ATSDR - Psychological Responses to Hazardous Substances · social responses to toxic exposures and...

RU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESAtlanta, Georgia

Prepared byPamela Tucker, MD

Senior Medical OfficerOffice of the Director

Division of Health Education and PromotionAgency for Toxic Substances and Disease Registry

Psychological Effects Team: David Brown; Annette Dodd; Wendell Webb;Maureen Lichtveld, MD, MPH; Pamela Tucker, MD; Deborah White, PhD

Editor: Karen Resha, MA

Report of the Expert Panel Workshopon the

Psychological Responses to

Hazardous Substances

CONTENTS

Executive Summary ....................................................................................................................................................... 1

Introduction ..................................................................................................................................................................... 7

Workshop Panelists ........................................................................................................................................................ 9

Background ..................................................................................................................................................................... 11

Keynote Speeches ........................................................................................................................................................... 13

Dean Baker, MD ............................................................................................................................................................ 15

Delores S. Herrera .......................................................................................................................................................... 19

Panel Results .................................................................................................................................................................... 23

Panel One: Biomedical and Psychophysiological Effects ........................................................................................ 23

Panel Two: Community and Social Science Perspectives ........................................................................................ 35

Panel Three: Protecting and Promoting Psychosocial Health ................................................................................ 45

Overarching Issues Discussed by All Three Panels ................................................................................................... 55

Next Steps ....................................................................................................................................................................... 59

References ........................................................................................................................................................................ 61

Appendix A: Background Documents From the Expert Panel Workshop on thePsychological Responses to Hazardous Substances .......................................................................................... 63

Appendix B: Bibliography for the Psychological Effects Program....................................................................... 67

Appendix C: There Is No Away! ................................................................................................................................ 75

Glossary ........................................................................................................................................................................... 85

Report on the Expert Panel Workshop on the Psychological Responses to Hazardous Substances - 1

Executive Summary

Introduction

Although much has been written about thephysical health effects of toxic substances andmuch research is underway today, there has notbeen a compilation of the social and psychologicaleffects that exposure to toxic substances canengender. In September 1995, ATSDR co-sponsored with Emory University and theConnecticut Department of Health, an expertpanel workshop on the Psychological Responsesto Hazardous Substances. The purpose of thisworkshop was to thoroughly explore and examineall that is known about how communities andindividuals respond socially and psychologically tohazardous substances and the possible effects ofthose responses on their health.

To present a broad view of this complex andintertwined subject, many different perspectivesand viewpoints are presented. Both communitymembers and scientists from different disciplines,including social, psychological, and neurological,were invited to interact and present their opinions.What emerged from the panels is an initial attemptto define and discuss a newly emerging publichealth issue—how to respond to the psychosocialdistress in communities affected by exposures tohazardous substances.

The approach taken during this workshop reflectsthe complexity of the topic to be examined. Theworkshop used the holistic biopsychosocialmodel as its underpinning philosophy. Thismodel, as opposed to the Cartesian dualisticmodel, which defines the body as separate fromthe mind, assumes that health is an intertwined,inseparable entity made up of biological,psychological, and social factors. Therefore, notonly were physical factors (e.g., hazardoussubstances and their potential impact on thenervous system) and the physical effects ofpsychological stress under discussion, but alsohow psychological coping skills and social

influences operating at Superfund sites can affectthe health of both individuals and communities.

The workshop consisted of three panels focusingon three sets of issues. Panel One (Biomedicaland Psychophysiological Effects) examined thepossible biological effects on the public’s healthrelated to the chronic stress documented to occurin communities near hazardous waste sites, aswell as how to perform neurobehavioral testing todifferentiate between neurotoxic effects ofchemicals and psychological stress effects on thenervous system. Panel Two (Community andSocial Science Perspectives) discussed howpeople respond psychologically to exposures tohazardous waste and the effect social and culturalfactors have on community reaction to hazardouswaste sites. Panel Three (Protecting andPromoting Psychosocial Health) begandeveloping public health strategies to prevent andmitigate psychosocial distress related toexposures to hazardous substances.

Workshop Findings

The first panel had the task of examining thebiological portion of the biopsychosocialresponses to exposure to hazardous substances.This area involves many topics such as:• How does the chronic stress, described in

studies of communities near hazardouswaste sites, affect public health, if at all?To what disease states would it renderpeople susceptible?

• In cases where sufficient levels ofcommunity exposures to neurotoxins haveoccurred (e.g., spills), can organic effectsfrom exposure be differentiated frompsychological effects of the trauma ofbeing exposed to a spill or high-doseexposure?

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The neurobiology panel noted the significant lack ofinformation available on the subjects they weregiven to consider. They stated that more studies areneeded on how often communities near hazardouswaste sites suffer chronic stress reactions. There ishowever much that is known about psychologicalstress and how it affects health. Psychological stresscauses both psychological changes that can bemeasured by self-reports and objective tests as wellas physical changes such as increased bloodpressure, heart rate, and biochemical parameters(e.g., changes in stress hormones). Stress reactionshave been studied in both individuals andcommunities near hazardous waste sites but thestudy of the full effect on the public’s health, interms of specific disease outcomes, is still in thevery early stages.

The panel discussed ways to clinically examine anexposed individual and differentiate whether or notthe results seen are from neurotoxic chemicals orstress. The importance of careful history-taking(especially to determine exposure parameters) wasemphasized as well as the importance of correctlyinterpreting the results of neuropsychological testbatteries.

The second panel, Panel Two, was composed ofpsychologists, social scientists, and communitymembers, (along with all the other panels) whooutlined the unique aspects of the psychological andsocial responses to toxic exposures and the reasonsbehind these responses. One of the first and mostimportant points they emphasized was that theviewpoint of the exposed person is crucial tounderstanding the diverse reactions that can occurin affected communities; that community membersmust be accepted as experts on their owncommunity. A second significant point made wasthat the majority of the responses people have toexposure to toxic substances are normal (i.e.,normal people behaving normally in an abnormalsituation).

There are many reasons why psychosocialresponses to hazardous substances are unique.

Unlike the damage and injuries caused by a naturaldisaster, many toxic substances are invisible to thesenses. This invisibility results in feelings ofuncertainty. People cannot be sure withoutinstrumentation if they have been exposed to a toxinand to how much they have been exposed. Also,due to the lag time between exposure and theappearance of a chronic disease related to theexposure (e.g., mesothelioma as a result of asbestosexposure), it is very difficult to relate past exposureto subsequent disease. Health outcomes thereforeare uncertain and leave individuals with a loss ofcontrol. Two areas where people have the mostdifficulty coping are with uncertainty and loss ofcontrol.

In the face of no external cues and uncertaincircumstances, each person affected by a hazardousexposure develops their own beliefs about thenature of the resultant harm. These beliefs are basedon the facts available to them, pre-existing opinions,cultural factors, sensory cues, and the beliefs ofleaders and others in the community. On the otherhand, scientists tend to rely on objective dataproduced by specialized testing that is subject tostatistical analysis. The results of surveys andstudies are highly technical and may be difficult toexplain to a lay audience that may not share thesame underlying beliefs and values as the scientist.Also, technical experts may and frequently do differin their interpretation of the data.

This lack of external validity makes a sharedcommunity consensus (i.e., a common point ofview) difficult to achieve. Many sociologists havenoted that communities affected by hazardousexposures tend to split into factions centeredaround shared viewpoints.

The generally long life cycle of a hazardous wastesite and slow response for clean up can also strain acommunity’s patience and lead to much frustration.At the beginning or incubation period, the threatexists but it is not recognized. During the discoveryphase, the hazard is discovered and the communitylearns of its existence. At this point, unlike a natural


disaster, which hits and has a low point after whichrecovery can begin, the response to a hazardouswaste site can take 12 to 20 years. The length ofthis response tends to embed communities in acycle of discovery, warning, threat, and impact witheventual recovery taking place over a very longperiod of time.

One theme repeatedly mentioned by communitymembers and social scientists was the importanceof understanding how each community is affectedindividually by its nearby hazardous waste site.Culture can have a strong effect both on howgovernment agencies involved in the Superfundprocess are perceived and on how the communityresponds to the contamination. For example,contamination may disrupt traditional lifestyles andties to the land and result in much more thanphysical or economic damage to a community ortribe. Cultural considerations also must be takeninto account in communicating and working withcommunities.

The third panel, Panel Three, was composed ofpsychologists, disaster relief specialists, andcommunity members and looked at solutions to theproblems facing communities and tribes affected bytoxic substances. One cause of the demoralizationfound in Superfund communities is a feeling ofisolation because many people have not shared theexperience of what possible exposure to toxicsubstances is like. Another cause is the difficulty ofworking with and trusting a complicated, multi-agency cleanup process. Panel Three made manysuggestions for solutions based on past experiencewith disaster relief work:• A community needs assessment based on

listening to the desires of a community is thecritical first step in shaping the design ofintervention and adapting an intervention tofit a community. The community’spermission and input should be obtainedbefore implementing any interventions toreduce stress in the communities.

• The 14 key concepts of disaster mental

health are crucial to guiding interventions incommunities near hazardous waste sites.The key concept of disaster relief is thatdisaster stress is a normal response to anabnormal situation and that most peopleinvolved in a disaster require practicalassistance dealing with problemsengendered by the disaster. There needs tobe recognition of the special problems ofSuperfund communities.

• There are specific strategies that have beenused in relief work for natural disasters formany years that could be modified to usewith communities affected by hazardoussubstances. These include earlyintervention, validation of the reality ofdisaster-related stress, educating peopleabout the normality of disaster-relatedstress, allowing people to tell their story,and involving the community in the design ofdisaster relief activities.

• A primary way to prevent or lessendemoralization in these situations is to helpcitizens gain a true sense of control overtheir situation. As much as possible,residents need to be involved in thedecision-making and problem-solvingprocesses involved in the public healthresponse to and the cleanup of theircommunity.

• Education regarding the normality of stressrelated to hazardous substance exposuresneeds to be given to both communitymembers and responders from the variousagencies involved.

Data Gaps and Future Steps

Disagreement existed among the experts regardingthe amount of data available on the range ofpsychosocial reactions at hazardous waste sites.Some felt the evidence was overwhelming, othersfelt there was a need for more precise

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epidemiological studies measuring the levels ofstress in communities near hazardous waste sites.Panel One outlined many data gaps, which, if filled,would clarify the public health significance ofpsychosocial distress following exposure tohazardous waste sites. To fill these gaps,instruments are needed to• measure stress in communities affected by

hazardous exposures;• determine how special populations such as

the elderly, children, and ethnic groupsrespond psychologically to hazardousexposures;

• estimate the time course of the chronicstress reaction at these sites;

• determine how health outcomes related tothe stress of the exposures can bequantified;

• establish long-term studies of the physicaleffects of neurotoxic substances on thedeveloping nervous system; and

• understand how aging affects the nervoussystem’s response to neurotoxins.

Panel Two emphasized the strong need tounderstand how culture affects an individual’s andcommunity’s psychosocial responses to hazardoussubstances and to the chance of exposure to toxinsdue to different lifestyles. This panel also stated theneed to respect each community’s values. The thirdpanel identified program evaluation as an importantarea to develop when implementing public healthintervention strategies designed to reduce stress.

At the conclusion of the workshop, ATSDRidentified five future steps to address the issue ofpsychosocial effects in communities near hazardouswaste sites:

1. Produce a proceedings of this expert panelworkshop,

2. Publish articles in the scientific literatureregarding the psychosocial effects found incommunities exposed to hazardous substances,

3. Write a training handbook for local and statepublic health officials on ways to minimize stress

in Superfund communities,4. Develop direct interventions in communities

faced with exposures to hazardous substances,and

5. Develop and implement an overall public healthstrategy to help prevent and mitigatepsychosocial distress found in Superfundcommunities.

This workshop was the first step in theimplementation of ATSDR’s Division of HealthEducation and Promotion’s Psychological EffectsProgram. The Program comprises a 4-phasedapproach: Phase 1-Define current science andpractice, Phase 2-Develop an action plan,Phase 3-Implement a public health action plan,Phase 4-Build capacity and evaluation efforts.

The Psychological Effects Program will providecommunities with the basic information necessary tohelp them cope with the stress of environmentalcontamination and potential relocation because ofenvironmental hazards. The Program will alsoprovide training for health care providers, socialworkers, and others to ensure they have theinformation needed to help reduce adverse healtheffects associated with the stress from exposure orpossible exposure to hazardous substances.


INTRODUCTION

On September 12 and 13, 1995, the Agency forToxic Substances and Disease Registry (ATSDR)

convened an expert panel workshop on the psycho-logical responses to hazardous substances. Participantswere asked to discuss an integrated approach toaddressing the neurobiological, psychological, andsocial health effects found in communities nearhazardous waste sites or following a chemical spill. Anintegrated approach to this issue was achieved byinviting experts from many different disciplines, aswell as public health personnel and concerned com-munity members, to share their viewpoints andexperiences.

The workshop was organized into three panels:

Panel One� Biomedical and PsychophysiologicalEffects�discussed the potential public health conse-quences (both physical and psychological) of a chronicstress response, which has been documented to occurin some residents of communities located nearhazardous waste sites or following a chemical spill.The panel outlined ways to approach how to definethe health effects caused by chronic stress.

Panel Two� Community and Social SciencePerspectives�discussed psychosocial effects in com-munities near hazardous waste sites and madesuggestions regarding ways of reducing possiblestress caused by these factors.

Panel Three� Protecting and Promoting Psychoso-cial Health�began developing public health strate-gies to prevent and mitigate distress related to

exposures to hazardous materials in communitiesnear waste sites.

Panel candidates were identified throughnomination by their peers or through a literaturesearch for authors of publications on theneurobehavioral and psychophysiological effects ofresidence near hazardous waste sites. Panelists wereselected to ensure representation with respect torelevant scientific disciplines and affiliations,including community members.

During the workshop, the panel members did notattempt to reach a consensus of opinion but toexpress a broad spectrum of viewpoints. This reportsummarizes the highlights of those discussions alongwith salient information from the backgroundliterature. This report includes the advice and recom-mendations of each panel as well as advice andrecommendations on overarching issues presented toall three panels. The panels also identified critical datagaps and knowledge needs that must be addressed todevelop effective science-based public health strategies.

The opinions and recommendations in this reportshould be continually reexamined and action plansupdated as new data become available.


WORKSHOP

PANELISTS

KEYNOTE SPEAKERSDean Baker, MD, MPH

Mrs. Delores S. Herrera

PANEL MEMBERSPanel Two

Community and SocialScience Perspectives

Stephen Couch, PhDChair

Pamela G. Tucker, MDRapporteur

Gershon Bergeisen, MD, MPH

Dianne Dugas, MSW, MPH

Michael Edelstein, PhD

Mrs. Sue Komick

Mildred McClain, PhD

Mrs. Mary Minor, SFO

John S. Petterson, PhD

Heather Tosteson, PhD

Panel Three

Protecting and PromotingPsychosocial Health

Jarrett Clinton, MD, MPHChair

Robert F. Spengler, ScDRapporteur

Mrs. Cynthia Babich

John Eyles, PhD

Charles R. Figley, PhD

Brian W. Flynn, EdD

Jeffrey D. Kindler, PhD

Stephen King, MD

Vincent La Fronza, MS

Teresa Richardson, BS, RN, MSN

Panel One

Biomedical andPsychophysiological

Effects

Richard Letz, PhDChair

MildredWilliams-Johnson, PhD, DABTRapporteur

Robert W. Amler, MD

W. Kent Anger, PhD

Rosemarie Bowler, PhD, MPH

Joan M. Cranmer, PhD

Laura Davidson, PhD

Eugene Emory, PhD

Jean Harry, PhD

Lawrence M. Schell, PhD

Randall M. White, MDOverall Conference Rapporteur

ACKNOWLEDGMENT

Participation by community members and others in this program was and is vital to its success. We would like to extend aspecial thank you to Mrs. Mary and Mr. Joe Minor, SFO, Mrs. Sue Komick, Mrs. Cynthia Babich, Dr. Mildred McClain,Gail Godfrey, and Cate McKinney.


BACKGROUND

The workshop was one activity of a largerATSDR program, the Psychological Effects

Program. The purpose of this program is to examinethe possible effects that psychological stress associatedwith exposures to hazardous substances can produceon psychological and physical health. Three situationsin which the public could possibly be affected byhazardous substances are proximity to a chemicalaccident, residence near a hazardous waste facility, orpermanent relocation from a community because ofits contaminated environment. A search of thescientific literature was performed regarding theneurobiological, psychological, and social effects ofpossible exposures in these three settings.

