Concept of Health and Environmental Medicine
Los determinantes de la salud se clasifican en torno a cuatro grandes categorías: medio
ambiente, estilo de vida, biología humana y servicios de atención.
Según el célebre Informe[4] de Marc Lalonde,[5] la salud y/o la enfermedad no están relacionadas meramente con factores biológicos o agentes infecciosos, de hecho desde hace décadas se enfatiza que la mayoría de las enfermedades tienen una base u origen marcadamente socioeconómico-ambiental. Este informe fundante fue aclamado internacionalmente por su enfoque orientado a la promoción de la salud y a la prevención de las enfermedades.
La salud ambiental estudia factores del ambiente y entorno que afectan a humanos, vegetales y animales. Involucra el proceso mediante el cual se evalúan, corrigen y controlan aquellos factores ambientales que puedan influir negativamente en la salud de las personas.
En México, se estima que los factores ambientales son responsables de entre el 25 y 33% de la carga global de la enfermedad, afectando primordialmente a la población menor de cinco años.
La medicina ambiental (en sus aspectos asistenciales) se centra en los agentes productores de enfermedad introducidos en el medio ambiente por actividades humanas, así como en el conocimiento de dichos agentes tanto con finalidad preventiva como terapéutica.
Si bien estudia y trata a las enfermedades ambientales, se ocupa en gran parte de aspectos de investigación y preventivos. Solo recientemente ha avanzado sobre los aspectos de impacto sobre la salud humana.
La medicina ambiental es una rama de la salud ambiental que establece el efecto sobre la salud humana de los factores físicos, químicos, biológicos, psicosociales, ergonómicos y de seguridad.
La terapéutica ambiental es una rama de la medicina ambiental que se ocupa del tratamiento de las enfermedades ambientales. Como tal, ante la multiplicidad de síntomas y signos nosológicos, recurre a todas las formas terapéuticas posibles, desde las convencionales hasta las alternativas y complementarias.
La prevención ambiental en salud apunta a diagnosticar, evaluar y corregir los factores ambientales, en especial aquellos perjudiciales para la salud humana, animal y vegetal.
El estudio de lo que apunta a la Seguridad y Salud Ambiental sirve a la sociedad y a las organizaciones de transformación y de servicios, aplicando conocimientos, destrezas y habilidades con una visión integral y actitud eficiente en la prevención, evaluación y control de los factores del ambiente laboral, de seguridad, salud ambiental y de gestión administrativa, ante las instituciones públicas y privadas.
Máxime considerando que las instituciones internacionales contemplan que los problemas de salud relacionados con lo medioambiental en contextos laborales, son susceptibles de prevención por definición, dado que sus factores determinantes se encuentran precisamente en las condiciones de trabajo.
En este sentido, en las últimas décadas se han fortalecido las acciones de los actores gubernamentales, empresariales y sindicales orientadas a la promoción y la protección del bienestar de los trabajadores mediante la prevención y el control de los accidentes de trabajo y las enfermedades profesionales, así como la eliminación de los factores y condiciones que ponen en peligro la salud y la seguridad.
En la misma línea, se han fortalecido los programas que tienen como eje la Salud Ocupacional tratada en forma multidisciplinaria para proteger el bienestar de los trabajadores. Esta serie de estrategias procura generar y promover el trabajo seguro y sano, así como buenos ambientes y organizaciones de trabajo, al realzar el bienestar físico, mental y social.[6].
Physical factors
• - Atmospheric with important factors in the air and climate changes that not only influence mood, but have been proven to affect health and well-being. For example, heat waves or ailments due to sudden or seasonal weather changes cause, in sensitive people, diseases such as allergies, angina pectoris, epileptic seizures, respiratory colds, dyspepsia, rheumatism, suicide, venous thrombosis, ischemic heart disease, lung cancer, which are attributable to increased exposure to contaminated air, causing approximately 3.8 million premature deaths.
• - Fulguration - lightning injuries - is a cause of injury and death.
• - Humidity changes. In those who, for example, work in very humid environments, skin problems are caused by maceration and a propensity for the appearance of papillomas (warts). There are people more sensitive than others to changes in atmospheric humidity. Excessively dry or permanently humid environments are harmful. For example, in hot desert environments, an exposed person may suffer dehydration quickly and not notice changes in thirst.
• - Pressure changes (dysbarism). Dysbarism is common in certain professions, for example, deep-sea divers.
• - Local, zonal, regional and global climatic characteristics. Global climate change. Greenhouse effect. Impact of meteorological changes and climate transformations on human health.
• - Physical load. Excessive physical loads cause everything from muscle-tendon injuries to bone fractures. There are also other injuries that can occur such as cardiovascular overload with collapse or acute abdominal hernias.
• - Colors. Colors have profound influences on, for example, affects and emerging physiological responses, from depression to arousal. Environmental pollution with uncontrolled excesses of advertising stimuli can cause nervous exhaustion and other injuries.
