Community Engaged Cumulative Risk Assessment of Exposure to Inorganic Well Water Contaminants, Crow Reservation, Montana

Geospatial analysis of toxic metal contamination in groundwater and associated health risks in the lower Himalayan industrial region

Once known for its clean and natural environment, the lower Himalayan region is now no exception to human-induced disturbances. Rapid industrial growth in Baddi-Barotiwala (BB) industrial region has led to degradation of groundwater resources in the area. Groundwater samples were collected from 37 locations to study the groundwater chemistry, geospatial variation of 15 toxic metals in groundwater, source apportionment, metals of concern and associated health risks in the region. The results showed rock dominated hydrogeology with decreasing order of anion and cation abundance as HCO3- > Cl- > SO42- > NO3- > Br- > F- and Ca+ > Na+ > Mg2+ > K+ > Li+ respectively. Concentrations of Iron (BDL-3.6 mg/l), Nickel (BDL-0.023 mg/l), Barium (0.22-0.89 mg/l), Lead (0.0001-0.085 mg/l) and Zinc (0.006-21.4 mg/l) were found above the permissible limits at few locations. Principal component analysis (PCA) and coefficient of variance (CV) showed both geogenic and anthropogenic origin of metals in groundwater of the BB industrial region. A consistent concentration of Uranium was detected at all the sampling locations with an average value of 0.0039 mg/l and poor spatial variation indicating its natural presence. Overall, non-carcinogenic (N-CR) risk in the study area via oral pathway was high for adults and children (Hazard Index > 1) with geogenic Uranium as the major contributor (Hazard Quotient > 1) followed by Zinc, Lead and Cobalt. Carcinogenic (CR) risk in the region was high for adults having mean value above the threshold (1E-04) with Nickel and Chromium as the metals of major concern. Spatial variation of health risks was overlayed on village boundaries of the region to identify the potential industrial sources of the metals of major concern. The results highlight the need for immediate remediation of groundwater resources in order to achieve a harmonious coexistence between industrialization and human well-being.

Exploring practices, challenges, and priorities for human health and ecological risk assessments in Indigenous communities in Canada

Indigenous peoples in Canada are disproportionately exposed to environmental contaminants and may face elevated health risks related to their unique cultural, spiritual, and economic relationships with the land, including the use of traditional food systems. However, to date, institutionalized approaches to assess risks to human and ecological health from contaminants have not been well developed or implemented with Indigenous community contexts in mind. There is regulatory interest in developing new approach methods for risk assessment, and thus an opportunity to increase their relevance to Indigenous communities in which they will be ultimately applied. Therefore, we conducted an anonymous mixed-methods survey of those involved with risk assessment in Indigenous communities in Canada to: (1) understand risk assessment practice in Indigenous communities, (2) explore challenges with conventional assessment methods and compare these across sectors, and (3) gather perspectives on the development of new approaches. In all, 38 completed survey responses were received (14% response rate). Respondents were from Indigenous community environment and health offices (21% of respondents), Indigenous governments (8%), federal and provincial governments (21%), and academia (45%). Risk communication was seen as the most challenging part of risk assessment (71% responded "difficult"), and nearly all respondents agreed that time (86%), cost (76%), and resource availability (86%) were "moderate" to "serious" problems. Few respondents (16%) had heard of "new approach methods" for risk assessment, and 76% of respondents (and 100% of community-based respondents) agreed on the need to develop improved risk assessment approaches. To modernize risk assessment, respondents recommended advancing cumulative risk assessment methods, improving risk communication, and promoting Indigenous leadership and Traditional Knowledge in assessment activities. Integr Environ Assess Manag 2024;00:1-16. © 2024 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

[Environmental risks and health literacy: a systematic review]

BACKGROUND

Environmental factors can play an important role in pathogenesis. However, the understanding of the relationship between environmental risks and health in the general population appears to be poor. The aim of this systematic review is to describe the state of research on the relationship between health literacy (HL) or environmental health literacy (EHL) and environmental risks differentiated by the researched environmental risks, the affected population, the measurement and level of HL or EHL, and their interaction with other variables.

METHODS

A systematic literature search was conducted using the Pubmed, Scopus, and LIVIVO databases. Original studies in German or English that investigated HL or EHL in the context of an environmental risk or pollutant in a population were included. The Navigation Guide was used to assess the methodological quality of the studies.