Much of the earlier work on psychosocialresponses to exposures to hazardous substances wasfield research. To do this research, social scientistsrecorded their observations of communities beingaffected by possible exposures to hazardous sub-stances. Psychologists and sociologists who observedcommunities exposed to toxic contaminants, such asthe toxic leachate at Love Canal, New York, andcontaminated groundwater in Legler, New Jersey,reported a splintering of the community intoopposing factions and possible increases in psycho-logic distress because of the difficulty of theexperience (1�3).

Since the early field studies, research hasbranched in several directions. First, psychologistsand psychiatrists have studied the coping mecha-nisms involved in how people deal with the threatof an �invisible� toxic exposure (4�6).

Second, several clinical descriptive studies onthe effects of possible exposures to hazardoussubstances on communities� psychology have been

performed. This line of inquiry grew out of researchinto the psychological effects of natural disasters.Disaster effects research, which began in the 1950s,indicates that a small portion of residents aftervarious disasters, such as fires, hurricanes, andfloods, can develop psychological complicationsfrom the stress involved in these experiences. Stresscan lead to disorders such as major depression,chronic anxiety, and post-traumatic stress disorder(PTSD). The stress following a natural disaster alsocan lead to temporary increases in stress-relatedphysical illnesses.

A third area of research emerged when psycholo-gists focused on the epidemiology of psychologicalresponses in communities affected by hazardoussubstances. The results of these psychiatric epidemio-logic studies have been mixed. The work of Baumand Fleming (7) points to the presence of physiologicchanges indicative of long-term chronic stress in acommunity near a hazardous waste site. Horowitz andStefanko (8) reported high levels of demoralizationbut no clinical disorders in a community located near ahazardous waste site. A study in Alsen, Louisiana, (9)revealed high levels of near-clinical anxiety anddepression in an African-American community locatednear a hazardous waste facility. One recent study (10)conducted in a California community following anevacuation because of a toxic railroad spill reportedsignificantly higher levels of depression and anxietysyndromes in the evacuated population versus thecontrol population. Another recent study by a groupof epidemiologists in Texas (11) documented a linearrelationship between the level of exposure to a spilledchemical and the amount of psychological stresspresent 2 years after the accident.

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If higher than normal levels of psychologicalstress and psychological sequelae are being found incommunities affected by possible exposures tohazardous substances, then this presents a publichealth problem. The effects of long-term stress onphysical health at these sites is unknown and

requires further study.

The psychological effects workshop was con-vened to outline the extent of this new publichealth issue and to develop a strategy to address thispotential public health problem.


KEYNOTE

SPEECHES


DEAN BAKER, MDDr. Baker is Director for the Center of Occupational and Environmental Health and a clinical professor at theUniversity of California at Irvine. His major areas of research are the cardiovascular effects of occupational stress andthe social and organizational factors that play a role in indoor air quality problems. He is the author of numerousarticles and chapters on occupational stress. Currently, he is the head of an ATSDR-sponsored program to providemedical education, community and professional help, and education and consultation to communities living near twohazardous waste sites in Torrance, California.

Dr. Baker�s speech is reprinted verbatim.

1 Barry L. Johnson, PhD, former Assistant Administrator for the Agency for Toxic Substances and Disease Registry. Dr. Johnsonpresented the workshop’s opening remarks.

We are currently doing projects with a communityout in California where these issues are very relevant.I have participated before in working with othercommunities around hazardous waste sites, but amajor focus of my research in the past has beenoccupational stress. One of the approaches that Ithought I would take today is to present some of theideas that we have derived from occupational stressresearch that I think are focused a little bit more onthe environmental characteristics that are constantlyresponsible for occupational stress.

It is interesting hearing Dr. Johnson�s1

comments about the emphasis on psychologicalfactors in environmental health, and it reminds meof the struggles that we have had in the field ofoccupational stress: from people working on theassembly lines and the physical hazards facing tolltakers in New York City, to people working in officebuildings, there has been a concern among indi-viduals and unions that discussions of psychologicaleffects might somehow detract from the need andthe emphasis on dealing with toxins and thephysical hazards directly. I think that one sees overtime that these are really inseparable; that you haveto deal with both. So, the theme that I want topresent to you is the need to present an integrated,more holistic approach where you don�t separateout the toxic physical hazards and the toxic psycho-social hazards.

Today, I am going to be talking about stress as aphenomenon that includes both physical and psycho-logical outcomes. Another theme from the literature isthe chronic perception of threat (in communities

around hazardous waste sites). There is uncertaintybecause of invisible exposures with possible healtheffects. In many instances, the degree and extent ofexposure is unknowable and therefore invisible. Thehealth effects are oftentimes unmeasurable because oflatency, etc. and are therefore invisible.

The literature on this topic focused on severalmajor human disaster episodes, such as Three MileIsland (TMI), Love Canal, or more recently, theExxon Valdez incident. Actually there have beendozens and dozens of human disasters and hazardouswaste sites that have been studied.

First of all, stress is a psychobiological processthat is heavily influenced by individual appraisals.The most classic definition of stress is that ofMcGrath: stress is a perceived substantial imbalancebetween demands and response capabilities undercircumstances where failure to meet the demands hasimportant perceived consequences. To give anexample of the importance of perception: if you arehot out on the beach, there might be an imbalancebetween your thermal comfort and the sun, but thismay be something you desire; however, if you aretrying to get work done in an office building, andyou have the same imbalance, and you can�t controlthe thermostat, and you can�t get your work done,the perceived consequences may be different.

The other thing about stress is that it is really atwo-way street. Psychosocial factors, such as stress andthreat, can cause both psychological and physiologicaloutcomes. The focus of my research has been onhypertension and cardiovascular disease, where there

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have been documented associations betweenoccupational stress and cardiovascular disease. Thereis some evidence for effects on immune andendocrine function. These are physiological effectsfrom psychosocial factors. On the other hand,psychological effects may derive from both psycho-social factors as well as toxic chemical exposures.For example, where you have hazardous waste siteswhere there may be neurotoxic compounds, theremay be both psychosocial contributions to psycho-logical effects as well as a toxic contribution fromvarious neurotoxins.

Let�s compare the effects of natural disasters toexposures to hazardous substances. For example,consider the effects of a hurricane. You can see thateven though hurricanes can have significant conse-quences, the effects are relatively transient. It iscoming, it is there, it lasts, it goes away, and recoverycan begin. There is a clear low point. You are hit veryhard, but then you can see that it is over and nowyou can move on to the point of recovery. At timeslike these, people feel like they don�t have any controlover the situation, but they feel that it is a naturalsituation, so nobody has any control over it. Incontrast, with exposure to hazardous substances, youdon�t know whether or not you�ve been exposed. Youdon�t know whether health effects could occur. Youdon�t know how much you�ve been exposed to.Oftentimes, the exposures are invisible to the senses,even in a spill. You can see a hurricane or a volcanoerupting. You can see the dust. You can see thedamages.

In some ways, hazardous substances exposures aremuch more like occupational stress exposures. Thetoxic hazards are the principal stressors. Oftentimes,in occupational settings, you will have multiplestressors. You will have multiple stressors in a com-munity, but oftentimes the focus is on the toxichazard. In both settings there are persistent stressors,and in both there is no clear low point. I think inboth settings there is a loss of control. Long-termuncertainty is existent for both, and in both theexposures can be visible and invisible. Oftentimes, theconsequences of occupational or environmentalexposures are not clear.

So, in many ways, occupational stress and

exposure to hazardous substances are similar. Letme present a model of occupational stress and tryto integrate some of those notions into environ-mental stress. First of all, there are the stressors thatexist out in the environment, and these are thefactors that cause stress. Cognitive appraisal of thosefactors occurs, meaning that a person looks andinterprets the nature of the threat�which would beboth the exposure and its possible consequences�aswell as how to respond or cope with the threat.Coping or adaptation involves many modifyingfactors such as social support and an individual�sresources. All these modifying factors lead tovarious responses, which can be psychological,somatic, emotional, cognitive, or behavioral (smok-ing or drug abuse), or social effects such as conflict.

You can see that the stressors go throughcognitive appraisal to a short-term response. If theresponse does not solve the problem, and it goesunresolved, over time this stress can lead to long-termhealth outcomes. In terms of modifying factors, thereare social or community factors that can help copingor pull individuals down. On an individual level,people with different coping styles may actually beable to look at the situation differently and be able tominimize exposure to the stress of the situation.

One thing the model of occupational stressdoesn�t answer is what makes an environment stress-ful? To answer this, we looked at the role of cognitiveappraisal. One of the concerns about that view�although it has been richly rewarding in understandingthe stress process�is that it gives the view that stress ispurely a subjective phenomenon. It is all in the eyes ofthe beholder. It tends to ignore somewhat what goeson in the objective environment.

The other contributing line of research has beenphysiological stress theories. These focus on what ishappening in the brain during stress. Basically, theyhave discovered two mechanisms of how the bodyresponds to stress. One is the adrenal medullaryresponse, which involves the secretion of epinephrine,norepinephrine, and the other is the adrenal corticalresponse, involving cortisol. The first response is thefight or flight response of an organism challenged bya threat. The second, the cortisol response, is reallymore of a response of defeat and withdrawal, and in


this state, you have higher levels of cortisol andbehaviors such as helplessness.

Another way to look at stress is to view humanbehavior and the environment as a transactionalprocess�where you say what goes on between thehuman and the environment is what results in stressand you look at what goes on in the environment.One offshoot of this model is demands and decisionlatitude, or demand-control in the workplace. There isnow a whole body of literature that has studiedworkplace conditions. Instead of looking just insidethe brain and inside the person, the environment hasbeen examined. The essence of this model is thatrather than looking at the limitations of being theindividual, being able to respond, it says, �what�s astressful environment?� A stressful environment is onethat presents demands on the individual and at thesame time constrains the individual�s ability to respondand therefore creates an imbalance between demandand response that leads to stress.

In looking at the literature, one area where I triedto make the transition from the occupational model tothe environmental exposure setting was in interpretingthe threat of long-term fear. The persistent threatfrom environmental exposures represents a psycho-logical demand on the individual, and the lack ofcontrol�either because the community and theindividual have relatively low control in the situation orbecause of uncertainty about the nature of the hazardor what to do about it�represents a constraint onresponding. Therefore, in these communities, you canhave a situation of persistent threat and at the sametime low control over response. This could plausiblybe associated with stress and high strain.

Let�s now focus on the issues of fear and threat asstressors and on lack of control interacting with fearas a combination stressor. First of all, fear is a rationalresponse to an imagined or actual threat. This is arational response. Fear is not a pathological response.Persistent fear may cause chronic stress situations, andthis has been documented in the literature that youwere given. Also, persistent repeated exposures maybecome increasingly frightening if the experiences aredeemed unavoidable, so there is a lack of control.Both psychological and physical risks from theseexposures could contribute to disease and diminished

mental health, so there is this interaction betweenthe physical and the psychological. I think that oneof the characteristics of living in a community neara hazardous waste site is that it is a very, very long-duration situation. There is loss of control. Again,there is this interaction between threat and loss ofcontrol.

Perceived control may be defined as the beliefthat one can influence an event, but the importantthing to keep in mind is that, ultimately, perceivedcontrol depends on actual control. I think that theissues that will come later in terms of strategies andapproaches are how much can we try to build up theconcept of perceived control among communitymembers and how much do we have to deal with theissue of actual control, particularly in a situationwhere the duration is long? How long can you getpeople to fool themselves? Learning that events areuncontrollable results in a whole range of motiva-tional, cognitive, and emotional deficits that caneventually result in learned helplessness. So, indi-vidual and community control is a key factor thataffects stress response.

I think that in these situations uncertainty isassociated with the perception of loss of control.Uncertainty not only represents a stressor, it makesappraisal and adaptation difficult. How can youadapt if you cannot fully grasp the threat? Theinvisibility of these exposures leads to the uncer-tainty. This concept occurs in an article by HenriVyner (12). Environmental invisibility is when thecontaminant cannot be detected by human senses.There is also medical invisibility associated withenvironmental exposures. Latent invisibility meansthat many of the chronic effects of toxic exposureshave a long latency period. Sometimes, this period isjust a few years for reproductive problems; forneurological disease, sometimes as long as 20; and itcan be up to 40 years for cancer. During that latentperiod of time, even if you have been exposed, andeven if you will develop that disease, there is usuallyno way of detecting that. There are yet no signs orsymptoms of that future illness, so it is medicallyinvisible during that latent period.

It is just amazing how many aspects of theproblem of environmental exposures are uncertain:

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whether or not you were exposed, how much of atoxic substance you might have been exposed to,latency of any health effects. You may getundiagnosable symptoms like headaches and fatigue.Prognostically, if you do develop a disease from anexposure, what is the future?

So what are some possible solutions? One thingis the importance of community cohesion. Some-times it is not totally possible to get rid of thehazard, but I think it�s important that the commu-nity can pull together and not just deal with peopleas individuals. There has to be an effective dialoguebetween community residents and the scientificexperts. There has to be a sharing of knowledge. Wehave to empower the community. Support of thecommunity�s development, cooperative communityproblem solving, coalition building, and advocacy

approaches are all things that you can do to try toempower the individuals in the community.

So ultimately, you see that one of my themeshere is that while I think emotion-focused approachesare essential and important, there is still going to bepersistent threat and uncertainty in these situations.People at some level have to learn to live with theenvironment. But at the same time, like in occupa-tional stress, we don�t want people to just continueworking in the same environment and just learn tolive with it, we want people to the extent possible tobe able to change the environment. The problem-solving approach is just as important where you workwith the communities to minimize threat, to mini-mize uncertainty, and to enhance individual andcommunity control.


DELORES S. HERRERA

Delores S. Herrera is the Executive Director of the Albuquerque San Jose Community Awareness Council, Inc.(ASJAC). She was born and raised in Albuquerque, New Mexico, and has lived in her neighborhood for 24 years.She received the 1995 Governor�s Award for Outstanding New Mexico Women, the 1995 Human Rights Award fromthe City of Albuquerque, and the Latino Peace Officer�s Association 1995 Community Service Award. Ms. Herrerawas featured in the project, �Women and Social Change�Education at the Grassroots: Women and the Struggle for aSafe Environment,� the Kathleen Ridder Conference, Smith College, Massachusetts. She was appointed as the firstHispanic/Latino to the National Environmental Justice Advisory Council (NEJAC) by the U.S. EnvironmentalProtection Agency (EPA) Administrator Carol Browner and is presently completing her second term. She sits on anumber of boards and organizations to improve the quality of life for people, especially children, in her communityand other similar neighborhoods locally, nationally, and internationally.

Ms. Herrera�s speech is reprinted verbatim.

Hello, I am Delores Herrera from the community ofSan Jose in Albuquerque, New Mexico. It is not SanJose, California; it is New Mexico. I am very, veryproud to come from New Mexico because every timeI go somewhere people ask about New Mexico. Theyalways have lots of questions. People still have notfigured out what I am or who I am. I am a servant ofthe people, not a slave; there�s a difference. Mycommunity is going to feel really proud when I tellthem I was validated by Dr. Baker as being crazy.People ask everyday, I do not know how many times,�Why do you do this work? You must be crazy.� So, Ithink I am crazy.

Many people have become so accustomed to thesmell, the pollution, the lack of attention, acceptingthe deterioration, the lower quality of life as everydayin the �hood,� the low student test scores, the crime,all of the negativism. That is the way that it hasalways been. Just accept it. Nobody cares aboutnormal. How can things change? San Jose is theoldest community in the South Broadway area of theAlbuquerque South Valley. It is the place I amprivileged to call home.

A �Mayordomo� system began when settlersmoved in around the river, organized the inhabitants,and completed a water irrigation system. Thecommunity�s boundaries were re-channeled byrelatives such as the grandpas giving parcels of theirland to their kids because that is all they had to passon to the future generations. All we have is our land.

We are tied to it and have always been. It is our hopethat we will thrive again some day. Our homes, ourland are not an investment in that we are going tobuy, sell, and trade it like stock on the stock exchangeor to buy a bigger house in a better neighborhood.San Jose is our neighborhood; it is our heritage, �LaTierra.� Most of the people stay because they arehistorically and spiritually tied to the land, becausetheir grandfathers and others before them are a partof it, and they continue the tradition. Sadly, itbecame a polluted mess. It is sickening. What hashappened? Many people feel trapped. The land todayis not worth much in dollars, but it is our home.Industry came in, raped it, and left it for dead untilthe government mandated cleanup, restoration. Wow,what a deal, 20 to 30 years of remediation�noguarantee?