• - Electricity. Exposures ranging from mild electrocution to severe high voltage exposures are common causes of disability and even death. Thousands of people die annually in the world from electrocution caused by household or industrial appliances. The fact that 1.2 billion people do not have access to electricity (many use kerosene for lighting) generates other risks, from burns to trauma and poisoning due to fuel ingestion, and restricts the development of activities that require adequate lighting (study or small-scale artisanal and commercial productions).
• - Non-ionizing electromagnetic radiation. The WHO communicates[7] precautionary recommendations[8] such as those proposed by the IEEE and the International Commission on Non-Ionizing Radiation Protection (ICNIRP) given the growing evidence regarding correlations between electromagnetic pollution and various physiological and pathological alterations.
• - Visible and invisible lasers, for civil and military uses. There are lasers of certain frequencies, for example, ultraviolet that are used for diagnostic, therapeutic or military purposes that positively or negatively influence health.
Chemical factors
They refer to the chemical characteristics of the medium - whether gaseous, liquid (water) or solid, salinity, acidity (pH) or alkalinity (pOH) and natural or synthetic chemical elements or compounds, including nutrients. They are among the most common.
• - Chemical agents can act alone or in combination. Its routes of entry into the body can be: a) digestive, b) respiratory, c) cutaneous, d) mucosal (conjunctival, vaginal, etc.) or e) percutaneous.
• - Natural inorganic elements: metals and non-metals such as lead, cadmium, arsenic and mercury "Mercury (element)").
- Arsenic in particular is worth highlighting the geological contamination[10] of this natural metalloid abundantly present in the earth's crust whose exposure occurs through the consumption of contaminated water and food (contamination occurs through release to soils and aquifers due to natural processes such as volcanic phenomena and rock disintegration). It is one of the most toxic inorganic contaminants,[11] mainly present in groundwater, and detected in a wide range of concentrations throughout the world. Human activities such as mining, industrial processes, metal smelting, the production of pesticides and wood preservatives contribute additional pollution to soils and aquifers.
- Lead exists naturally in the Earth's crust, where it is extracted and processed for various uses. When lead is ingested, inhaled or absorbed it can be highly toxic to living beings. Lead can enter the body through three main entry routes, the most important for lead being the gastrointestinal tract. Absorption by this route not only depends on the bioavailability of the compound, but on other factors such as gastric emptying, gastrointestinal motility, gastric pH, the interaction of the compound with other components of the gastrointestinal tract, dietary factors and, in general, the chemical environment of the gastrointestinal lumen. Through inhalation, lead is deposited in the respiratory tract, the deposition rate depends on the size of the particle, the solubility of the compound, the ventilation rate and the presence of some pathology, and ranges between 30 and 50% of the total lead inhaled.
- Mercury "Mercury (element)") is a metal found in nature and is the only one that is liquid at room temperature. Metallic mercury is the pure form of mercury. It is characterized by being a shiny, silver-white, odorless liquid, much heavier than water. Mercury salts cause lesions on the skin and mucous membranes. Methylmercury, one of the most toxic forms known, dissolves easily in fat and passes the blood-brain barrier and placenta. It has mutagenic and teratogenic potential, which is why it has been included in the list of substances that affect pregnancy.
• - Natural organic substances.
• - Inorganic synthetic substances.
Biological factors
• - Bacteria and their toxins (exo and edotoxins).
• - Viruses- RNA viruses and DNA viruses -.
• - Other microorganisms (mycoplasmas, rickettsiae, etc.).
• - Unicellular and multicellular parasites and their toxins.
• - Fungi and their toxins (mycotoxins). Mycotoxins are common in foods that have been in a poor state of storage (aflatoxins, cerealenones, etc.).
• - Biological toxins in general.
• - Allergens in general of biological origin including haptens.
• - Decreases in vaccination.
In 2019, the World Health Organization classified anti-vaccine movements as one of the main threats to global health.[15]
Concerns regarding preservatives and effects have been forcefully resolved by international organizations[16].
In Argentina, the recent state of alert regarding measles outbreaks[17] indicates the toxic influence of such campaigns.
• - Vegetables in which pesticide residues remain.
• - Higher organisms, for example, ingestion of vertebrates with their toxins such as decomposing fish (histamine, scombrotoxins and others), bites[18] of mammals, etc.
Social factors
Our relationship with the psycho-sociocultural environment is a continuous "feed back", we provide mutual feedback in a positive or negative way.
The environment, the environment, gives us what we need to live, however, human beings are increasingly misusing their availability. Continuously for hundreds of years, we are damaging the environment with our human activities and this has its nemesis.
Although it is true that nature sometimes behaves strangely, the hand of man has a lot to do with it. And this behavior of nature (including social) and the environment affects our health.
A non-exhaustive multidimensional approach allows us to point out the multiple incidence factors, some such as:
• - General education and instruction. Education can determine adoption or ignorance regarding favorable or detrimental environmental factors.