RESULTS

Twenty-four studies were included in the qualitative analysis. The operationalization of HL or EHL was heterogeneous in 22 studies. Nine studies referred to environmental issues in general, and 15 studies analyzed individual environmental risks. Eleven studies referred to the general population, 12 to specified target groups, and 1 study examined both. The level of HL or EHL proved to be in need of improvement in all populations. Interventions such as trainings were able to increase HL or EHL.

DISCUSSION

The heterogeneous operationalizations impede the comparability of the studies. Future work should target the standardization of methodological aspects. Overall, it appears that interventions such as trainings were conducive to improving HL or EHL. In practice, this should therefore be given greater focus in order to increase HL or EHL.

Methods in Public Health Environmental Justice Research: a Scoping Review from 2018 to 2021

PURPOSE OF REVIEW

The volume of public health environmental justice (EJ) research produced by academic institutions increased through 2022. However, the methods used for evaluating EJ in exposure science and epidemiologic studies have not been catalogued. Here, we completed a scoping review of EJ studies published in 19 environmental science and epidemiologic journals from 2018 to 2021 to summarize research types, frameworks, and methods.

RECENT FINDINGS

We identified 402 articles that included populations with health disparities as a part of EJ research question and met other inclusion criteria. Most studies (60%) evaluated EJ questions related to socioeconomic status (SES) or race/ethnicity. EJ studies took place in 69 countries, led by the US (n = 246 [61%]). Only 50% of studies explicitly described a theoretical EJ framework in the background, methods, or discussion and just 10% explicitly stated a framework in all three sections. Among exposure studies, the most common area-level exposure was air pollution (40%), whereas chemicals predominated personal exposure studies (35%). Overall, the most common method used for exposure-only EJ analyses was main effect regression modeling (50%); for epidemiologic studies the most common method was effect modification (58%), where an analysis evaluated a health disparity variable as an effect modifier. Based on the results of this scoping review, current methods in public health EJ studies could be bolstered by integrating expertise from other fields (e.g., sociology), conducting community-based participatory research and intervention studies, and using more rigorous, theory-based, and solution-oriented statistical research methods.

Behavioral determinants of arsenic-safe water use among Great Plains Indian Nation private well users: results from the Community-Led Strong Heart Water Study Arsenic Mitigation Program

BACKGROUND

The objective of this study was to evaluate the behavioral determinants associated with exclusive use of arsenic-safe water in the community-led Strong Heart Water Study (SHWS) arsenic mitigation program.

METHODS

The SHWS is a randomized controlled trial of a community-led arsenic mitigation program designed to reduce arsenic exposure among private well users in American Indian Great Plains communities. All households received point-of-use (POU) arsenic filters installed at baseline and were followed for 2 years. Behavioral determinants selected were those targeted during the development of the SHWS program, and were assessed at baseline and follow-up.

RESULTS

Among participants, exclusive use of arsenic-safe water for drinking and cooking at follow-up was associated with higher self-efficacy for accessing local resources to learn about arsenic (OR: 5.19, 95% CI: 1.48-18.21) and higher self-efficacy to resolve challenges related to arsenic in water using local resources (OR: 3.11, 95% CI: 1.11-8.71). Higher commitment to use the POU arsenic filter faucet at baseline was also a significant predictor of exclusive arsenic-safe water use for drinking (OR: 32.57, 95% CI: 1.42-746.70) and cooking (OR: 15.90, 95% CI: 1.33-189.52) at follow-up. From baseline to follow-up, the SHWS program significantly increased perceived vulnerability to arsenic exposure, self-efficacy, descriptive norms, and injunctive norms. Changing one's arsenic filter cartridge after installation was associated with higher self-efficacy to obtain arsenic-safe water for drinking (OR: 6.22, 95% CI: 1.33-29.07) and cooking (OR: 10.65, 95% CI: 2.48-45.68) and higher perceived vulnerability of personal health effects (OR: 7.79, 95% CI: 1.17-51.98) from drinking arsenic-unsafe water.

CONCLUSIONS

The community-led SHWS program conducted a theory-driven approach for intervention development and evaluation that allowed for behavioral determinants to be identified that were associated with the use of arsenic safe water and changing one's arsenic filter cartridge. These results demonstrate that theory-driven, context-specific formative research can influence behavior change interventions to reduce water arsenic exposure. The SHWS can serve as a model for the design of theory-driven intervention approaches that engage communities to reduce arsenic exposure.