People in our community and others around thecountry�of color, poor communities, lower socioeco-nomically depressed neighborhoods�do not votebecause they do not believe in a system that does notwork for them. And why should they? We couldattack the scientific statistics to validate the problemsbecause that is a part of the process, but there is ahuman side, the people side�El corazon de la gente:the heart of the people.

Going back to the �gente,� what we are left withis the political structure of the Mayordomos, whowere actually perceived as �mini-mayors.� Theydecided who was to receive water. They relinquished

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power to the individuals in communities. They had thevoice and established the social and economic climatethat retains a pseudo presence today. San Jose was anagricultural community, a farming community. Thenthe railroad came in and people became attached towage labor. The railroad shut down major operationsand left, leaving an unemployed population and acreosote deposit which is now our Superfund site II.The historical and human perspective should not berelinquished in favor of �true science.� We must lookat the biological and psychological effects coupled withthe socioeconomic and environmental impacts. Thewhole enchilada, total, including the multifacetedstresses that attack our people and make them feelhelpless and trapped. I always visualize those big trapsin which a bear or wolf or some other animal�s leg isclamped within the metal teeth. You watch theanimal�s terror-stricken eyes, squirming. It is a hor-rible, ugly scene! Those poor creatures, trappedwithout mercy. The people in contaminated commu-nities are victims with no retreat...sick and dying aslow death....Think about it. How would you feel?The neighborhood didn�t have to change in thenegative. What a price we pay for progress.

I am an activist for people who have been leftout, left behind, and without a voice. Many of thereasons people stop being part of the system maypossibly be categorized as sometimes my people donot feel comfortable enough; they lack the self-confidence and self-assurance to stand up and becounted; or they are suffering from apathy. The listis probably endless. For whatever reason, it is atragedy because their destiny is not under theircontrol but rather someone else�s. That is a real drag!We do not have grocery stores or shopping centers inour community. The infrastructure is decomposing.We have lots of crime, contamination, and sickpeople living in an industrial corridor. The totalityof injustice sometimes is that the self-confidenceneeded is nonexistent to assume the challengingleadership position. This is stress unto itself. I amnot a scientist; I am a community organizer. I willnot dictate the stats. I do know and understandpeople and I work with them everyday. As I drive outof my driveway, I am in my community. I work in mycommunity, and when I come back home, I am inmy community. It is very difficult for me to be here

today, as I am always torn between here and thereand San Jose.

Now poor, what�s poor? Let�s talk poor.... I donot know how many people have ever been poor. Iam not talking about poor in spirit. I am speakingfinancially�moolah, dollars, sin dinero.

Empowering? No, in fact it�s the completeopposite. Our youth and others in our communitiesare not being educated. They take all kinds of stuff�drugs�to become numb and escape from reality.

In communities that are so environmentallycontaminated, we are all crazy, and everybody in thisroom is crazy. We have to be. Right? I am not goingto leave here saying anybody in here is real rational. Ithink the whole world is crazy in some fashion.Don�t you? Think about it: everyone in here caresabout what happens to people. Yet, when we lookaround and see the people that are suffering, whatcan we do to help in the struggle? What happens tothe less fortunate? What will we do? We will stay andfight, work with the system as far as it works for us,and then formulate another plan. Mother Earth andher people are in trouble. What is our recourse?Taking drugs? Young women getting pregnant? Lastyear, we had 25, 27 students in 3 classrooms of analternative education program in Albuquerque, andout of 75 of the young ladies, there were 30 that were12 and 13 years old. What happens? The moral fiberin our society is decaying and we are all to blame.The situation is frightening! Look at the social andfinancial burdens on all of us, the lives lost andwasted. It isn�t just environmental contamination; itis degradation of the human spirit. What are wedoing about it?

In my community, people are worried about howthey are going to pay their gas bill or light bill, aboutbecoming homeless, and many, many other prob-lems. The most important issue is not about what isgoing on at Chevron or what the AT&SF railroad hasdone to poison the people, the environment, or whatcancer risks are out there. They are worried abouttoday, survival! They are worried about domesticviolence, alcohol, insurmountable social concerns,their sons, their daughters, grandchildren, hearinggunshots, living in the midst of violence every nightand day. There are many forms of contamination.


Yesterday, I was visiting with one of my neigh-bors. On Saturday night, she heard a loud noise andthought it was a gun. Sure enough, somebody hadshot at her son�s car. She lives in the middle of theSuperfund area. It is stressful enough when she looksout her kitchen window to see the GE (i.e., GeneralElectric) water tanks around her, and compoundedwith the violence, she is feeling under siege.

When we talk about negative effects we aretalking about socioeconomics correlated with envi-ronmental racism�poor, no money. Turn on thetelevision and everything is about money. I got a kickout of a show this morning. Somebody was talkingabout retiring, where they would go. Wow! Retiring,we are going to see that rainbow in the sky and reachthe pot of gold. Retirement for some is not a reality.The trapped animal syndrome, where the heart isbeating and we wait to die a slow death. We stay, westruggle, we fight.

Another story is about a woman named Esther,with whom I started teaching religious educationabout 18 years ago. She began experiencing a littlecough. She lives right in Superfund, right by thedrainage dump. Over the years, she said, �it�s okay,it�s okay, my little cough.� I know that it is not okay.Her cough is upper respiratory and it has progres-sively worsened. She still says, �it�s nothing.� Thecough is not normal, but her demeanor is anotherform of acceptance. We as Chicanos, Mexicanos,Latinos, as Hispanics suffer silently. It is an assum-able part of our culture�the culture of people ofcolor and what we stand for. Linking that with thefact of poverty, helplessness, and lack of self-esteemhas bolstered our spirit, and we are still going strongas a people.

Whenever I go visit anybody, I am very respectfulof their home and their valuable time. As a commu-nity, we ask for respect from other people; that isimportant. We are all products of society. We areresponsible for each other. We share a commondignity; remember that. Our problems are environ-mental, economic, and social. When you go to abank and you cannot get a loan because the area thatyou live in has environmental problems or it�slocated in a socioeconomically depressed area, that isunfair lending banking practices and against the

federal law. Hello? How many times do corpora-tions/potential responsible parties break the law?Our community has suffered redlining. We pay backthe loans, don�t owe as much, but we are manytimes refused those very things that others take forgranted. Does that make sense?

I visit many places and I have to laugh becausesometimes people are so freaked and so stressedbecause they cannot visualize the next half-hour,much less tomorrow. They have lost hope. I neverlaugh at their misery. I laugh to keep from sobbing.Life is so precious. This work is hard, and you watchpeople who are suffering that do not even know thatthey are suffering. Many have learned to accept it. Ido not. I will never accept injustice for anyoneanywhere. We will mobilize and continue to share allwe have to teach others, to stand up for civil andhuman rights. Not being in control of your owndestiny, whether it is because of economics or poweror whatever, is injustice. America was built on justicefor all the people, not just for some, for everyone�rich, poor, male or female, young or old, or color ornot.

A hand-up stabilizes; a handout controls. Wewant to be in control of our future, and therefore weunderstand that partnerships stabilize. A goodexample may be when the ASJAC was approached byan engineer to work with the Sandia National Labs.Condescending in his attitude, he bugged me, tellingme what they could do for the �poor� people in theneighborhood. I said, �We don�t need anyone comingin to our community wearing a white hat and ridinga white horse to tell us what�s best for us. We are the�experts.� We will solve our own problems. If youwant to help and partner, that�s a different story. Theproblems do not belong to us alone. People drivecars, have gas and electric utilities, flush toilets, andrunning water. We have conveniences, right? San Josesuffers the impact of having industry in our commu-nity because they are located here, but it is not justSan Jose�s problem.� He looked at me and said, �Well,Delores, we need to have some serious discussion.� Ireplied, �No, first what we really need to do is cometo an understanding.� The understanding is thathuman life is not expendable. Every living creatureand every living thing matters. It took a while, but he

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got it. We have formed a wonderful relationship,and we help each other. I respect him to this daybecause the partnership is based on trust andmutual accountability.

In conclusion, I wish to state that the impactsfrom social, economic, and environmental racism arestrongly felt in San Jose. The helplessness, the guilt,the unhealthy communities, the stuff that people feelevery day and every night from every negative forceflourishes. It isn�t a bed of roses yet, but we are

planting seeds and have hope that we will nurtureaccordingly, and we will grow a strong, healthy,beautiful future for all. We all want a better qualityof life for our future generations, especially for ourchildren. We all love babies. What are we going to doabout the babies? They grow up into adults. We wantto raise healthy, productive members of society thatsustain their families and stimulate the economy.That creates a better San Jose, better neighborhoodseverywhere, a better world.


PANEL RESULTS

PANEL ONE:BIOMEDICAL AND

PSYCHOPHYSIOLOGICAL EFFECTS

Composition: Neurobiological scientists (such as psychologists with expertise on the psychophysiology ofchronic stress and resulting health effects), neurobehavioral toxicologists, neuropsychologists,and psychiatric or psychological epidemiologists.

Charge: To examine what is known about the potential effects of possible chronic stress onpublic health. Some studies provided information on possible chronic stress occurringin communities near hazardous waste sites. Focus areas for the panel included thepattern of stress�acute, chronic, or both� that may occur among community membersliving near hazardous waste sites; the effects of psychological stress on physiologicalresponses to exposure; and whether neurobehavioral disorders caused by chronic low-dose exposure to neurotoxicants, which may manifest as psychological distress, are apublic health phenomenon near hazardous waste sites.

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BackgroundResearch into the psychological effects of disastersbegan with the study of natural disasters in the 1950s.Scientists and clinicians recognized that a smallnumber of people exposed to the stress of variousnatural disasters, such as fires, hurricanes, andfloods, could develop psychological sequelae suchas major depression, chronic anxiety, and post-traumatic stress disorder (PTSD). Current thoughtamong disaster relief workers holds that mostpeople will suffer no or only transient effects fromthe stress of a natural disaster (i.e., acute stressdisorder) or, in other words, �people reactingnormally to an abnormal situation� (B. Flynn, 1995,personal communication). For excellent summarieson the psychological sequelae to natural disasters,see Rubonis and Bickman (13), Dew and Bromet(14), and Green and Solomon (15).

There are important differences betweentechnologic and natural disasters that are believedto affect the psychological and social responses totechnological disasters. In addition to direct healtheffects, exposure to technologic disasters�acuteexposure, as in chemical spills; or chronic exposure,as in residence near a leaking hazardous waste site�can cause people to experience psychologicaluncertainty, worry, and chronic stress. Some postu-late that the chronic stress documented to occur insome communities near hazardous waste sites couldpossibly lead to an array of biopsychosocial effects,including physical health effects from chronic stress(possible health outcomes affected by stress includecardiovascular, gastrointestinal disorders, and skin),increases in the prevalence of certain psychologicaldisorders, and social disruption.

Sociologists studying communities near leakinghazardous waste sites have defined this kind ofsituation as a �chronic technological disaster� (Kroll-Smith and Couch [16]). Unlike a natural disaster�which has a discernible low point and a recoveryphase during which life begins to return to �nor-mal��many chronic technological disasters have nodiscernible starting points, no distinct low points,

may last for many years, and may leave behindpeople at risk for latent health effects (2). Theseevents are not clear-cut, easily defined disasters, andthe slow onset and recovery may make the adjust-ment more difficult (17).

The first scientific studies of the health effects ofstress associated with environmental contaminationoccurred after the Three Mile Island (TMI) accident.Baum and colleagues (18) found indicators of psycho-physiological effects from stress, including elevatedlevels of psychological distress, perceived threat,subclinical anxiety disorders, and depression in manyof the community members they surveyed at TMI ascompared with controls. The comparison revealedbiological signs of chronic stress consisting ofincreased blood pressure (elevations were subclinical)and higher than normal levels of urinary cortisol andnorepinephrine metabolites. They also found that thepsychophysiological pattern of anxiety, poor concen-tration, and biological indicators of stress in commu-nity members affected remained subclinically el-evated for 6 years and only returned to normal levels10 years after the accident. Baum and colleagues thenlooked for this same chronic stress response in acommunity located near a leaking hazardous wastesite and found similar results. Baum and Fleming (7)concluded that �distress and mental health outcomesalso represent major outcomes of environmentaldisasters.�

The findings of Baum and colleagues are sup-ported by observations made by a group of research-ers in California who studied the towns affected bythe Cantara loop railway spill (10). They studied thephysical, psychological, and psychophysiologicalreactions of those who had been exposed to a spill ofmetam sodium. Psychological assessments of theresidents showed increased worry, perceived decreasesin social support, and biological changes indicativeof chronic stress. Testing also showed greater levels ofdepression, anxiety, and somatic symptoms�whichthe researchers felt were possibly connected tochronic arousal states�in the exposed versus a controlpopulation. They postulated that �physiological and

Topic OneWhat is known about the long-term health effects of chronically increased stress amongindividuals living near hazardous waste sites?


psychosocial effects of the chemical spill traumaprecede long-term physiological manifestations.�

Other recent findings also suggest that theexperience of exposure to hazardous substances andthe resulting psychosocial changes can result inadverse physical and psychological health effects. In1994, epidemiologists at the University of Texasinvestigated the physical and psychological effectsfound in a community that had been exposed to atoxic cloud of hydrogen fluoride (11). These research-ers first performed a study that documented bothshort- and long-term physical health effects in thoseexposed to the vapors. Then, they evaluated thepsychological effects of this exposure situation andfound that a linear relationship exists between thedegree of gas exposure and increased psychologicaldistress. Specific findings included increased anxietyand somatic concerns among the affected persons.

Panel DiscussionThe panel members generally agreed that the

background literature on long-term health effectsfrom chronic stress associated with living near ahazardous waste site is sparse; however, the panel alsoreferred to knowledge on effects of chronic stressgained from related studies on chemical or naturaldisasters and in the occupational setting.

Stress is a whole-body process with effects thatcan be measured using self-reports from groups orindividuals as well as from other more objectivemeasurement techniques. There are inherent difficultiesin self-reporting measures because the reports mayreflect concerns or actual changes related to theincident. Other methods used to evaluate the conse-quences of dealing with a stressor for a prolongedperiod include direct behavioral observations by atrained observer; psychophysiological measures ofstress, such as increased blood pressure, heart rate, andchanges in skin conductance; and biochemical param-eters, such as measurable changes in stress hormones(cortisol) and in the catecholamine levels, such asnorepinephrine and epinephrine. Though theseindicators may provide some clues to the alteredwhole-body response to stress, interpretation of theresults may be problematic (e.g., the timing ofcortisol measures is crucial because the secretion of

cortisol shows a daily, biphasic variation). It isimportant to control for other factors such assmoking, exercise, and diet, which may elevatemeasurements.

The panel discussed studies conducted using themethods mentioned above. A study by Davidson andcolleagues (19) found that, compared with a controlgroup, residents near TMI showed significant stresseffects over the first 5 years of follow-up. The effectsnoted included increased symptom reporting;difficulties with attention and concentration; andalteration in heart rate, blood pressure, levels ofurinary catecholamines (epinephrine and norepi-nephrine), and blood cortisol levels. In other re-search on effects of chronic stress in communitiesexposed to toxic substances, residents living near ahazardous waste site showed alterations in psycho-logical and psychophysiological stress indicatorssimilar to those seen at TMI (20).

An important general discussion point was thatthe critical factors and underlying causes for sensitiv-ity to the effects from stress are not clearly under-stood. Studies done at TMI and the toxic waste site, aswell as other studies, conclude that effects may belargely related to event characteristics and the re-sponses of each person to the event. These responsescan range from little concern to extreme agitation.The differing reactions most likely reflect manyfactors, such as the characteristics of the event (e.g.,did actual chemical exposures occur?); imageryassociated with the episode; media coverage; and theindividual�s coping mechanisms, perceptions of thesituation, appraisal of threat, and perceived sense ofcontrol over the circumstances.

Data Gaps and Recommendations 1. How well do commonly measured indices of

stress used in the past to study natural disasters orcombat-related trauma in Vietnam veterans applyto residents living near hazardous waste sites?

2. What are the age-specific effects of living near ahazardous waste site? How do children respond?How do the elderly respond? More information is

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needed on how these special populationsrespond to this type of experience.

3. What is the time course of the physical andpsychological responses to chronic stress?During periods of recorded stress at TMI,physical measures showed increased stresscompared to controls; however, self-reports ofstress showed no differences. Are psychophysi-ological baselines being shifted to future stress?

4. There is a need to quantify the effects ofchronic stress on the health of these communi-ties, especially when conditions express them-selves in nonspecific outcomes (e.g., increasedfrequency of headaches). It is recommended thatATSDR evaluate existing instruments for theiradequacy in assessing the prevalence of thesenonspecific health outcomes.

