sciences in the United States: A Case for Spanish as a Language of Science

BACKGROUND

Increasingly, marginalized communities are disproportionately facing the worsening effects of environmental hazards, including air pollution, water pollution, and climate change. Language isolation and accessibility has been understudied as a determinant of health. Spanish, despite being the second-most common language in the United States with some 41.8 million speakers, has been neglected among environmental health scientists. Building capacity in high-quality Spanish-language science communication, both for scientific and nonscientific audiences, can yield improvements in health disparities research, public health literacy, international collaborations, and diversity and inclusion efforts.

OBJECTIVES

In this article, we discuss the context of language diversity in environmental health sciences and offer recommendations for improving science communication in Spanish.

DISCUSSION

English is currently the predominant language for scientific discourse, but Spanish and other non-English languages are routinely used by many environmental health science students and professionals, as well as much of the public. To more effectively conduct and communicate environmental health work in Spanish, we suggest that researchers and scientific institutions a) foster structural changes, b) train emerging scholars and support established researchers, c) tap into community ways of knowing, and d) leverage emerging technologies. https://doi.org/10.1289/EHP12306.

Geospatial Assessment of Racial/Ethnic Composition, Social Vulnerability, and Lead Water Service Lines in New York City

BACKGROUND

The state of New York expects to receive $ 115  million in 2022 alone from the U.S. Infrastructure Investment and Jobs Act to support the replacement of lead water service lines.

OBJECTIVES

Our objective was to determine the number and proportion of potential lead water service lines across New York City (NYC) and to evaluate the association between census tract-level racial/ethnic composition, housing vulnerability, and child lead exposure vulnerability with service line type (Potential Lead, Unknown) for n = 2,083 NYC tracts.

METHODS

We conducted a descriptive analysis assessing water service line material recorded in the NYC Department of Environmental Protection's Lead Service Line Location Coordinates database. We used conditional autoregressive Bayesian Poisson models to assess the relative risk [RR; median posterior estimates, and 95% credible interval (CrI)] of service line type per 20% higher proportion of residents in a given racial/ethnic group and per higher housing vulnerability and child lead exposure vulnerability index scores corresponding to the interquartile range. We also evaluated the associations in flexible natural cubic spline models.

RESULTS

Out of 854,672 residential service line records, 136,891 (16.0%) were Potential Lead, and 227,443 (26.6%) were Unknown. In fully adjusted models, higher proportions of Hispanic/Latino residents and higher child lead exposure vulnerability were associated with Potential Lead service lines in flexible spline models and linear models [RR = 1.15 (95% CrI: 1.11, 1.21) and RR = 1.11 (95% CrI: 1.02, 1.20), respectively]. Associations were modified by borough; Potential Lead service lines were associated with higher proportions of non-Hispanic White and non-Hispanic Asian residents in the Bronx and Manhattan, and with higher proportions of non-Hispanic Black residents in Queens.

DISCUSSION

NYC has a high number of Potential Lead and Unknown water service lines. Communities with a high proportion of Hispanic/Latino residents and those with children who are already highly vulnerable to lead exposures from numerous sources are disproportionately impacted by Potential Lead service lines. These findings can inform equitable service line replacement across New York state and NYC. https://doi.org/10.1289/EHP12276.

Structural racism, air pollution and the association with adverse birth outcomes in the United States: the value of examining intergenerational associations

Structurally racist policies and practices of the past are likely to be a driving factor in current day differences in exposure to air pollution and may contribute to observed racial and ethnic disparities in adverse birth outcomes in the United States (U.S.). Non-Hispanic Black women in the U.S. experience poorer health outcomes during pregnancy and throughout the life course compared to non-Hispanic White women. This disparity holds even among non-Hispanic Black women with higher socioeconomic status. Reasons for this finding remain unclear, but long-term environmental exposure, either historical exposure or both historical and ongoing exposure, may contribute. Structural racism likely contributes to differences in social and environmental exposures by race in the U.S. context, and these differences can affect health and wellbeing across multiple generations. In this paper, we briefly review current knowledge and recommendations on the study of race and structural racism in environmental epidemiology, specifically focused on air pollution. We describe a conceptual framework and opportunities to use existing historical data from multiple sources to evaluate multi-generational influences of air pollution and structurally racist policies on birth and other relevant health outcomes. Increased analysis of this kind of data is critical for our understanding of structural racism's impact on multiple factors, including environmental exposures and adverse health outcomes, and identifying how past policies can have enduring legacies in shaping health and well-being in the present day. The intended purpose of this manuscript is to provide an overview of the widespread reach of structural racism, its potential association with health disparities and a comprehensive approach in environmental health research that may be required to study and address these problems in the U.S. The collaborative and methodological approaches we highlight have the potential to identify modifiable factors that can lead to effective interventions for health equity.

Environmental Health: A Position Paper From the American College of Physicians

Environmental health refers to the health effects associated with environmental factors, such as air pollution, water contamination, and climate change. Environmental hazards are associated with poor outcomes in common diseases, including diabetes and heart disease. In this position paper, the American College of Physicians (ACP) seeks to inform physicians about environmental health and offers policymakers recommendations to reduce the adverse health consequences of climate change, improve air and water quality, reduce exposure to toxic substances, and address environmental injustice. ACP affirms that all communities, including people of color, people with low income, and marginalized populations, deserve to live in a healthy environment.