TRIAL REGISTRATION

The SHWS is registered with ClinicalTrials.gov (Identifier: NCT03725592).

A Current Review of Water Pollutants in American Continent: Trends and Perspectives in Detection, Health Risks, and Treatment Technologies

Currently, water pollution represents a serious environmental threat, causing an impact not only to fauna and flora but also to human health. Among these pollutants, inorganic and organic pollutants are predominantly important representing high toxicity and persistence and being difficult to treat using current methodologies. For this reason, several research groups are searching for strategies to detect and remedy contaminated water bodies and effluents. Due to the above, a current review of the state of the situation has been carried out. The results obtained show that in the American continent a high diversity of contaminants is present in the water bodies affecting several aspects, in which in some cases, there exists alternatives to realize the remediation of contaminated water. It is concluded that the actual challenge is to establish sanitation measures at the local level based on the specific needs of the geographical area of interest. Therefore, water treatment plants must be designed according to the contaminants present in the water of the region and tailored to the needs of the population of interest.

Assessment of groundwater potability and health risk due to fluoride and nitrate in groundwater of Churu District of Rajasthan, India

The availability of potable drinking water is a tough challenge particularly in arid and semiarid regions as it is closely linked to human health. Fluoride and nitrate are widely reported concern in different districts of Rajasthan. Therefore, this study was engaged in the Churu District of Rajasthan to appraise the water quality especially in reference to fluoride and nitrate and health risk associated with its consumption. The overall potability of water was evaluated using water quality index and PCA indicated major sources responsible for water contamination. A total of 515 groundwater samples were collected from different locations of Churu District and16 water quality parameters were analyzed as per the standard protocol of APHA. The results showed that the values for all analyzed water quality parameters were greater than the prescribed limit of WHO and BIS. F^- levels in 191 samples and nitrate levels in 147 samples were found to be over than BIS-acceptable limit. The results of the fluoride and nitrate risk assessment revealed that the Hazard Index value was greater than one of 393 groundwater samples for males, 403 groundwater samples for females, and 397 groundwater samples for children, indicating that drinking groundwater poses a significant health risk in the study area. Only 46.02 percent of groundwater samples may be utilized for drinking, according to the water quality index (WQI), while the remaining are unfit for drinking purpose without treatment. The huge number of variables impacting the overall quality and chemistry of groundwater were reduced using principal component analysis (PCA), which identified four key components that account for 69.11 percent of variance in the dataset. The PCA indicated that both geogenic and anthropogenic factors significantly influenced the water quality of the study region.

Addressing systemic problems with exposure assessments to protect the public's health

BACKGROUND

Understanding, characterizing, and quantifying human exposures to environmental chemicals is critical to protect public health. Exposure assessments are key to determining risks to the general population and for specific subpopulations given that exposures differ between groups. Exposure data are also important for understanding where interventions, including public policies, should be targeted and the extent to which interventions have been successful. In this review, we aim to show how inadequacies in exposure assessments conducted by polluting industries or regulatory agencies have led to downplaying or disregarding exposure concerns raised by communities; that underestimates of exposure can lead regulatory agencies to conclude that unacceptable risks are, instead, acceptable, allowing pollutants to go unregulated; and that researchers, risk assessors, and policy makers need to better understand the issues that have affected exposure assessments and how appropriate use of exposure data can contribute to health-protective decisions.

METHODS

We describe current approaches used by regulatory agencies to estimate human exposures to environmental chemicals, including approaches to address limitations in exposure data. We then illustrate how some exposure assessments have been used to reach flawed conclusions about environmental chemicals and make recommendations for improvements.

RESULTS

Exposure data are important for communities, public health advocates, scientists, policy makers, and other groups to understand the extent of environmental exposures in diverse populations. We identify four areas where exposure assessments need to be improved due to systemic sources of error or uncertainty in exposure assessments and illustrate these areas with examples. These include: (1) an inability of regulatory agencies to keep pace with the increasing number of chemicals registered for use or assess their exposures, as well as complications added by use of 'confidential business information' which reduce available exposure data; (2) the failure to keep assessments up-to-date; (3) how inadequate assumptions about human behaviors and co-exposures contribute to underestimates of exposure; and (4) that insufficient models of toxicokinetics similarly affect exposure estimates.