5. There remains uncertainty in the interpretationof measures of stress. ATSDR should attempt todefine criteria for when a change in these stressmeasures is considered a problem. In toxicologicterms, when are changes in stress indicatorsconsidered �adverse� or capable of causingunwanted health effects in a person and in acommunity?

6. Although there is some background informa-tion on what the disease outcomes are and howthey are related to chronic stress, these out-comes are not fully characterized. What do thephysiological and biochemical changes in thesepopulations mean (i.e., what is their relationshipwith diagnosable illnesses?).

Topic TwoAre there certain neurobehavioral effects found in individuals exposed to chronic low-dosesof toxins who live near hazardous waste sites that, if detected, could constitute sentinelhealth events at these sites? If they exist, can their early detection be used as anintervention screening tool?

BackgroundBefore the beginning of industrial hygiene, employ-ees in some industries were chronically exposed tovery high levels of chemicals that led to toxiceffects on their nervous systems, specifically in theneurobehavioral diseases of sensory, motor, andcognitive functions, as well as memory and atten-tion. Examples of chemicals that are known neuro-toxins at occupational levels of exposures arecarbon disulfide, hexacarbons, mercury, lead,organophosphates, and organic solvents.

Historically, there have been far fewer episodesof neurotoxic effects found in the general commu-nity as compared with the occupational population,and most of those episodes resulted from contami-nated food. During Prohibition in the UnitedStates, there was an outbreak of �Ginger Jake�paralysis, which was associated with drinkingextracts of Jamaican ginger that were contaminatedwith tri-ortho cresyl phosphate (21). In 1968, anoutbreak of Yusho (the name of the disease causedby polychlorinated biphenyls [PCBs]) occurred in

Japan after adults and children drank rice oilcontaminated with high levels of PCBs. Chloracneand numbness and weakness of the extremitiesoccurred in the adults. Children born to mothersexposed to the oil during pregnancy had abnormalpigmentation, decreased reflexes, and intelligencequotients of 70 (22).

The most well-known case of environmentalcontamination leading to neurotoxic effects in acommunity occurred in Minamata, Japan. Metallicmercury used as a catalyst by a local factory wasdischarged into the bay. The bacteria and micro-scopic aquatic life in the bay bottom converted themetallic mercury to organic mercury compounds,especially methyl mercury. The fish and shellfish inthe bay picked up the high levels of methyl mercury.After a period of time, an epidemic of neurologiceffects (e.g., paresthesias, ataxia, and deafness) wasnoticed in the fisher people who lived by the bay.These effects were traced back to the mercury in thebay. Median doses of 11 milligrams per kilogram ofmethyl mercury in fish resulted in these effects (22).


Neurobehavioral disorders, such as lead poison-ing, have occurred in communities exposed to highdoses of lead.

There is still a great deal of controversy aboutthe potential occurrence of neurobehavioral effectswith chronic, low-dose exposure to hazardoussubstances. The panel discussed this specific con-cern.

Panel DiscussionMuch is known and substantial evidence has

been found about the neurobehavioral effects inhumans resulting from exposures to neurotoxicsubstances; however, much of this informationcomes from observations from high exposures inoccupational settings. Occupational exposures toneurotoxins differ significantly from chronic low-dose exposures experienced by most communitymembers near a hazardous waste site. Occupationalexposures tend to be high-level, sometimes short-term exposures that happen to a more homoge-neous population (i.e., healthy adult employees).

How does our knowledge about occupationalneurobehavioral effects compare with the possibleeffects of chronic low-dose exposures? Existingliterature (Baum and Bowler [5, 7, 10, 18, 20, 23])points to measurable changes in memory andattention as neurobehavioral effects observed ingroups living near hazardous waste sites. What is thecause of these neurobehavioral effects�chronic lowlevel toxic exposure or effects of concern over apossible exposure?

Neuropsychological methods are used to testfor neurobehavioral effects. Field batteries, such asATSDR�s Adult Environmental NeurobehavioralTest Battery (AENTB), are sufficiently sensitive todetect psychophysiological effects associated withchronic stress, such as decrements in memory andconcentration. The data gathered could then beinterpreted epidemiologically in light of several

potential confounders, such as clear indicators ofexposure to a neurotoxin, test administration bias,subject bias, ethnic or cultural factors, education,sex, and age. The need to document exposure toneurotoxins points to the lack of selectivity in theneurobehavioral testing methods (i.e., the inability todifferentiate whether changes in memory andattention are toxicant-induced effects versus stress-related effects).

Data Gaps and Recommendations1 . The components of existing field neurobehav-

ioral testing batteries would likely captureanxiety-related responses on a group basis.Therefore, they would be useful as tools forscreening groups of people, but would not beuseful as clinical instruments or individualscreening instruments. They also would not beuseful for separating physiological from psycho-logical effects. To gain maximum usefulness forcommunity evaluations, there is a need forcommunity-based norms for many tests. Thesescreening measures would be helpful in deter-mining the magnitude of a problem in a com-munity, but not for determining specific inter-vention strategies.

2. Existing field neurobehavioral testing batteriesare not capable of detecting adverse healtheffects resulting from chronic, low-dose expo-sures, which would constitute sentinel healtheffects. It is unlikely that differences betweengroups can be detected by existing fieldneurobehavioral testing batteries, such asAENTB. Results on specific subtests would behelpful in identifying issues for further evalua-tion. However, results from existing batterieswould not allow attribution of observed groupdifferences to physiological versus psychologicalmechanisms.

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Topic Three

What is known about how to clinically differentiate between organic behavioral disorderscaused by exposure to certain neurotoxicants and purely psychologic responses to possibleexposures? This discussion will consider methodological questions such as testing forstress and neurobehavioral effects as well as other issues.

BackgroundThe previous discussions were based on instrumentsdesigned to screen large groups of people for neuro-logical and behavioral problems possibly related tochronic low-dose exposure to neurotoxins. Thisdiscussion relates to the individual, clinical workupof a person concerned about possible health prob-lems from a previous neurotoxic exposure, withconsideration of methodological questions such astesting for stress and neurobehavioral effects.

Panel DiscussionDr. Rosemarie Bowler and Dr. Eugene Emory

were co-leads on this topic. Dr. Rosemarie Bowlerdiscussed work she has done studying communitiesthat have been exposed to acute chemical spills. Astudy of approximately 1,500 people who wereevacuated following a spill of Catacarb was pre-sented (23). Catacarb contains boron, potassium,metavanadate, and diethanolamine. Environmentaldata suggested that exposures to the spill were low;however, despite the low exposures, there were asubstantial number of self-reported health effects atstatistically significant levels compared with theeffects reported by the control group. These effectsincluded problems with memory, anxiety, depres-sion, sleep disorders, headaches, chemical sensitivity,dermatological problems and rashes, visual prob-lems, respiratory and gastrointestinal problems, andeye discharge. Dr. Bowler�s clinical evaluations of theresidents affected by the Catacarb showed that 60%had post-traumatic stress syndrome and 30% showedcognitive deficits involving verbal learning andmemory. In another study performed with a com-munity that had experienced a spill of metamsodium following a railroad accident, Dr. Bowlerfound a significant increase in salivary cortisol, aphysiological indicator of elevated stress, comparedwith the level found in controls (10). In both ofthese studies, it was noted that all of the effects(self-reported versus objective) were observed within

a relatively short period following exposures. It wasnot possible to differentiate whether these changesresulted from chronic psychological stress or theeffects of exposures to neurotoxins.

There are many considerations in diagnosingorganicity (i.e., effects of neurotoxic exposures onthe brain versus the psychological stress from theexposure). The issues and questions to be consid-ered when attempting to differentiate organiceffects from psychological effects are as follows:

Is the agent a known neurotoxicant (i.e., danger-ous to the human nervous system)?

What are the exposure variables (e.g., theduration of exposure, level of exposure, andpatients� prior knowledge of the effects ofneurotoxicants)?

Are the symptoms consistent with neurotoxiceffects (such as micromercularism, which resultsfrom chemical mercury poisoning, or cognitiveand attentional deficits associated with moder-ate lead exposure)?

Are mediating factors taken into consideration(e.g., age, prior exposures, prior illnesses,premorbid mental health, premorbid personal-ity, social support, other central nervous system[CNS] trauma, and prior sensitization to othertoxins)?

What are the general effects observed onneuropsychological function (e.g., are thereperceptual disturbances, changes in states ofconsciousness or awareness, or memory impair-ment)?

What are the specific effects on neuropsycho-logical functions such as verbal learning andshort-term memory?

Are the deficits observed consistent acrossneuropyschological domains?


Have developmental (i.e., age-specific) issuesbeen considered? In children, the maturation ofthe nervous system influences their susceptibil-ity. Children are frequently the most sensitivepopulation to neurotoxins, and assessing theeffects of an exposure on the youngest(preverbal) children may be difficult.

Other diagnostic considerations in differentiat-ing neurotoxicity versus psychological effectsinclude looking for inconsistent test perfor-mance, varied medical history, secondary gain(e.g., dependency, avoidance of activity, andfinancial gain), consistent history of exposure,and whether test results indicate an organicversus a psychological disorder.

When performing individual clinical tests, thefollowing pattern of results indicate a probableorganic cause rather than a psychological cause.Neuropsychological findings consistent with organicimpairment are 1) impairments in cognitive flexibil-ity, memory (especially sustained concentration andvisual memory), verbal fluency, motor speed, gripstrength, reaction time, and visual-spatial and visual-motor deficits; and 2) intact functions or normalscores in the area of word knowledge, simpleattention, malingering scores (i.e., frequency ofpretending illness or disability), and comprehension.

Data Gaps and Recommendations1 . There is a need for long-term, longitudinal

studies of neurotoxic substances. These studieswould examine exposure, specific effects ofexposure on neuropsychological functions,developmental issues such as maturation of the

nervous system, and how factors such aspremorbid personality and other CNS traumaaffect responses. Also examined would be agingand susceptibility to neurotoxins.

2. There is a need for further study on the issuesrelated to psychological effects of exposures tohazardous substances. Among the factors to beconsidered in these studies are actual or per-ceived control over the exposure situation orability to develop a personal solution, commu-nity factors affecting responses, cultural im-pacts, and what actual measures of stress shouldbe taken.

3. Multiple indicators of psychological stressshould be included when evaluating communi-ties that have experienced exposure to hazard-ous substances. This stress battery wouldinvolve multiple psychological indicators andphysiological measures of stress, as well asbiochemical indicators such as cortisol re-sponses/catecholamine levels and immunesystem functions. In terms of the physiologicalmeasures that could be used to differentiatepsychological from neurotoxic reactions,cortisol levels may be good indicators ofcognitive coping strategies and catecholaminelevels may be indicative of physical coping.

4. When interpreting results of stress batteries, it isvery important to consider how factors such asperceived control over the situation and havingor not having community and social supportnetworks may affect stress responses in thecommunities at hazardous waste sites.

Topic 4Given what is known regarding the psychobiology of stress, are there interactions betweenchronic stress and exposure to neurotoxicants that could shift the dose-response curve forneurotoxins?

BackgroundThis section discusses how to investigate thehypothesis that biological changes caused bychronic stress could shift the dose-response curve ofthe body to various types of neurotoxins, therebychanging the possibility of human health effectsfrom possible exposures. According to Casarett and

Doull�s Toxicology (22), a dose-response relationshipdescribes the correlation between the characteristicsof exposure to a toxin and the spectrum of effectsthat it causes. Other factors can also influence thebody�s response to toxins (e.g., age, gender, generalhealth).

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Three assumptions must be met if a dose-response curve is to accurately show the relationshipbetween exposure and effect: 1) the observedresponse is caused by the chemical administered; 2)the response is related to the dose; and 3) there is away to measure, quantify, and express the toxicity.

Panel DiscussionNeurotoxicants can have a multitude of effects,

including systemic effects. Neurotoxicity caninclude an early noticeable effect on a specific partof the nervous system and/or a delayed healtheffect that may manifest with aging or illness.

Three assumptions must be met if a dose-response curve is to accurately show the relationshipbetween exposure and effect: 1) the observedresponse is caused by the chemical administered; 2)the response is related to the dose; and 3) there is away to measure, quantify, and express the toxicity.

One of the panelists, Dr. Jean Harry presentedon how to investigate this possible interactionexperimentally. Currently, there are no humanstudies available to support this hypothesis.

A methodology does not exist that would allowfor discrimination between stress or neurotoxicant-mediated effects in community-based studies. Anyefforts would also require knowledge of the toxicchemical present and its expected biological effects.Experimental animal data exist to suggest that stresslevels can modulate a toxic response; however, thequestion of specificity remains. Given that stress caninduce or unmask a latent effect of a toxicant, thereis the possibility that chronic stress could alter basallevels of neurofunctioning and shift the thresholdfor neurotoxicity. Indeed, one may find a shift inthe dose response to a neurotoxicant; however, aspecific effect of the neurotoxicant needs to beexamined in greater detail than the generalized non-specific end points. Detecting such a shift wouldrequire the knowledge of toxicant-specific biologicalmechanisms of actions, which most often are notknown.

A possible question to be investigated is whatend points should be measured to determine if ashift in dose-response has occurred?

Data Gaps and RecommendationsThe following data gaps will affect the ability to

investigate the proposed question:

1 . Neurotoxic end points may be specific to thechemical, but most often they are not.

2. We often do not know the optimal range ofdose to measure the effects.

3. We may know the mechanism of action but notthe health consequences of the measuredbiochemical response (e.g., catecholamines).

The panel had the following recommendationsfor investigating the effects of stress on susceptibil-ity to neurotoxicants:

1 . There needs to be an examination of shifts ingeneral toxicity or other target organs with endpoints not confounded by stress. Experimentaldescriptive animal models need to be used totest the hypothesis about the synergistic interac-tion between stress and specific neurotoxiceffects of chemicals. Animal models of stress,such as auto-analgesia, reactivity (startle re-sponse), learned helplessness, and yoked-controlcould be used.

2. Target organs other than the nervous system,such as the cardiovascular and gastrointestinalsystems, must be included in the examination.

3. Common cellular pathways (i.e., mechanisms ofaction) need to be investigated.

4. The expected toxicant-induced responses needto be identified and a shift in that specificendpoint rather than an unrelated endpointshould be found.


Topic 5

What is known about the proportion of individuals who are most sensitive to the uncertaintyof possible exposures? This question includes consideration of populations who aremedically, psychologically, and physiologically sensitive.

BackgroundIn public health practice, consideration of medi-cally, psychologically, and physiologically sensitivepopulations who are unusually sensitive or suscep-tible is especially important. Identification of thoseunusually susceptible to a pathogenic influence�beit bacterial, viral, or toxic�enables specificallytargeted interventions to be designed to preventexposure or to mitigate exposure that has alreadyoccurred. People may be unusually susceptible to achemical because of a medical condition thatinterferes with the body�s detoxification process orexcretion of a toxin. They may be culturally at riskbecause of traditional practices that expose them toa greater than average dose of a toxin (e.g., nativetribes who live extensively on �country� food, suchas fish and wild game, that may havebioaccumulated [i.e., toxins have built up in theorganism]). Other people can be physiologically atrisk because of a genetic variant in an enzymeneeded for the detoxification of a chemical.

Panel DiscussionDr. Lawrence Schell was the discussant for this

topic. Dr. Schell stated that there is substantialscientific evidence to demonstrate that there arecategories within populations that are defined inbiological terms, such as the very young and thevery old, that are unquestionably more susceptibleto toxic effects than others. In addition, othersubpopulations might show more psychologicaleffects and other indirect effects because of theircultures.

Biological/Developmental FactorsSensitivity to a given toxicant exposure varies

with stage of human development. The fetus is theclearest example of heightened sensitivity, butaspects of sensitivity may be present in later stagesof development such as the neonatal period,childhood, and adolescence. Specific �windows ofinjury� may exist when exposure occurs during

critical periods of growth and development. Accord-ing to the theory of critical periods, there existspecific developmental periods when environmentalfactors can be especially disruptive, with immediateor late-developing effects. These critical periods maybe related to times of rapid cell proliferation, cellmigration, or other processes that are specific to thedevelopment of each organ system, as well as theinteraction of these processes. Another developmen-tal theory�set point theory�states that physiologi-cal parameters are �tuned� (i.e., operating limits andmodal functioning parameters set) within theindividual at specific times of development andthat these �set point� times may be influenced bythe environment.