Developing an Exposure Burden Score for Chemical Mixtures Using Item Response Theory, with Applications to PFAS Mixtures

BACKGROUND

There are few existing methods to quantify total exposure burden to chemical mixtures, independent of a health outcome. A summary metric could be advantageous for use in biomonitoring, risk assessment, health risk calculators, and mediation models.

OBJECTIVE

We developed a novel exposure burden score method for chemical mixtures, applied it to estimate exposure burden to per- and polyfluoroalkyl substances (PFAS) mixtures, and estimated associations of PFAS burden scores with cardio-metabolic outcomes in the general U.S.

POPULATION

METHODS

We applied item response theory (IRT) to biomonitoring data from 1,915 children and adults 12-80 years of age in the 2017-2018 National Health and Examination Survey to quantify a latent PFAS burden score, using serum concentrations of eight measured PFAS biomarkers, each considered an "item." The premise of IRT is that through using both information about a participant's concentration of an individual PFAS biomarker, as well as their exposure patterns for the PFAS mixture, we can estimate the participant's latent PFAS exposure burden, independent of a health outcome. We used linear regression to estimate associations of the PFAS burden score with cardio-metabolic outcomes and compared our findings to results using summed PFAS concentrations as the exposure metric.

RESULTS

PFAS burden scores and summed PFAS concentrations had moderate-high correlation (ρ=0.75). Isomers of PFOS [n-perfluorooctane sulfonic acid (n-PFOS) and perfluoromethylheptane sulfonic acid isomers (Sm-PFOS)] were the most informative to the PFAS burden scores. PFAS burden scores and summed PFAS concentrations were both significantly associated with cardio-metabolic outcomes, but associations were generally closer to the null for summed PFAS concentrations vs. the PFAS burden score. Adjusted associations (95% CIs) with total cholesterol (in milligrams per deciliter) were 8.6 (95% CI: 5.2, 11.9) and 2.4 (95% CI: 0.5, 4.2) per interquartile range increase in the PFAS burden score and summed concentrations, respectively. Sensitivity analyses showed similar associations with cardio-metabolic outcomes when only a subset of PFAS biomarkers was used to estimate PFAS burden. In a validation study, associations between PFAS burden scores and cholesterol were consistent with primary analyses but null when using summed PFAS concentrations.

DISCUSSION

IRT offers a straightforward way to include exposure biomarkers with low detection frequencies and can reduce exposure measurement error. Further, IRT enables comparisons of exposure burden to chemical mixtures across studies even if they did not measure the exact same set of chemicals, which supports harmonization across studies and consortia. We provide an accompanying PFAS burden calculator (https://pfasburden.shinyapps.io/app_pfas_burden/), enabling researchers to calculate PFAS burden scores based on U.S. population exposure reference ranges. https://doi.org/10.1289/EHP10125.

Simulating toxicokinetic variability to identify susceptible and highly exposed populations

BACKGROUND

Toxicokinetic (TK) data needed for chemical risk assessment are not available for most chemicals. To support a greater number of chemicals, the U.S. Environmental Protection Agency (EPA) created the open-source R package "httk" (High Throughput ToxicoKinetics). The "httk" package provides functions and data tables for simulation and statistical analysis of chemical TK, including a population variability simulator that uses biometrics data from the National Health and Nutrition Examination Survey (NHANES).

OBJECTIVE

Here we modernize the "HTTK-Pop" population variability simulator based on the currently available data and literature. We provide explanations of the algorithms used by "httk" for variability simulation and uncertainty propagation.

METHODS

We updated and revised the population variability simulator in the "httk" package with the most recent NHANES biometrics (up to the 2017-18 NHANES cohort). Model equations describing glomerular filtration rate (GFR) were revised to more accurately represent physiology and population variability. The model output from the updated "httk" package was compared with the current version.

RESULTS

The revised population variability simulator in the "httk" package now provides refined, more relevant, and better justified estimations.

SIGNIFICANCE

Fulfilling the U.S. EPA's mission to provide open-source data and models for evaluations and applications by the broader scientific community, and continuously improving the accuracy of the "httk" package based on the currently available data and literature.

A comprehensive framework for operationalizing structural racism in health research: The association between mass incarceration of Black people in the U.S. and adverse birth outcomes

Structural racism represents a key determinant of the racial health disparities that has characterized the U.S. population throughout its existence. While this reality has recently begun to gain increasing acknowledgment and acceptance within the health sciences, there are still considerable challenges related to defining the concept of structural racism and operationalizing it in empirical study. In this paper, building on the existing evidence base, we propose a comprehensive framework that centers structural racism in terms of its historical roots and continued manifestation in most domains of society, and offer solutions for the study of this phenomenon and the pathways that connect it to population-level health disparities. We showcase our framework by applying it to the known link between spatial and racialized clustering of incarceration - a previously cited representation of structural racism - and disparities in adverse birth outcomes. Through this process we hypothesize pathways that focus on social cohesion and community-level chronic stress, community crime and police victimization, as well as infrastructural community disinvestment. First, we contextualize these mechanisms within the relevant extant literature. Then, we make recommendations for future empirical pathway analyses. Finally, we identify key areas for policy, community, and individual-level interventions that target the impact of concentrated incarceration on birth outcomes among Black people in the U.S.