CONCLUSION

We identified key issues that impact capacity to conduct scientifically robust exposure assessments. These issues must be addressed with scientific or policy approaches to improve estimates of exposure and protect public health.

Fluoride and nitrate in groundwater: a comprehensive analysis of health risk and potability of groundwater of Jhunjhunu district of Rajasthan, India

Groundwater contamination is a major concern in front of the scientific community because it is directly related to human health, especially in arid and semi-arid regions. Therefore, a comprehensive study was engaged to evaluate the water quality, potability, and human health risk assessment due to the consumption of fluoride- and nitrate-contaminated water in Jhunjhunu district of Rajasthan. In order to assess the water quality, samples were collected from 87 locations in the study region, and a total of 16 parameters were analyzed as per the standard methods. The results showed that the value of the number of quality parameters consisting of pH, EC, TDS, fluoride, chloride, nitrate, sulfate, total hardness, calcium, magnesium, and total alkalinity was higher than the recommended limit of BIS and WHO. The fluoride in 11% and nitrate in 6% of samples were observed to exceed the permissible limit of WHO. The results of risk assessment due to fluoride and nitrate revealed that hazard index values of 71% of groundwater samples for males, 78% of groundwater samples for females, and 75% of groundwater samples for children were greater than 1, indicating the significant health hazard due to consumption of groundwater. The water quality index (WQI) found that 39% of groundwater samples belong to categories that cannot be used for drinking purposes. Principal component analysis (PCA) reduced the large number of variables affecting the overall quality and chemistry of groundwater and determined four major components which account for 69.50% variance in the data. PCA concluded that both geogenic and anthropogenic sources of contamination influenced the groundwater of the study area.

Toxic Substances Control Act (TSCA) Implementation: How the Amended Law Has Failed to Protect Vulnerable Populations from Toxic Chemicals in the United States

Exposures to industrial chemicals are widespread and can increase the risk of adverse health effects such as cancer, developmental disorders, respiratory effects, diabetes, and reproductive problems. The amended Toxic Substances Control Act (amended TSCA) requires the U.S. Environmental Protection Agency (EPA) to evaluate risks of chemicals in commerce, account for risk to potentially exposed and susceptible populations, and mitigate risks for chemicals determined to pose an unreasonable risk to human health and the environment. This analysis compares EPA's first 10 chemical risk evaluations under amended TSCA to best scientific practices for conducting risk assessments. We find EPA's risk evaluations underestimated human health risks of chemical exposures by excluding conditions of use and exposure pathways; not considering aggregate exposure and cumulative risk; not identifying all potentially exposed or susceptible subpopulations, and not quantifying differences in risk for susceptible groups; not addressing data gaps; and using flawed systematic review approaches to identify and evaluate the relevant evidence. We present specific recommendations for improving the implementation of amended TSCA using the best available science to ensure equitable, socially just safeguards to public health. Failing to remedy these shortcomings will result in continued systematic underestimation of risk for all chemicals evaluated under amended TSCA.

Water Quality from the Sources of Non-Centralized Water Supply within the Rural Settlements of Zhytomyr Region

The research was conducted within the territories of rural settlements of Zhytomyr region. A total of 72 sources of non-centralized water supply were surveyed. Water quality was assessed by physical and chemical (pH, iron total, total water hardness) and toxicological (nitrites, nitrates, and ammonium) indicators, the content of which was compared with the norms given in the State Sanitary Regulations and Standards 2.2.4-171-10 “Hygienic Requirements for Drinking Water Intended for Human Consumption.” The assessment of drinking water quality was carried out in accordance with DSTU (National Standards of Ukraine) 4808:2007 and with the water quality index (WQI). It was found that the largest deviations from the norm among toxicological indicators were observed for nitrates – 63.9%. In terms of water quality classes according to DSTU 4808:2007, drinking water from sources of non-centralized water supply of villages showed the following distribution: 2.8% of the samples belonged to class 1 (excellent water quality), 72.2% to class 2, and 25% to class 3. According to WQI, 16.7% of the examined sources of non-centralized water supply had excellent water, 63.9% had good water, and 19.4% had poor water. Despite the fact that the water from the investigated sources of non-centralized water supply was of acceptable quality, it is impotable due to the excessive nitrate content. The results obtained show that there is a need for monitoring of drinking water quality from the sources of non-centralized water supply, especially in rural settlements that are not provided with centralized water supply.