Exposure itself varies with developmental stage,whether the intake is passive or active. Absorptioncan vary with developmental stage whether theabsorption is passive dermal, respiratory, or gas-trointestinal (GI). The heightened GI absorption oflead during infancy is a prime example. Anotherwould be the heightened affinity of fetal neuronsfor methyl mercury in comparison with that oftheir mothers. Intake of toxicants also varies devel-opmentally. Infants and children breathe morerapidly per unit body weight than adults and theirhigher dietary intakes related to their growth mean agreater intake of foodborne and waterborne toxi-cants per unit of body weight compared with adults�intakes. Furthermore, there are developmental stage-specific behaviors, such as mouthing, that increaseintake of dust and contaminants. Metabolism,detoxification, and excretion vary with developmen-tal stage as well.

Interaction of Culture and EnvironmentIn addition to extra sensitivity because of

biological factors, heightened susceptibility toexposure can occur because of cultural factors. Anexample of this is Native American groups that areat heightened risk because of their religious beliefsand subsistence diets that generally involve greater

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contact with indigenous wildlife as well as water andsoil. A specific example comes from the experienceof the Mohawk Indians of Akwesasne (St. RegisMohawk Reservation, New York) with contaminantsfrom a Superfund hazardous waste site on the St.Lawrence River. Traditional Mohawk subsistencelifestyle includes consuming locally grown plantsand local game, including fish from the St.Lawrence River, waterfowl, and wild mammals.Because of the PCB levels in locally caught fish, theSt. Regis Mohawk Environmental Health Servicesand the New York State Department of Healthsuggested in the mid-to-late 1980s that people limitconsumption of locally caught fish or, if of child-bearing age, to avoid consumption entirely. Locallygrown foods and waterfowl are suspect as well.

Avoiding locally caught fish and other types ofsubsistence food constitutes a significant departurefrom the traditional diet and a loss of one aspect oftraditional culture (24). The social importance ofdiet should not be underestimated. Today, diet is acommon marker of ethnicity, and it is also inte-grated into a culture in several ways. For example, inNative American cultures, the traditional subsis-tence methods were carefully taught to each genera-tion. This teaching itself was an important compo-nent of culture building in each generation; how-ever, if eating locally obtained foods is no longerhealthy, children are not taught how to obtain,prepare, serve, or consume them and a core compo-nent of the culture is affected. In addition, NativeAmericans are caught between two diet-relatedhealth risks. They are already at high risk because ofobesity, with its attendant health risks of diabetesand cardiovascular disease. To reduce the risk ofthese conditions, they are advised to eat fish andvegetables�the very foods that are lost from thelocal diet because of contamination. One may ask,�Which poses the greater risk, consumption ofcontaminated food or consumption of processedfoods?� Thus, the loss of the traditional dietconstitutes not only a loss of the culture but can beperceived as a direct blow to one�s health.

Culturally imbedded values can strongly impactreactions to the discovery of a hazardous waste site inone�s community (25). For example, among many

Native American groups, land has a differentmeaning than it does in mainstream Americanculture. In some groups, land has religious meaningand/or is a symbol of sovereignty and cannot besold. In contrast, in mainstream American culture,land rarely has this significance. Thus, most U.S.residents would move away from a hazardous wastesite without feeling that their religion has beenaffected. Some lands are regarded as sacred bymainstream culture. Arlington National Cemetery isa good example, because many Americans would bedismayed if a hazardous site were discovered there.There probably are sacred lands in every culture,but, in some cultures, all of one�s homeland issacred in some sense. Restricting access to, or use of,such lands because of contamination could bedisturbing and stressful.

Culture has other, wider effects on susceptibil-ity to toxic exposures; culture can affect symptomexpression. Certain �diseases,� called culture boundsyndromes, are found only among specific cultures.These syndromes include susto (a folk illness that isattributed to a frightening event). This illness isfound among some Latinos in the United States andamong people in Mexico, Central America, andSouth America. Nervios (a general state of vulnerabil-ity to stressful life experiences and to a syndromebrought on by difficult life circumstances) is com-mon among Latinos in the U.S. and Latin America.There is a similar concept of �nerves� among Greeksin North America (nerva), and pibloctoq (an episodeof extreme excitement, which lasts up to 30 minutesand is often followed by convulsive seizures andcoma lasting up to 12 hours) is found amongAlaskan Eskimos (26). Culture can also affect howsymptoms are reported. People in some societiesmay be more comfortable reporting a certain typeof symptom (bodily versus emotional); alternatively,certain symptoms may be emphasized. Thus, thebiological effects of a hazardous waste site may beexperienced and reported differently depending onthe culture of the people affected by it.

Culture affects the individual�s role in day-to-day activities, thereby directly influencing behaviorthat could lead to exposure. People with culturesthat involve more subsistence activities will have a


greater chance of contact with hazardous waste inthe land or native plants and animals affected bycontamination.

The psychological stress found among somepeople reacting to exposures to hazardous waste maybe mediated by social support. Culture�as a sharedsystem of values, rights, obligations, and expecta-tions�defines the conditions under which support isgiven, the members of the social network, and thetypes of support available (27). Measuring socialsupport in a multicultural situation will probably notaccurately define social support in each culturalgroup.

A disaster is the result of an unexpected loss ofapparent or perceived control of natural ormanmade forces. Baum and Fleming have shownthat in the United States a key psychological dimen-sion in predicting health-related reactions todisasters is individual control (7). Furthermore, theyhave shown that disasters caused by human failure,including the creation of a hazardous waste site,produce greater stress and health effects thannatural disasters.

In the United States, hazardous waste sites aremore likely found near communities populated byminority groups, especially African-American andHispanic groups. Minority communities may have atradition of distrust of government authorities. Aculture of distrust may prepare residents for thediscovery that the government�s control of hazard-ous waste has broken down and human exposure totoxicants is likely. Models of reaction to hazardouswaste sites that are based on the assumption that theloss of control is a significant feature may requiremodifications when applied to communities thathave a history of disempowerment and genuinelyexpect ill treatment by governments.

Members of subordinated cultures and minoritygroups that have been dominated by a mainstreamculture may perceive less control of events andcircumstances because of their history of powerless-ness against mainstream culture. The premise thataccidents caused by breakdowns in technology aredifferent from nature-caused misfortunes is culturallylimited (25). While members of mainstream Ameri-can culture may perceive human failure as more

surprising, less forgivable, and less understandablethan nature-based �failure,� non-mainstream mem-bers may see human systems as more prone todisaster, less trustworthy, and their failure not assurprising as compared with circumstances createdby nature.

Two types of control may be considered in amulticultural context (28). Primary control refers tocontrol exerted by changing existing circumstances.It is proactive and the form of control emphasizedon most scales that measure control. Secondarycontrol refers to control exerted by changing one�sself to suit the existing circumstances. Primarycontrol is the type most Western observers prefer,and secondary control may be viewed asnoncontrol, an absence of responsibility for circum-stances. Secondary control may be more typical ofnon-Western cultures. Among these heterogeneousgroups, accommodation to the natural environ-ment may be more common, and fewer technologi-cal means are used to make large-scale changes to theenvironment.

Data Gaps and Recommendations1 . Little work has been done on how various

subcultures within the United States respond toexposure to hazardous substances.

2. Measurement of control mechanisms in toxi-cant-impacted populations will need to takeinto account different cultures� varying styles ofcoping.

3. Cultural factors affect the actual risk of exposure,the perception of risk from exposure, theperception of consequences of exposure, andthe perception and expression of personalsymptoms. Reactions to the breakdown ofcontrol over hazardous waste exposure dependon culturally defined expectations of controlover human-made and natural forces.

4. Non-Western cultures and minority groups thathave been dominated by mainstream cultureand society may experience hazardous waste sitesdifferently and more severely than peopleintegrated into mainstream American culture.Health consequences of hazardous waste sites

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may exacerbate already existing social and healthproblems.

5. Recommendations for working with sensitivepopulations:

Create a true and equal partnership with theaffected community.

Base the project in the community. This willmean learning the community values andempowering the community to solve itsproblems.

Use a holistic approach. The indirect effectsof hazardous waste exposure (e.g., culturaldamage, socioeconomic impacts, and psycho-logical distress) may have more severe healtheffects than the chemicals.

Use good science.


Composition: Composed of community and social psychologists, sociologists, anthropologists, politicalscientists, and community members affected by hazardous waste sites.

Charge: To review what is known about the psychosocial responses in communities located nearhazardous waste sites and to make recommendations regarding ways of interacting withcommunities, outline problems in need of further investigation, and suggest possiblepsychosocial interventions to reduce stress.

Panel members were not asked to evaluate community and psychosocial issues associatedwith specific sites. Instead they were asked to use their complementary backgrounds andareas of expertise to provide an overview of the following three areas: 1) the factors thatmight render some community members susceptible to the stress of living near a hazard-ous waste site, 2) the known psychosocial responses of community members living nearhazardous waste sites, and 3) the psychological impact of experienced uncertainty of theconsequences of toxic exposures.

PANEL TWO:COMMUNITY AND

SOCIAL SCIENCE PERSPECTIVES

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Topic OneAre there factors (both internal and external) that might render some communities more orless susceptible to the stress of living near a hazardous waste site?

bility of accidents occurring in complex, interdependenttechnical systems (29). The work of Ulrich Beck on the�risk society� is about how modern society organizes thedistribution of risks (30).

With chronic technological disasters, the impact variesin different communities. At the worst, the impact can besevere, causing social conflict both within and betweencommunities and other social entities. These conflicts areseen not only in our society but in other cultures. I traveledto Minamata, Japan, where methyl mercury contamina-tion and resulting health sequelae occurred. There I foundsocial conflict occurring more than 30 years after thecontamination. The fact that all the community factionscould sit face-to-face at a table and talk was viewed asgreat progress.

In chronic technological disasters, the social processexacerbates rather than ameliorates the primary stress ofthe exposure. There are two types of stressors: the stress ofliving near contamination and the stress that results fromthe social process that arises from contamination.

The members of the panel who are residents ofcommunities living near hazardous waste sites asked thatcommunity members be fully accepted as experts on theproblems in their community.

Panel DiscussionThere are ethical issues associated with how a

community effectively works through the stressfrom a technological rather than a natural disaster.For example, industry has suggested affectingpublic perceptions at a hazardous waste site bygiving tours of the site and making therapy avail-able at the site. This would be an unethical use oftherapy to change people�s minds in a pre-deter-mined way.

This raises the question, should efforts befocused on helping people to cope with an unjustsituation or helping them to change the situation.According to represented community members, thisis the heart of the matter.

However, the community also feels that if the

Background

With the discovery of toxic contamination, manyaffected communities will suffer social conflicts.The sources for social conflict are many. Theinvisibility of most toxic contaminants may make itdifficult for community members to reach agree-ment on their effects. The uncertainty can heightenindividual and family distress and may lead todisputes between neighbors, particularly when thecontamination is spread unevenly throughout acommunity. Residents who live close to hazardouswaste sites frequently have different views of theirpossible exposure and its health effects thanresidents of the same community who live fartheraway and do not believe themselves to be affected.For that reason, factions can develop in communi-ties between those living inside and those livingoutside the affected area.

The chair of the panel, Dr. Stephen Couch,introduced this topic by comparing how communi-ties respond to natural disasters with how theyrespond to technological (human-related) disasters.

Dr. Couch: (Dr. Couch�s introduction is reportedas transcribed from tapes of the meeting.)

I began my work on this topic in a town calledCentralia, Pennsylvania, in 1981. This was a communityaffected by an underground mine fire. Rather than thepulling together of a community as described following anatural disaster, I observed a community breaking apart,neighbor fighting neighbor over what to do. Since then, Iand my colleague Steve Kroll-Smith have studied socialresponses to human-made disasters. We define locationnear a hazardous waste site as a chronic technologicaldisaster�chronic because it�s a long-lasting experience withpotentially long-lasting or future health effects andtechnological because it is caused by the use of humantechnology. As Erikson so eloquently said, here is a �newspecies of trouble.�

I see chronic technological disasters as the consequencesof how we have set up our technological society. CharlesPerrow�s paper on normal accidents explains the inevita-


The following are some prevariables that affectsusceptibility: age, length of residence, location orproximity to the site, socioeconomic status, specificcultural factors, and coping vulnerabilities (e.g.,state of psychological health). Intrinsic factors arepreexisting health status and the physiologicalimpacts of hazardous substances. Extrinsic factorsare the social context in which the contaminationoccurs and the social response to that contamina-tion. To evaluate the community, the ecohistoricalcontext in which the contamination occurs must beunderstood.

Environmental contamination or chronictechnologic disasters take place over time. Thischanges the disaster cycle known from studies ofnatural disasters. In a natural disaster, such as ahurricane, there are distinct stages�warning, threat,impact, and so on�to recovery and rehabilitation. Inenvironmental contamination, communities get stuckin certain stages; there is no linear progressionthrough them. Environmental contamination leadsto cycles of the warning, threat, and impact stages.

Another difficulty of these situations is thedependence of communities on external govern-ment agencies. Few communities have the resourcesto cope with or respond to environmental contami-nation. Another important factor is the trustrelations between the parties involved. The decen-tralized structure of dealing with a hazardous wastesite means that many government agencies partici-pate but without a clear line of command. Thisresults in differing information from variousagencies, which leads to a loss of trust and a reasonfor dissension in the communities.

Also, what can these communities expect in theway of final outcome and resolution of chronictechnologic disasters? The solutions range from atechnical fix (which many people may have diffi-culty believing has solved the problem) to reloca-tion (which destroys the community because itdisperses the individuals within it).

Cultural Factors Affecting ResponseDr. John Pettersen led the panel discussion on

this topic. Culture plays a direct role in perceptionof threat and response to threat. People of certain

consequences for the public�s health could bestopped as soon as detected, the high price ofhaving to treat continuing stress, resulting from acontinuing identified hazard entering the environ-ment, could be avoided. If the causes of stress arecurtailed or stopped completely, it won�t have to betreated.

This discussion includes:

Individual and community dynamics,

Cultural factors affecting responses,

Community (e.g., marginalized), and

Factors involved in a community�s response(i.e., duration of exposures, socioeconomic anddemographic factors, and factors unique to acommunity).

Consideration of Both Individual andCommunity Dynamics

The panel began by discussing the chronology ofthe Superfund process as presented by Dr. MichaelEdelstein. It is important to realize that the environ-ment of a Superfund site changes over time. At thebeginning, there is the incubation phase. A hazardexists but is not recognized as such by the commu-nity. Then, there is the discovery stage. The publiclearns of the existence of a problem with a hazardoussubstance, usually by some type of announcement.After the discovery of a hazard, a long stage ofenvironmental turbulence begins. First, there isshort-term adjustment or initial coping on indi-vidual, family, social network, and institutionallevels. If the initial coping fails, then a disabling andfrustration of the community occurs with socialturbulence. At this stage, efforts at collective copingare initiated. These efforts include mobilizing socialsupport, seeking sources of trusted information,and utilizing community or individual power. Ifproactive coping works, then the community cansuccessfully form a response to contamination. Ifefforts at collective coping fail, social turbulenceoccurs, dissension or community destructionensues, and an environmental stigma is cast on thatcommunity.

All communities are susceptible to the stress ofenvironmental contamination but in different ways.

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cultural backgrounds are more sensitive to threatand have lower thresholds for suspicions. Some ofthese perceptions are based on historical events (e.g.,Native Americans� history with U.S. governmenttreaties), lack of political control, and impoverish-ment.

Additionally, traditional communities are oftenmore tightly knit, have kinship groups, have reli-gious ties to the land, and find it harder to leave anarea impacted by environmental contamination.Different groups of people have different vestedinterests in the land (i.e., development versussubsistence) and even different belief systems inrelation to the land.

After an environmental disaster, such as theExxon Valdez accident or the discovery of a leakinghazardous waste site, the response may alter existingcustoms within a culture. For example, in Alaskaafter the Exxon Valdez accident, the high-wage clean-up jobs displaced employees from traditionalsubsistence hunting. When you alter existing cus-toms within a culture, structures within a commu-nity, or even regulations within a large social struc-ture like an industry, the rebound amplificationscreate social tensions and disruptions. These aresecondary responses to contamination. The primarystress comes from exposure to the contamination;other parts of the psychosocial stress come from thesecondary social response to the contamination.

Other secondary responses are related to mitigat-ing suspected, potential, or actual exposure tocontaminants within a community. For example, if afish consumption health advisory is issued becauseof environmental contaminants present in fish, thestress for some community members worried aboutthe contamination will decrease but may increase inother groups within the community, such as com-mercial or subsistence fishermen. Such an interven-tion could reduce or eliminate the income of thecommercial fishers or the low-fat dietary source ofprotein for subsistence fishers. Either of theseoutcomes could ultimately have a negative effect onthe health status of the members within thesegroups. The health benefits of any interventionwithin a community should be assessed in relationto the health risks they could potentially generate.