• - Labor and non-labor relations (social security). Unemployed individuals have a greater tendency to suffer from certain diseases.
• - Particular customs and habits. For example, those in certain groups may be healthier than the rest of a community according to the Jewish dietary-religious rules of cashrut or kosher or those of naturopathic, macrobiotic or vegetarian groups.
• - Group relations (intra- and extra-group).
• - Fashions, customs, habits "Habit (psychology)"), etc. Biased and/or misleading advertising and propaganda can induce the consumption of products that are harmful to health, such as ultra-processed products, linked to the rapid increase in the prevalence of overweight and obesity, diabetes and other non-communicable diseases.
They result in threats not only to health and well-being since ultra-processed products usually contain few or no whole foods.[19]
They are industrial formulations mainly based on substances extracted or derived from food, as well as additives.
These include soft drinks and other sugary juices and drinks, sweet and salty snacks, candies, industrial breads, cakes and biscuits, sweetened breakfast cereals, reconstituted meat products and pre-prepared meals.
In addition to sugars and synthetic sweeteners, oils, fats and salt, ultra-processed products include substances also derived from food, but not used in homemade food, such as hydrogenated oils, modified starches or protein isolates, and additives such as color, flavor and aroma enhancers. Additives are used to imitate and increase the sensory qualities of natural foods or to hide unattractive qualities of the final product.
• - Macro and microeconomic models such as those that can affect, for example, insufficient (salaries) impacting, in turn, incomplete and/or unbalanced nutritional practices.
• - Educational, social and economic policies. An educational framework that does not teach how to know and manage environmental variables tends to generate preventable diseases.
Ergonomic and safety factors
Ergonomic factors or variables are related to the adaptation of the individual to the task and/or their adaptation to the instrument, for example, machine or seat where they perform it.
The spaces where tasks are carried out are also related, especially if they are excessively small or too large.
The general security of tasks within the job is also codified in several institutions.
Mixed factors
Rarely do the factors described above occur in isolation. For example, a volcanic eruption causes: vibrations; particulate matter emissions; gas emissions, all these factors originating from a single natural phenomenon are harmful to human health, also affecting animals and plants present in the affected areas, which can cause food insecurity, general insecurity problems, unemployment, among others.
In urban environments the action of mixed factors is verified more clearly. The combined action of most agents in the cause of environmental diseases is observed, for example, in the syndrome of multiple chemical sensitivities (in English, Multiple Chemical Sensitivity). In SSQM - referred to as "a modern epidemic" by some quarters and as a manifestation of depression and anxiety by others - these detrimental interactions could be revealed.
Beyond multiple chemical sensitivity (SSQM) and perhaps in relation to SSQM, it is worth mentioning drug intoxication, its abuse and polypharmacy or simultaneous administration of remedies and medications with contradictory and paradoxical actions (here not only their action but also their incompatibilities and those of vehicles, improvers, preservatives, etc.) intervene.
The growing dependence on medications in "advanced" societies results in new environmental factors of morbidity and mortality such as drug resistance.
Scope of environmental medicine
Although environmental medicine is quite effective when it comes to establishing diagnoses and possible causes of pathologies, when it comes to providing treatment it is more limited. For example, in communities massively affected by combinations ("mixtures") of factors (chemical, physical, social), the solution to their diverse impact on individual and collective health ("epidemics" of cancer, congenital malformations) is usually partial, ineffective and inefficient. Even so, it is a branch of extraordinary importance that provides us with security in the face of environmental dangers and risks.
Toxicology is one of the most useful disciplines of environmental medicine when diagnosing, treating and prognosing environmental diseases.
The environmental clinic is underdeveloped in general. Some environmental clinical histories have been established but have not entered massively into medical practice. For this reason, most environmental diseases go undiagnosed and therefore untreated.
Environmental therapy is very broad and ranges from the remediation or exclusion of a contaminating factor or place to the clinical and pharmacotherapeutic treatment of the condition itself. For this, both conventional medicine and disciplines such as homeopathy, psychotherapy or so-called alternative and complementary medicines are used.
The driving forces model
The driving forces model -MFM-")[20] consists of a methodological instrument through which it is intended to establish a cause-effect link between health and the environment. It focuses, in particular, on the establishment of actions that allow intervention on the structural conditions that determine the state or quality of the environment, which in turn affects human health.
• - Environmental Health Network Archived September 22, 2019 at the Wayback Machine.
• - Vaccination and Immunization.
• - Health is health Health Portal in Spain.
• - Health-EU The public health portal of the European Union.
• - The American Academy of Environmental Medicine.
• - E. Schinder. Ecology, Health and Environmental Medicine. College of Physicians of Buenos Aires.
• - World Health Organization WHO.
• - WHO Environmental Health Information.
• - Agency for Toxic Substances and Disease Registry (ATSDR) United States Department of Health and Human Services.