Knowledge and Beliefs Associated with Environmental Health Literacy: A Case Study Focused on Toxic Metals Contamination of Well Water

Environmental health literacy (EHL) is developing as a framework that can inform educational interventions designed to facilitate individual and collective action to protect health, yet EHL measurement poses several challenges. While some studies have measured environmental health knowledge resulting from interventions, few have incorporated skills and self-efficacy. In this study, a process-focused EHL instrument was developed, using the Newest Vital Sign (NVS) health literacy instrument as a model and tailoring it for the context of private well contamination with toxic metals. Forty-seven (47) participants, including undergraduate students and residents of communities with contaminated well water, piloted a prototype EHL instrument alongside NVS. Results suggested a moderate degree of correlation between NVS and the EHL prototype, and significant differences in scores were observed between students and residents. Responses to a self-efficacy survey, tailored for drinking water contaminated with arsenic, revealed significant differences between students and residents on items related to cost and distance. In response to open-ended questions, participants identified a range of potential environmental contaminants in drinking water and deemed varied information sources as reliable. This study highlights differences in knowledge and self-efficacy among students and residents and raises questions about the adequacy of EHL assessments that mimic formal education approaches.

The widespread and unjust drinking water and clean water crisis in the United States

Many households in the United States face issues of incomplete plumbing and poor water quality. Prior scholarship on this issue has focused on one dimension of water hardship at a time, leaving the full picture incomplete. Here we complete this picture by documenting the full scope of water hardship in the United States and find evidence of a regionally-clustered, socially unequal nationwide household water crisis. Using data from the American Community Survey and the Environmental Protection Agency, we show there are 489,836 households lacking complete plumbing, 1,165 community water systems in Safe Drinking Water Act Serious Violation, and 21,035 Clean Water Act permittees in Significant Noncompliance. Further, we demonstrate this crisis is regionally clustered, with the specific spatial pattern varying by the specific form of water hardship. Elevated levels of water hardship are associated with the social dimensions of rurality, poverty, indigeneity, education, and age—representing a nationwide environmental injustice.

Proper water and sanitation access remains an issue for many in the United States. Here the authors estimate and map the full scope of water hardship, including both incomplete plumbing and water quality across the country.

Our Relationship to Water and Experience of Water Insecurity among Apsáalooke (Crow Indian) People, Montana

Affordable access to safe drinking water is essential to community health, yet there is limited understanding of water insecurity among Native Americans. Therefore, the focus of this paper is to describe Apsáalooke (Crow Indian) tribal members' experiences with water insecurity. For Apsáalooke people, local rivers and springs are still vitally important for traditional cultural activities. We interviewed 30 Native American adults living on the Crow Reservation in Southeastern Montana. Participants answered six open-ended interview questions about their water access, costs of obtaining water and changes in their domestic and traditional water uses. Participants emphasized how the use of water has changed over time and described the complex challenges associated with addressing water insecurity in their community, including the importance of considering the spiritual and cultural impacts of water insecurity on health. Water insecurity is a growing global problem and more attention and efforts are needed to find appropriate and affordable solutions.

Differential response of human T-lymphocytes to arsenic and uranium

Elevated levels of arsenic and uranium have been detected in water sources near abandoned uranium mines in the Southwest. Evidence suggests uranium exposure increases the likelihood of immune dysfunction and this study investigates the impact of arsenic and uranium on human immune cell lines. Concentration-dependent cytotoxicity occurred following exposure to arsenite, whereas cells remained viable after 48 -h treatment with up to 100 μM uranyl acetate despite uptake of uranium into cells. Arsenite stimulated an oxidative stress response as detected by Nrf-2 nuclear accumulation and induction of HMOX-1 and NQO1, which was not detected with up to 30 μM uranyl acetate. Cellular oxidative stress can promote DNA damage and arsenite, but not uranium, stimulated DNA damage as measured by pH2AX. Arsenic enhanced the cytotoxic response to etoposide suggesting an inhibition of DNA repair, unlike uranium. Similarly, uranium did not inhibit PARP-1 activity. Because uranium reportedly stimulates oxidative stress, DNA damage and cytotoxicity in adherent epithelial cells, the current study suggests distinct cell type differences in response to uranium that may relate to generation of oxidative stress and associated downstream consequences. Delineating the actions of uranium across different cell targets will be important for understanding the potential health effects of uranium exposures.