All stakeholders should be identified and theirconcerns addressed before interventions are imple-mented to reduce the psychosocial effects and stressassociated with the interventions.

It is important to remember that often health isstated as the central concern of communitiesaffected by contamination; however, a healthconcern is also often the only issue that somecommunity members feel they can cite to legitimizetheir concerns. Quality of life, social �toxic� stigma,and reduction in community resources (e.g., loss ofequity and tax base resulting from property devalua-tion) are valid areas of concern. Frequently, however,those issues go unstated because residents believethey will not generate much response and support.

Finally, communities and scientists have differ-ent cultural assumptions. The scientists look formaterial proof of physical health problems. Com-munity members rely on feelings (i.e., symptoms) ascues for problems. These differing assumptionsmake communications between the groups difficult.

Marginalized CommunitiesDr. Mildred McClain led this discussion. (Dr.

McClain�s comments are reported verbatim from the tapesof the workshop.)

In marginalized communities, disenfranchisedcommunities, uncertainty is an everyday way of life.People are not recognized as full citizens. There is a loss ofcontrol over community life. There are multiple layers ofstress: violence, poverty, poor health, lack of knowledgeabout environmental problems, and lack of understandingof the science.

There is a lack of understanding of the problems of amarginalized community in the mainstream culture.African-American communities are a non-homogeneouspopulation. There is a diversity of political persuasions.We suffer from poor health services. There are economicdeprivations. We are dependent on jobs with the pollutingindustry. Racism. Acceptance of what is. Fear of speakingout. Programmed belief in Cain vs. Abel. The curse ofCain rooted in Biblical validation. Lack of any services orsystems to help deal with any stress. Internal violencewithin these communities coupled with substance abuse andlack of respect. There is a high level of mistrust in govern-ment agencies�history of not addressing the problems. Add


to that a lack of resources to empower people to participateand a perceived lack of power. Add to this stress the extrastress of living near a hazardous waste site as well as therecurrence of pollution and accidents in an industrializedzone.

What is the impact of the stress and impact ofenvironmental toxins? What was the effect of industrialintrusions in our communities? �Walking poison timebombs.� How does poor nutrition affect our response toenvironmental contamination? We believe the environ-ment is everything. Environment encompasses everything.If the land is injured, then the people are too. The generalsociety believes �we are in control.� In marginalizedcommunities there is no separation. The Superfund assumption isthat you can isolate one source of contamination. This assump-tion ignores the multiple sources of contamination.

What Factors to Consider WhenAssessing a Community’s Response

As stated before, communities are not homoge-neous. When you consider the various copingmechanisms of different groups within a community,group culture plays a large part in shaping responsesto situations. Groups provide alternatives, differentstrengths, as well as resilience and capacities torespond.

The following is a list of factors to considerwhen assessing a community�s response to anexposure to a hazardous substance:

Other stressors affecting the community,

Community values,

Sex roles,

Demographics,

Percentage of renters versus homeowners,

Primary language (may not be English),

Odors from the hazardous waste site,

Visibility of toxins such as fires and smoke, and

Physical factors (e.g., cancer incidence andoutcome, low-term birth weights, stillbirths,birth defects).

Data Gaps and Recommendations1 . There is a need for more work on explicating

the following gaps in the data:

Sources of stress in conversations aboutenvironmental hazards,

Amount of stress inherent in learning ofcontamination,

Nature of known or believed exposures,

Fear of the unknown regarding hazardousexposures, and

Stages of where a community is in theSuperfund process.

2. There is a need to explore and compare responsesof mainstream culture to hazardous substanceswith that of traditional and marginalized com-munities.

3. There is a need for greater understanding of howculture shapes response to the threat of environ-mental contamination.

To meet these needs, the following recommen-dations must be considered:

1 . Treat communities with dignity and respect.

2. Don�t try to solve the communities� problemsfor them; rather, assist them in solving theirown problems.

3. Be thoughtful of race/ethnicity.

4. Realize that scientists may not have all theanswers for a community near a Superfund site.

5. Give communities practical actions to take.

6. Identify the different sectors of a community.Take into account that communities are diverse,and identify centers of respect between diversegroups.

7. Don�t use technical language or jargon whencommunicating with communities.

8. Two-way communication between governmentagencies and communities is critical.

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Topic TwoWhat are some of the psychosocial responses that communities have given to the stress ofliving near a hazardous waste site, and what have the results of those responses been?

hazardous waste site was compiled from letters fromher community. The letters indicate that the com-munity members are experiencing the following:outrage, anger, depression, stigmatization of af-fected community members, distrust, fear, guilt,redlining of properties, violence inside the commu-nity, threats of violence because of social discord,intimidation, disenfranchisement, activism, and lossof community members through illness, burnout(i.e., exhaustion), or death.

Audience ResponseThere is a gap between the government agencies

that deal with environmental contamination andthe communities that experience it. The agencieshave the power and authority to deal with theproblem. The scientists know the problem betterthan community members, so agency representa-tives have a tendency to talk rather than listen tocommunity members. Often, agency control over asituation produces little communication about theprocess. On the other hand, the community mem-bers are often fearful, lack true knowledge of theconsequences of environmental contamination,can�t or don�t express their feelings about thesituation, have no control over the situation, andneed more communication with agency representa-tives. The situation must change so that agenciesand communities work together to find solutionsfor environmental contamination.

Joint Audience and PanelRecommendation1 . There is a need for a training handbook for

state and local public health officials on how towork with communities in these situations.

BackgroundA survey of the literature shows that living near ahazardous waste site can cause great stress within acommunity and within the individuals living in thatcommunity. Some of the psychosocial responses ofcommunity members living near a hazardous wastesite are:

Fear and uncertainty over the possible healtheffects of exposure,

Feeling a loss of control over the present situa-tion and the future,

Anger over loss of security and safety within thecommunity,

Confusion brought on by trying to understandvarious government documents,

Community conflict over who is to blame andwhat actions to take,

Frustration over the lengthy clean-up process,

Increased family conflict,

Concerns over economic losses (e.g., propertydevaluation, doctor bills, and business losses),

Feelings of being stigmatized and isolatedbecause of living near a hazardous waste site,

Frustration of dealing with bureaucratic agencies,and

Frustration of being accused of �overreacting.�

Panel DiscussionMrs. Mary Minor led a participatory discussion

between the audience and the panel on this topic. Alist of responses to the experience of living near a


Panel PresentationDr. Heather Tosteson presented her work on

this question. (Dr. Tosteson�s presentation is transcribedfrom tapes of the workshop. It is not printed verbatim.)

To get us started, I�m going to present some ideasabout uncertainty and environmental health. First, I�llrun through some of the effects uncertainty can have at theindividual, social, and political levels, then discuss thedistinctive content of our uncertainty in situations ofenvironmental exposure. I�ll conclude with some suggestionsabout how this content might affect our choice of a socialresponse as a government agency to the distress we areseeing.

DistinctionsDisaster: I�d like to begin by making three

distinctions to help us better define the specificsituations we are looking at. Although we arediscussing a disaster paradigm here, the situation atmost of the sites we see is very different from thedisasters�even technologic disasters�that have beenstudied because of the pervasiveness of the uncer-tainty involved. The Three Mile Island, Bhopal(India), and Exxon Valdez incidents were all sociallydefined as threats or disasters. The situation atNational Priorities List (NPL) sites is often not thatclear. Although listing on the NPL means the site isan environmental threat, whether it is a humandisaster is often not as clearly defined. The disasterhere is the undefinedness of the situation.

Siting/Exposure: The uncertainty posed by a sitingdecision and that posed by possible current or pastexposure are quite different because the types ofthreat are different. It is not uncertainty alone that isstressful. For example, we can be uncertain if thesun will shine next weekend but not lose any sleepabout it. What bothers us is uncertainty associatedwith possible danger to ourselves or those close tous combined�as is the case with technologicdisasters�with some sense of responsibility fordetermining and avoiding the danger. When people

fear they have suffered toxic exposures, they feelpersonally implicated in a more immediate andinescapable way than if they are contemplating theacceptability of a future risk. In other words, thesituation we have here is one that is deeply unde-fined, but also one where the personal stakes areperceived as very high.

Normal/Abnormal: All the responses here arenormal responses to chronic and pervasive uncer-tainty in general and to the range of uncertaintycommon to these specific situations of environmen-tal exposure.

CopingUncertainty in these situations accentuates an

already threatening and divisive situation. Its effect isto polarize views and to freeze the natural sequenceof our responses so that we find it difficult to reachpsychological or social closure and to integrate theexperiences either individually or as a society. Wecannot fight or flee. We can�t resolve and move on.At a personal level, uncertainty interferes with thefirst step of coping, which is our ability to appraisethe level of threat a situation poses for us. If we can�tdecide how dangerous a situation is, we can�t decidehow to cope with it. Further, if other people can�tdecide how dangerous a situation is or come toradically different interpretations from us, it isdifficult for us to act in concert. And environmentalthreats are communal threats, so the role of commu-nity consensus is central.

A number of panelists�in particular Drs. Couchand Edelstein�have studied the damaging socialeffects of differing appraisals of threat, differencesthat cannot be resolved because the science is notthere to �prove� who has been exposed and whatwill happen to them. Dr. Edelstein wrote in hisbook on Legler that there may be no psychologi-cally healthy way to respond to the uncertainty oftoxic exposures�there was only obsession anddenial. At a social level, fragmentation and stigmati-

Topic ThreeDiscuss how the human response to uncertainty may lead to different understandings of apossible exposure to a hazardous substance and its relationship to psychologicalresponses such as learned helplessness.

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zation are ways of trying to limit uncertainty�obsession and denial on a larger scale. Differentgroups may be frozen at different stages in thedisaster process�some still at the appraisal stage,while others are convinced that impacts have alreadyoccurred and that concerted communal action isrequired. Uncertainty also pervades public policyand politics because science cannot be used in itsconventional role as an �objective� basis for deci-sions. Litigation and protest are evidence of thebroad social and philosophical conflict theseuncertain but highly resonant situations provoke.

ContentBecause science as we now know it is insufficient

to resolve the questions people have about the safetyof their environment, what uncertainty does in thesesituations is put up a blank screen on which some ofour greatest fears flash continuously. This is a situa-tion that as human beings we try to protect ourselvesfrom constantly. It is the resonance and the un-boundedness of the content of our fears aboutenvironmental hazards that we need to talk aboutbecause we can�t get away from them. It�s not justthat we are uncertain, but that we are uncertain aboutthings that are deeply�I would suggest primally�frightening. This is what gives these situations theirparticular emotional force. And it is the broadsymbolic power, the philosophical and emotionalvalidity of these issues, that ensures that we cannotwish them away. Environmental exposures can cometo challenge our faith in ourselves, our physical andsocial worlds, and in our future.

Here are some of the issues that come up whenconsidering environmental exposures:

Disease and mortality: Usually people begin toget actively involved in issues of toxic exposurebecause they have seen some evidence of harm,usually diseases in their family or community. Oftenthese diseases are poorly explained by existingparadigms. Disease itself is frightening, particularlycertain kinds of diseases, for example cancers andespecially childhood cancers. Cancers frighten usbecause they are evidence that the body can turn onitself, that normal processes can suddenly twist backon themselves and become deadly.

Contamination: Environmental exposures alsoprovoke our fear of contamination, which is a fearabout the boundaries between ourselves and ourenvironment dissolving. How can we protect our-selves from something we can�t see or touch, some-thing we can�t measure, something whose effects wecan�t predict? Horror movies often play on this basicfear of a threat we can�t see, control, or escape�onethat can invade our homes and threaten everyone wehold dear.

Stigma: An extension of the fear of contamina-tion is the fear of the consequences of social con-tamination, or stigma. Even if scientists think there isno threat, the world may see the situation differently.People can find their property values falling and theirfuture economic security jeopardized by socialprocesses over which they have no control.

Justice: Environmental exposure can challenge ourtrust in the justice of our social system because werealize that environmental exposures are not evenlydistributed in society, that the people who suffermost from the fallout of our highly technologicsociety are not usually those who benefit most fromthe fruits of our way of life.

Social Structure: Our trust in our whole socialstructure can be challenged. We can begin to distrustindustry, and more devastating, our scientists, whoare meant to know what dangers they are creatingwith their technologies. We can begin to distrustour medical and health systems, which we havecounted on to be able to identify and treat ourillnesses, and we can begin to distrust our govern-ment, which is charged with protecting us.

Community: Environmental exposures can poseeven more immediate, thus more devastating, threatsto our sense of community. We can find that oursense of the reality of threat and our neighbor�s senseof the reality of threat are so different that it is as ifwe live in completely different worlds. We can beginto wonder if anything holds us together.

Physical World: Our relationship with our physicalworld can be changed dramatically. What seemedbeautiful and benign can now seem filled withinvisible and thus unlimited threat.


Future: Most devastating, environmental expo-sures, particularly our uncertainty about them, leadus to questions of ultimate concern. One of the mostfrightening of these is the issue of irreparable harm�that the way we are living now may end up destroyingus and our children without our willing it. When wefind out the true level of danger, it may be too late tochange it. This fear is especially triggered by pastexposures�things that have happened to us withoutour knowing it but which may pose threats to us andour families for generations to come.

Because of the resonances of these ideas andbecause of the sheer number of shocks to our beliefsystem that can be associated with these environmen-tal issues, people can come to see both their physicaland their social worlds as profoundly unsafe. There isno place they can escape to and there is no one theycan trust to help them. This, finally, is an unbearableway to live. The social distrust may well be the mostdamaging consequence, particularly when we aretalking about past exposures. In siting decisions,people require fair choice�an equal voice in decid-ing on the acceptability of exposure to risks. Illnessspeaks more specifically to our dependency on eachother. Here the relationship people need with theirsociety is one of care. Part of that care is acknowledg-ing the psychological and social stress caused bythese situations of ineradicable uncertainty andpotentially disastrous personal threat.

People who have been profoundly affected bythese situations are different people when the situa-tion is over. They see the world differently and maywell need to have this shift in their world viewexpressed in social terms. Psychologically, it is theimpact of this crisis of faith that needs to be ad-dressed because it won�t go away. Even if you labelpeople as anxious or demoralized, any interventionwill require that you return in the end to the contentof that demoralization�the issues and ideas involved.Only by respecting both the rational source of thedistress, its specific symbolic/philosophical/emo-tional power, and the need for us as a society toprovide a social fabric that can contain these ques-tions�that can discuss and debate them consciouslyrather than be driven by them�will we be able to findsocial, if not scientific, resolution. And I thinksocial resolution is crucial in these situations.

Uncertainty is a fact of life. It is also a dreadfulmystery and one that we all find difficult to look attoo long and too directly. It is a function of cultureand of social structure to help us find ways to makethe uncertainty of life bearable, and it is this role thatI think we are not successfully fulfilling at this time. Ithink one of the questions we are being asked toanswer here is who will care for us when we havelooked too long and too directly into the abyss. How,when our faith in our way of life has been so severelychallenged in so many ways, can we find a way tomake life meaningful and trustworthy again?

Here it might be important to point out that theuncertainty of these situations has strong emotionalimpact on scientists as well. The level of scientificuncertainty can bring scientists to question theadequacy of the scientific method, to question thebiomedical paradigm, to question the rightness ofthe professional control of the discipline, tochallenge their belief that science is a value-freeactivity and that science plays a benign role in socialconflicts. These challenges to their way of life are aspervasive and threatening as the challenges toxicexposures have been to communities. Thus, theyresist any suggestion that they enlarge their defini-tion of the problem to include the psychologicaland social effects of exposure, for to include them,to acknowledge the emotional force and philosophi-cal resonance of the experiences of the communi-ties, will expose them to a crisis of faith.

Data Gaps and Recommendations1 . There needs to be open, honest discussion of

the victims� concerns. They need to be treatedwith respect and compassion as real people, notjust as scientific or clinical cases.

2. Part of a community assessment for aSuperfund site should include an overview of acommunity�s options for action and the con-straints to action.

3. The process needs to openly confront the issueof values involved in environmental contamina-tion. No amount of data will resolve fundamen-tal differences in world views or belief systems.

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Special TopicWhat are the psychosocial effects of relocating a community when environmentalcontamination cannot be safely remediated?

have help and guidance in solving problems of dailylife�mail forwarding, change of address, addressexpenses of increased travel to and from work, andpossible change in schools for children.

Effects of temporary relocation: These effects aredifferent from permanent relocation.