Metagenomic Profiling of Microbial Pathogens in the Little Bighorn River, Montana

The Little Bighorn River is the primary source of water for water treatment plants serving the local Crow Agency population, and has special significance in the spiritual and ceremonial life of the Crow tribe. Unfortunately, the watershed suffers from impaired water quality, with high counts of fecal coliform bacteria routinely measured during run-off events. A metagenomic analysis was carried out to identify potential pathogens in the river water. The Oxford Nanopore MinION platform was used to sequence DNA in near real time to identify both uncultured and a coliform-enriched culture of microbes collected from a popular summer swimming area of the Little Bighorn River. Sequences were analyzed using CosmosID bioinformatics and, in agreement with previous studies, enterohemorrhagic and enteropathogenic Escherichia coli and other E. coli pathotypes were identified. Noteworthy was detection and identification of enteroaggregative E. coli O104:H4 and Vibrio cholerae serotype O1 El Tor, however, cholera toxin genes were not identified. Other pathogenic microbes, as well as virulence genes and antimicrobial resistance markers, were also identified and characterized by metagenomic analyses. It is concluded that metagenomics provides a useful and potentially routine tool for identifying in an in-depth manner microbial contamination of waterways and, thereby, protecting public health.

Guardians of the Living Water: Using a Health Literacy Framework to Evaluate a Child as Change Agent Intervention

BACKGROUND

American Indian communities in the United States experience considerable health inequities, including increased exposure to environmental contaminants. Consequently, community members of the Apsáalooke (Crow) Nation identified the lack of water-related environmental knowledge among children as an area of concern.

AIM

The purpose of this study was to provide a feasibility evaluation of an increasingly sophisticated environmental health literacy program for children.

METHOD

A community-academic partnership developed and piloted the Guardians of the Living Water program to increase environmental health literacy among children and their families on the Crow reservation. Nutbeam's framework for health literacy, a schema based on functional, interactive, and critical literacy, shaped the program evaluation. We used a within-subjects, quasi-experimental design without a control group. Interviews with children and parents were used to assess the feasibility of the program, while pre-/posttests assessed changes in knowledge, skills, and behavior.

RESULTS

Compared with preintervention responses, those from postintervention indicated significant increases for selected knowledge and attitude components. Based on qualitative interviews with children and caregivers, the camp was a valuable experience and increased knowledge of water quality science and reinforced cultural knowledge.

DISCUSSION

This success of our program stems from the trust initially built between partners and then expanded throughout the community. The program and the evaluation benefited from both the health literacy framework and from our integration of Apsáalooke values.

CONCLUSION

Our findings suggest that a community-based intervention designed to increase environmental health literacy among youth and their social networks is feasible and acceptable to this American Indian community.

Challenges and Opportunities for Tribal Waters: Addressing Disparities in Safe Public Drinking Water on the Crow Reservation in Montana, USA

Disparities in access to safe public drinking water are increasingly being recognized as contributing to health disparities and environmental injustice for vulnerable communities in the United States. As the Co-Directors of the Apsaálooke Water and Wastewater Authority (AWWWA) for the Crow Tribe, with our academic partners, we present here the multiple and complex challenges we have addressed in improving and maintaining tribal water and wastewater infrastructure, including the identification of diverse funding sources for infrastructure construction, the need for many kinds of specialized expertise and long-term stability of project personnel, ratepayer difficulty in paying for services, an ongoing legacy of inadequate infrastructure planning, and lack of water quality research capacity. As a tribal entity, the AWWWA faces additional challenges, including the complex jurisdictional issues affecting all phases of our work, lack of authority to create water districts, and additional legal and regulatory gaps-especially with regards to environmental protection. Despite these obstacles, the AWWWA and Crow Tribe have successfully upgraded much of the local water and wastewater infrastructure. We find that ensuring safe public drinking water for tribal and other disadvantaged U.S. communities will require comprehensive, community-engaged approaches across a broad range of stakeholders to successfully address these complex legal, regulatory, policy, community capacity, and financial challenges.