There is separation from the rest of the commu-nity by �being privileged� to be relocated. Coordina-tion is needed with schools regarding the effects ofenvironmental contamination and temporaryrelocation on children�s performance at school. Inour experience, children in our neighborhood whohave been relocated have shown improved opportu-nities for learning, decreased rage, and less problemswith concentration and attention.

Data Gaps and Recommendations1 . There is a need to look at the effect of environ-

mental contamination and relocation onchildren in these communities.

2. There may exist a need to consider such actionsas retraining for new jobs (if relocation involvesloss of old jobs) and how relocation affects jobperformance.

3. Early interventions to prevent physical andpsychological stress need to be implemented inthese communities. Maybe they could be basedon the Federal Emergency Management Agency(FEMA) emergency response model.

4. We recommend providing a list of governmentagencies involved in the Superfund process tothe communities so they can sort out theplayers.

Special PresentationAt the request of Dr. Gershon Bergeisen, from theEPA, a special presentation of a relocated communitymember�s perspective was given by Mrs. CindyBabich, a community member from the Del Amo sitein Torrance, California. The following is a summaryof Mrs. Babich�s presentation.

Mrs. Babich: To address the question of reloca-tion, you must consider the effects of no relocationon a community affected by hazardous substances,the effects of relocation, as well as the psychosocialreasons to relocate a community.

Effects of no relocation: To the Superfund commu-nity, no relocation represents a lack of caring fromthe wider community. �Condemned� and �trapped�are terms frequently used to describe communityperceptions. Real or perceived continuing exposureto the contamination occurs as well, and this maylead to continued stress.

Effects of permanent relocation: Governmentagencies could take steps to keep costs of relocationdown by preplanning. There is a need for a set ofpermanent environmental relocation criteria. Therealso needs to be policies to address differing needsof homeowners versus renters. Home owners willwish to be bought out at fair market price. Renterswill need help in finding similar housing. Agencieswill need to consider whether or not the wholecommunity wishes to move together. There will be aneed for special outreach to inform communitymembers and help them deal with relocation. Thereare the needs of special populations. Elderly can�tdeal with relocation. On the basis of our experience,there is a need for those undergoing relocation to


Composition: Composed of clinical psychologists, psychiatrists, occupational medicine physicians,disaster relief specialists, and community members affected by hazardous waste sites.

Charge: To develop public health strategies to prevent and control long-term stress-related healthproblems in communities near hazardous waste sites. Panel members were not asked toevaluate prevention and intervention strategies associated with specific sites. They wereasked to use their complementary backgrounds and areas of expertise to provide anoverview of 1) what is known and not known about the effectiveness of previous preven-tion and therapeutic strategies in these communities, 2) the most effective methods forpreventing and mitigating stress-related health problems in communities near hazardouswaste sites, and 3) methods for increasing public and professional capacity to respond topsychological issues related to hazardous waste sites.

PANEL THREE:PROTECTING AND PROMOTING

PSYCHOSOCIAL HEALTH

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Topic One.How has the extent of the psychosocial effects and possible public health impacts in thesecommunities been assessed to date?

How we might assess impacts and effects: A determi-nants of health approach could be used to assessimpacts and effects. This approach looks at howcertain demographics and socioeconomics contrib-ute to health, well-being, or illness. This importantinformation can add to the assessment process.Another approach that could be used involves thevalues and interests of stakeholders or other in-volved parties. This means understanding theirvalues and what they feel threatens their interests.This may involve property values, children, and/orthe future in general. Essentially, that is what hascome from the in-depth studies of Edelstein andothers. For this type of study, a partnership with thecommunity is critical. Strategies that could be usedinclude those mentioned above, as well as datapooling to look for common themes, reviewing andlearning from occupational health studies of stress,and creating and instituting rapid assessment toolsto assess the problem swiftly.

The context of assessment: Responses to contami-nating events are socially and culturally mediated incomplex ways. To some degree, they are unique tothe particular study setting and cannot be divorcedfrom context. Each community�s circumstances areunique.

Data Gaps and Recommendations1. The extent to which psychosocial public health

impacts have been assessed to date is relativelylimited. There are opportunities for more studiesto define the problem. There are varioustechniques and processes that warrant furtheruse.

2. A comprehensive community needs assessmentis a critical first step in shaping the design ofinterventions and adapting implementationplans to unique community characteristics.

BackgroundMost of the recent psychological research on theeffects of technologic disasters has been designedaccording to the principles of psychiatric epidemiol-ogy with the use of case-control populations andknown standardized instruments. According to thesestudies, psychological disorders found in populationspossibly exposed to hazardous substances are similarto those found in communities that have experiencednatural disasters: heightened incidence of anxiety,clinical depression, and post-traumatic stress disorder(PTSD).

Panel PresentationDr. John Eyles began the discussion on this

question. The following is a summary of thediscussion and is divided into three parts:

How we currently assess impacts and effects: Cur-rently, there are three to four scientific ways ofassessing psychosocial impacts and effects. Theseinclude a small number of epidemiologic studies,clinical studies, case studies of communities, and theuse of key informants� studies. Epidemiologic studiesare usually based on cross-sectional or case-controldesigns. The evidence from these few epidemiologicstudies does not seem to be particularly strong.Clinical studies are symptom-based and rely to agreat extent on case studies by physicians or selfreports of symptoms. Studies based on physicianjudgments are few in number and have very smallsample sizes. Therefore, they lack the power toprovide the usual quality of evidence that scientistswant. Many more of the studies of psychologicaleffects rely on self reports, and there are differencesof opinion on what is scientific evidence. Some inthe scientific community regard self-reports as quitemeaningless and open to reporting and observerbiases. Others regard self-reports as key informationsources. Self reports are the first means to identifythe psychosocial impacts of any event. Key infor-mants can be used to help chart out the effects oncommunities. This might be useful in the earlystages as a rapid assessment technique.


Topic Two.What previous prevention and therapeutic strategies have been used in thesecommunities? What were the results of these interventions and what issues did they raise?

in intervention activities.

In addition, 14 key concepts of disaster mentalhealth have come out of the outreach/crisis inter-vention model (32). These key concepts could serveas a valuable framework and guide for planning andimplementing successful mental health services athazardous waste sites. These concepts are as follows:

No one who sees a disaster goes untouched by it.

There are two types of disaster trauma: individualtrauma and collective trauma.

Most people pull together and function duringand after a disaster, but their effectiveness isdiminished.

Disaster stress and grief reactions are normaland appropriate responses to an abnormalsituation.

Many emotional reactions of disaster survivorsstem from problems of everyday living broughtabout by the disaster.

Disaster relief procedures have been called �TheSecond Disaster.�

Most people do not see themselves as needingmental health services following a disaster andwill not seek out such services.

Survivors may reject disaster assistance of alltypes.

Disaster mental health assistance is often morepractical than psychological in nature.

Disaster mental health services must beuniquely tailored to the communities theyserve.

Mental health staff need to set aside traditionalmethods, avoid the use of mental health labels,and use an active outreach approach to intervenesuccessfully.

Survivors respond to active interest and con-cern.

Interventions must be appropriate to the phaseof disaster.

BackgroundPrior research on stress prevention and therapeuticstrategies following trauma has focused primarily onnatural disasters. Scientists and clinicians recognizedthat some people who have been exposed to variousnatural disasters, such as earthquakes, hurricanes,and floods, could develop psychological sequelaesuch as major depression, chronic anxiety, andPTSD. As the number of studies devoted to thepsychological effects of disasters increased, findingsindicated that disasters did not always result inwidespread, severe psychological disturbance. Thesestudies found that only a relatively small number ofdisaster victims suffer serious, long-term psychologi-cal damage. A somewhat larger portion of theaffected community may be expected to manifest atleast transient symptoms of various forms ofemotional disturbance (31). Current thought amongdisaster relief workers is that these symptoms ofemotional disturbance are normal reactions to anextraordinary and abnormal situation and shouldbe expected.

The treatment model used for victims ofnatural disasters involves aggressive outreach andcrisis counseling that combines psychologicalsupport, education, and practical disaster relief (e.g.,helping meet needs for food and shelter). Peoplewho appear more severely affected by the disasterare referred to the local mental health system forcontinued care. The use of crisis interventiontechniques in the aftermath of a disaster is recom-mended for several reasons. 1) As previous studiessuggest, disaster victims typically do not sustainserious, long-term mental health impairment. Muchof the initial mental health response involvesnormalizing feelings. Victims need to be assuredthat the emotions they are experiencing are normal.2) Disaster victims are often reluctant to seek outmental health services or facilities on their own.Because of this, outreach to the community isessential. 3) Outreach and crisis interventionemphasizes the use of paraprofessionals and volun-teers. Individuals who are perceived by the affectedcommunity as �being one of us� can play a vital role

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Stable support systems are crucial to recovery.

Panel PresentationMrs. Cynthia Babich reported her observations

of the things that have been conducted at theSuperfund site in her community. There are nowsome counselors in the community who are talkingto some of the people, but there is a stigma associ-ated with doing so. Some residents, particularly themen, see asking for help as a weakness. Mrs. Babichbelieves what is needed is someone who is going tolisten to the community members and documentwhat they are saying.

Dr. Brian Flynn followed up by talking aboutnine strategies that have been consistently used indisaster mental health programs. These experience-based, not research-based, strategies are as follows:

Early intervention: Intervention should begin assoon as possible. It is a myth that psychologicalproblems occur only later in a situation. We know agreat deal about what can be done early in situa-tions to help mitigate stress. Providers who assistearly are much more accepted than those who arelate-comers. This can be a problem because themajority of Superfund sites have been around formany years, but the sooner psychological aid isprovided, the less total stress individuals willexperience. Additionally, residents at hazardouswaste sites may believe that their circumstance issomething that cannot be understood by someonewho has not shared the experience. Early interven-tion allows providers to see, hear, and feel experi-ences very similar to those of the residents. It canalso help establish the community members� trustin the provider.

Validation: The effects of stress are real, and anyprevention or intervention strategy should includevalidation of the stress-related problems.

Normalization of reactions: Many people findthemselves demonstrating signs or symptoms ofstress. Counseling interventions, such as those basedon psychoeducational or psychosocial models, aremore appropriate as opposed to the more tradi-tional mental health interventions. This counselingshould help individuals understand that theirresponses are normal, typical, and expected in anabnormal situation.

Telling of the story: The intervention strategyshould promote the �telling of the story.� Thisseems to be a common thread across various kindsof trauma. There are three benefits to telling one�sstory: 1) it is a way to gain control of an experiencethat is outside of the individual�s past experience; 2)it can have a cathartic effect; 3) it provides anopportunity for bearing witness to what happenedand for documenting and putting on the recordwhat the experience has been. Whether you�redealing with disasters, refugee situations, torturesituations, or other situations, it seems to beimportant for people to tell their story.

Outreach orientation: People do not usually seekassistance for a variety of reasons, including stigmaand not identifying themselves as appropriaterecipients of psychological services. Providers ofintervention strategies need to be aggressive in theiroutreach to people in the community. Services willhave to be provided in nontraditional, community-based settings where people live, work, and socialize.

Blending response teams: Licensed mental healthprofessionals and trained community leaders shouldwork together. Some services could be provided bytrained nonprofessionals who are part of thecommunity. This community involvement helps tobuild trust and may be more appropriate whereethnic and cultural differences exist betweencitizens and outside intervention teams.

Designing and encouraging actions: Actions thatinvolve the community and increase communitycontrol have a high probability of some success.

Training: A need for training in crisis interven-tion and traumatology exists; therefore, trainingshould be provided to survivors on how to prevent,identify, and reduce their stress. Training should alsobe provided to the members of helping professions(e.g., clergy, school counselors) and mental healthprofessionals or any others in the community thatpeople may turn to for assistance.

Consulting with community leaders: It is importantto establish ongoing communication with commu-nity leaders and to keep them involved throughoutthe process.

The rest of the panel discussion focused onwhich of the nine techniques outlined by Dr. Flynn


would be most amenable or transferable to aSuperfund setting and which might be problematic.Panel participants stated that in contrast to disastersituations, in which communities affected usuallypull together, community division often exists atSuperfund sites. Communities tend to coalescearound problems, so having a community take anaction that is noncontroversial is tougher in thiscontext. Consultation with community leaders maynot be as easy at a hazardous waste site as it is in anatural disaster. The types and number of supportsystems may be lacking.

Validation may be difficult as well. Naturaldisasters are more salient. People can see the prob-lems and aftereffects. This is not always true ofSuperfund sites where the contamination is ofteninvisible. Some may deny there is a problem. Othersmay state that they know or feel there is a problembut not be taken seriously. At times, environmental

agencies are a part of the problem because they statethere is an environmental problem but do not showcompassion for the affected community or providea rapid response to the problem. Governmentagency staff do care, but often are experiencingtheir own set of frustrations and worries.

Data Gaps and Recommendations1. If early interventions are provided, many of the

remaining eight actions would not be needed.

2. Some type of measurement and programevaluation should be built into any interven-tion strategy to determine its success.

3. Another action to take is to �help the helpers.�Sometimes those most impacted are thehelpers�researchers, government field workers,therapists, or the first responders. As a result ofoverwork, they may experience burnout. Helpersshould be trained to recognize early signs ofburnout, and support should be provided.

Topic Three.What methods are most effective in preventing the acute stress of learning of the existenceof a hazardous waste site from becoming chronic in adults? In children?

BackgroundThe basic principle in working with children oradults who have experienced any type of disaster isto remember that they are essentially normal peoplewho have experienced great stress (33). Many peoplecan effectively use their existing coping skills todeal with the consequences of a traumatic event ifthey are made aware of the normal and predictableresponses to expect as recovery progresses. Thus,education about stress reactions and ways to handlethem should be provided. This normalizing orvalidating of feelings and help in recognizing somevery common signs of a stress reaction can help tomitigate the effects of acute and chronic stress inboth adults and children.

For adults living near a hazardous waste site, theuncertainty about health consequences inherent inexposures to hazardous substances will most likely betheir greatest source of stress. For example, in somecases people (e.g., community residents, epidemiolo-gists, and health assessors) aren�t sure who has been

exposed to a hazardous substance or how muchthey have been exposed to. In most cases, the exactdegree of individual exposure, in terms of durationand level, cannot be determined. This createsuncertainty and heightened feelings of powerless-ness and lack of control, both of which are associ-ated with higher levels of stress (34). Access toinformation and educational activities about theconsequences of toxic exposure is necessary toprevent or mitigate chronic stress in these adults;therefore, primary care physicians and mental healthand other health care providers should be informedabout the contamination, its potential healthconsequences, and field assessment difficulties thatmay contribute to their patients� feelings of uncer-tainty (e.g., fluctuating contamination levels).Provider support and understanding of the con-tamination and psychological stressors associatedwith living near a hazardous waste site are vital tohelping individuals living near the site cope withthe situation.

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Panel PresentationDr. Charles Figley discussed the possibility of

using PTSD research; traumatology research such asthat done with prisoners-of-war (POW) and missing-in-action (MIA) families, agent-orange families,hostage families, and terminally ill patients; andcrisis intervention strategies as models for prevent-ing acute or chronic stress in individuals living neara hazardous waste facility.

Dr. Figley also made the following recommen-dations for preventing stress in adults and childrenliving near a hazardous waste site:

Establish trust: The situation invites a general lossof trust in others and in government specifically.Efforts will have to be made to establish trust andcredibility. If you don�t have trust, no one is going tolisten to you, not to mention hear you or follow yourinterventions.

Bear witness: Individuals should be encouragedto bear witness. They should be given the opportu-nity to articulate what took place and what hap-pened to them, why it happened, and their beliefsand fears about the situation. One very effectivestrategy that has been used in traumatology researchis to videotape these conversations so that when aperson is talking into the videotape, they are talkingto everybody. This method can provide an oralhistory, not only for the person giving the account,but in many cases, for those people who don�t wantto bear witness. For those community members whodon�t want to share their pain and emotion, theycan watch the videotapes and their heads will nodquite a bit, and they will feel understood. They willsay �that person on that video is like me.�

Identify standards of measurement: Substantialresearch exists with respect to understanding theimmediate and long-term psychosocial consequencesof highly stressful events. What we now need is amodel to understand the trauma induction andtrauma reduction processes. On the basis of anestablished model, ways to prevent suffering andother consequences can be identified�ways to stopand prevent peoples� suffering from reactions to atraumatic event as thoroughly and quickly aspossible.

Identify needs: Do not assume knowledge of what

a community wants. Ask the community membersto identify their needs and goals. Listen during theprocess of bearing witness and identify what theindividuals think their needs are.

Implement interventions: Implement the mostappropriate types of interventions (e.g., stressreduction and management, psychosocial education,post-traumatic stress symptom elimination) one at atime or together.

Utilize existing infrastructure: Utilize the media,business groups, religious organizations, schoolsystems, and other social institutions as a means toproviding psychosocial education to both adultsand children.

These principles are the same for children andadults. What is critically important, however, is thatchildren even more than adults live in an externalworld, defined by the outside environment. Anytime intervention is necessary, even in terms ofassessment, the work must involve the significantpeople in the children�s lives.

Data Gaps and Recommendations1 . A number of public health agencies in the

United States are finding their resources increas-ingly cut back. Their efforts to try to get outinto the community and to deal with thebehavioral and social issues around a site areoften limited by a lack of adequate resources.However, a number of individuals in the faithgroups or church communities share our valuesabout health. By enlisting these individuals, wemay find very natural allies and trusted sourcesin a community. These groups may be able toreach the people we cannot.

2. In preventing stress, anger must also be consid-ered. Anger often exists at these waste sites andneeds to be validated. It�s part of the method ofcoping for some. When people are angry, theyneed to know that they have every reason to beangry. In both natural and technologic disasters,there are so many system frustrations andproblems that are real that, as they build up,people naturally react with anger. That�s whenintervention is needed to help them find andsolve problems that are within their control tochange and cope with those that are not.


Topic Four.What are the best methods to prevent demoralization from occurring in these communities?

BackgroundDemoralization, according to the ComprehensiveTextbook of Psychiatry, is a �state of mind of hopeless-ness and helplessness� (35). Demoralization is acommon distress response when people find them-selves in a serious predicament and can see no wayout. Demoralization stems from a perceived lack ofcontrol. Control is defined as the belief that onecan influence an event; whereas, lack of control isdefined as the belief that nothing one does or cando will change what will occur (19). Some studies oftechnologic disasters have reported increased ratesof demoralization in affected communities (8, 19).For example, Dohrenwend and colleagues (36)found evidence of heightened demoralizationduring the months following the Three Mile Islandincident.

Panel PresentationDr. Jeff Kindler and Dr. Charles Figley led the

discussion on the issue of demoralization.

Dr. Kindler suggested that environmentalagencies concentrate on enhancing two-way commu-nication between agency representatives and com-munity residents. In other words, communicationplans should be designed to increase the mutualunderstanding of issues, data, and possible solu-tions to the problems that are contributing tocommunity demoralization. These agencies shouldcontinually strive to improve their partnershipswith communities and the sharing of decision-making power with residents.

Models for improving partnerships can befound in the adult education, group dynamics, andinteraction analysis research literature.

When communicating scientific information incommunities, residents need to be assisted in process-ing this information through an encouraging,indirect style. This will help residents talk about anddiscuss their concerns about the meaning of theinformation provided. Talking with the communityand inviting residents into the process helps reducetheir anxiety, anger, and suspicion and is a good

beginning to building trust. In return, communitiesgive back ideas that agency representatives can useto develop better scientific models to help us all.

Dr. Figley stated that there is significant overlapbetween demoralization and learned helplessness.There are a number of ways to prevent learnedhelplessness. Part of demoralization and learnedhelplessness is the extensive isolation and notknowing that other people are having the sameexperience. Communities should be given as muchaccurate information as possible so they can devisesolutions or options to improve their situation. Ahelpful intervention may be to help them connectwith other communities that have experiencedsimilar circumstances.

Data Gaps and Recommendations1 . A primary way to prevent or lessen demoraliza-

tion is to help citizens gain a sense of controlover their situation. Government, state, andlocal agencies should seek meaningful input andparticipation of community members. Ofparticular importance is residents� involvementin the decision-making and problem-solvingprocesses concerning the cleanup of theircommunity. In most instances, the cleaning orremediation of the waste site is lengthy, andcauses residents chronic stress and feelings ofhelplessness. Cleanup of the site should bequickened, when possible, and the communityshould be involved throughout the process.

2. Demoralization often occurs when people feelisolated and alone. Often conflicts occurbetween those neighbors living within theimpacted area and those living outside theimpacted area. Many of those living within theimpacted area may disagree on exposure andhealth effects. Better communication betweenneighbors could prevent this.

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Topic Five.How can seriously affected individuals be identified and appropriately referred in thesecommunities?

BackgroundAn effective method for identifying seriouslyaffected individuals is an active outreach approachlike that used in crisis management programs afternatural disasters. The first step is to perform athorough needs assessment with the community todetermine which individuals and groups are mostseverely impacted and which persons are experienc-ing the most difficulty. The second step is to contactthose who can be assumed to be in the most need ofpsychological help. Such persons include those whohave lost one or more family members, those whosehomes have been destroyed, those being relocatedfrom their homes, those who are seriously ill, andthose who have been or are currently under psychiat-ric care (37).

In toxic contamination, there may be an absenceof concrete (i.e., identifiable) death and destruction.High-risk groups should include those who are likelyto have been exposed to chemical hazards or whohave experienced property devaluation. Underservedsegments of the population, such as the poor andracial and ethnic minorities, should be given priorityas well. The third step should be to attempt to reachthose who are geographically isolated or withouttransportation.

Educational efforts should be designed to reachas many people as possible and should expresssimple themes relating to Superfund sites andcommunities, such as stress reactions and manage-ment. Educational materials should also includeinformation about available sources of mental healthservices and provide specific directions on how tolocate help. Because people often identify �mentalhealth� with �mental illness,� measures should betaken to avoid these labels. Emphasis should beplaced on the common practice of people experienc-ing stress to use such services.

Not all community members will experience thesame types of needs at the same time; therefore, theneeds assessment should be ongoing and shouldinclude periodic reassessment of both mental health

needs and services.

Panel PresentationDr. Brian Flynn led the discussion on this issue.

Dr Flynn:

In some cases, these individuals will �selfidentify,� i.e., they will seek treatment on their own.Others may be identified by their support systems(e.g., family, friends), while others may be identifiedby their family doctors, counselors, or other healthproviders.

Once these individuals are identified, how theyare referred for further treatment varies. Referraldepends on their eligibility for treatment andwhether they have the financial resources (e.g.,private monies or health insurance) to cover treat-ment costs. They may be limited in their choice ofproviders for treatment, and their geographicallocation may hinder access to treatment.

To whom they get referred may vary as well.Before referral, trained professionals with expertisein crisis counseling or traumatology should beidentified. Often the local mental health system isthe least prepared to handle these problems. Itsservices and resources are generally restricted tothose with serious mental illness and/or drugaddictions. In addition, they often lack staff withexpertise or training in crisis counseling or disasterrelief work.

The expertise of volunteer providers shouldalso be qualified. Sometimes those who go out oftheir way to volunteer their help are the leastprepared and qualified. Additionally, mental healthproviders should coordinate their efforts andestablish a close link with the primary care physi-cians in the area. There may be a need to providetraining to the mental health and primary careproviders. This training should be designed to helpproviders develop a sensitivity to the issues ofcontaminant invisibility and health uncertainty.


Data Gaps and Recommendations1. Because individuals stress response can vary, those

living near hazardous waste sites will differ in thedegree of stress they exhibit. Some may experi-ence little or no stress, others a moderateamount of stress, and some will exhibit highlevels of stress. Individuals who exhibit highlevels of stress might include those who areunable to deal with the situation because ofinadequate coping skills, an inadequate supportsystem, a lack of trained providers to accuratelydiagnose and treat their problems, or a preexist-ing mental or physical illness. Those experienc-ing high stress levels may require more long-

term, structured treatment, so identification ofthese individuals is important.

2. Public health agencies should be in a positionto deal with stress or mental health problemsemerging at waste sites. Unfortunately, they arenot in that position at present. This is one ofthe problems facing public health officers rightnow: the whole business of redefining the roleof public health.

Topic 6.What is the best method for increasing public and professional capacity to respondeffectively to psychological issues related to hazardous waste sites?

BackgroundOne of the most effective ways to build capacitywithin a community is through education. Neitherpublic nor professional community members caneffectively respond to psychological issues unlessthey understand what those issues are. An awarenessand understanding of disaster-related psychosocialeffects, in particular those associated with livingnear a hazardous waste site, are vital to increasing acommunity�s ability to respond. An effective way toprovide this education is by establishing a commu-nity-level outreach program.

Panel PresentationThe discussion centered around five key factors

for increasing public and professional capacity:

Community-based education: Community-basededucation programs would help to heighten aware-ness of community members, public health profes-sionals, and providers and to teach them how toidentify psychological sequelae.

Evaluation: An evaluation of any existingprograms in the community should be conductedto determine their appropriateness and usefulness inaddressing psychological issues.

Empowerment: Ask community members whattheir needs and concerns are. Give them the infor-

mation and training they need to help them under-stand and cope with the problem. Agencies shouldform partnerships that enable discussions anddecisions about their community.

Collaboration: Trained mental health and healthcare providers should collaborate and communicatewith each other on the issues.

Data Gaps and Recommendations1 . Increase public and professional capacity for

responding, including making the issue ofpsychological responses at hazardous waste sitesless marginalized. Rather than �preaching to thechoir,� attempts should be made to bring thissocial issue to the attention of the Americanpublic.

2. More must be done to enable communities torespond to the problem. Ask communities whatassistance, resources, and education efforts theywant, and then make sure you can come throughfor them. Give them technical assistance andeducation. Teach them how to access environ-mental resources from the Internet, libraries, andother information sources.


Topic One.Evaluate information about susceptible populations. This information may includepreexisting conditions (i.e., medical and/or psychological), as well as individual variability inreactions to stress, cultural patterns of reaction to stress, and targeting interventions tovulnerable populations.

OVERARCHING ISSUES DISCUSSED

BY ALL THREE PANELS

Panel DiscussionMost people cope very well with stress; however,people with preexisting mental or physical healthproblems, limited coping strengths, or meagerfamily and community support systems may bemore vulnerable to psychological stressors thanothers. For example, the following question wasraised: �Can an individual already experiencingdepression from other circumstances experienceexacerbated depression from the stress associatedwith living near a hazardous waste site?� Anindividual�s response to stress is multifactorial.Episodes of mood disorders, such as depression,may be triggered by psychosocial stress associatedwith different situations.

In addition, some age groups appear to be morevulnerable than others, particularly young childrenand older adults. Children�s perceptions of stressand their coping skills differ by developmental leveland are not the same as that of adults�. A change in

environment, such as that which occurs withrelocation, may leave children frightened andinsecure. They may display a variety of emotionalresponses. How a parent reacts to the situationmakes a great difference in the child�s understand-ing and recovery. People with children may be asusceptible group themselves because of theirconcerns over the potential adverse health effect ontheir children. Older adults may suffer because theirfamiliar routines are disrupted, particularly whenthere is residential loss and relocation.

In marginalized communities, there is a sense ofinternalized oppression. This results in incapacita-tion and loss of self-esteem and efficacy. Drawingsite boundaries (e.g., putting a fence around thecontaminated area) can create a specific susceptiblecommunity by attaching an environmental stigmaand changing a community�s perception of safety.The trigger for psychosocial effects is perception.

Environmental cues, such as odors associated

56

with waste sites, may make a community moresusceptible to the stress associated with exposure.Communities who have suffered changes in threatlevels (i.e., being told at first that there is no harm,then that the exposure is a threat, or vice versa) maybe more at risk to have increased stress. Communi-ties exposed to multiple contaminants might alsobe more susceptible to the stress associated withmultiple exposures.

Helpers and responders themselves have thepotential to become �secondary victims.� They may

experience �burnout� syndrome�a state of exhaus-tion, irritability, and fatigue.

Data Gaps and Recommendations1 . Acknowledge the unique problems of

Superfund communities.

2. Seek to understand the problem from a com-munity point of view.

3. Train staff of various agencies in recognizingdifferent patterns and types of psychosocialresponses to environmental contamination.

Topic Two.Examine the reports of increased incidence of psychologic disorders in these communitiesand make recommendations regarding the directions for future strategies.

Panel DiscussionThe members of all three panels had very mixedopinions on the adequacy of the literature onpsychological disorders from the stress related tohazardous waste sites. Some felt the evidence wasadequate to overwhelming; others thought that theliterature was sparse and that more studies, includ-ing epidemiologic and qualitative methods wereneeded before drawing any firm, final conclusions.

The first question to be answered by thesestudies would be to assign statistical causality to thesite (i.e., to determine how much of the reaction iscaused by the site and how much to a preexistingcondition). How do we differentiate effects fromdifferent stressors? The suggestion was made that aconvergent strategy be used to do this. This conver-gent strategy would involve using a mix of qualita-tive (e.g., clinical screenings by neuropsychologistsand sociological studies of the factors that influencecommunity responses) and quantitative methods(e.g., psychophysiological research, application ofstandardized research instruments to measure thepsychological disorders in the communities nearthese sites, and pre- and post-data on how stresslevels change in a community affected by hazardoussubstances). Two important points to remember arethat 1) the psychosocial effects of a hazardous wastesite change over time and 2) not every community isaffected in the same way.

Panel Three suggested rewording the issue to

read �psychological distress� rather than �psychologi-cal disorders.�

Data Gaps and RecommendationsFor a specific site, one must first ask whether the

site is old or new. For a new site, the relevant issuesare prevention and intervention before stress has achance to build within a community. A recommen-dation was made to incorporate mental healthservices into the process of helping victims of anacute technologic disaster (e.g., a spill). Anotherrecommendation was to standardize the psychologi-cal assessment tools and to work toward a widerrecognition for the need to address psychologicalresponses to hazardous substances, includingencouragement of state health departments toincorporate means of addressing these effects.

All panels recommended a need for furtherstudy on the topic of psychosocial stress in commu-nities exposed to hazardous substances. Panel Twogave the following set of recommendations for howto conduct further research in these communities:

1 . Listen to the concerns of the community.

2. During a community needs assessment, look atcensus data and demographics for factors such asthe male-to-female ratio, number of children andelderly, number of homeowners versus renters,and the minority makeup.

3. Map the community using geographical infor-mation systems to assist in tracking health


impacts and community psychological andsocial needs.

4. Have joint fact-finding activities with communi-ties to build trust in the data.

Topic Three.What ethical concerns need to be addressed in dealing with the psychological responses tohazardous substances? This question addresses the appropriateness of variousintervention strategies.

Panel DiscussionThe panel concluded that the following are practicalquestions that will help preserve an ethically bal-anced and appropriate intervention:

Do we know enough about the pathophysiologyand natural history of the psychological condi-tions that are present?

Can we provide effective remedies?

Who is responsible for the intervention?

Which organization (e.g., federal, state, or local)is most appropriate to deliver services?

What is the appropriate way to deal with thequestion of invasion of privacy?

How would the situation change if the event werenatural?

Topic Four.Identify future directions for investigation of the biopsychosocial effects from possibleexposures to hazardous waste substances.

What are the appropriate parameters for policygoverning the behavior of the media? Theprincipal responsible party? The governmentagencies?

Should the principal responsible party be a partof the planning, implementation, and evalua-tion of the intervention?

Data Gaps and Recommendations1 . Do no harm.

2. Obtain the community�s permission and inputbefore designing or implementing any interven-tions intended to reduce stress in that commu-nity.

3. Have experts on the subject, such as bioethi-cists, explore the issue further.

Panel Discussion andRecommendationsThe panel identified four areas in need of greaterattention:

Data collection: There is a need to collect moredata on psychosocial effects of living near a hazard-ous waste site. This data collection should include asystematic, community-based study that collects awide range of psychosocial data, such as thecommunity�s level of knowledge and understandingof stress reactions; variations and characteristics ofpositive coping skills; evaluation of policy re-sponses; and an evaluation of the efficacy of varioustreatment methods, including early intervention.

Training: Further training on psychosocialeffects should be provided to community membersand their health care providers to elevate their

knowledge and understanding of stress reactions.This should include validation of the community�sstress response as a normal reaction to the situation.

Earlier intervention: Early intervention with morecommunity involvement is needed. Noninvolve-ment and mistrust can be avoided by establishingpartnerships early with key stakeholders and treatingthem as equals. These partnerships should includelocal officials and respected community members.

Evaluation: The impact of the governmentresponse should be evaluated. Do certain policyresponses, such as relocation of the community,cause more stress or additional harm? Additionalconsideration should be given to how informationis delivered and understood by the community.Attempts should be made to know what and howthe community thinks and feels before deliveringthe message.


NEXT STEPS

At the end of the workshop, Dr. MaureenLichtveld presented a five-point action plan for

the agency to address the issue of psychosocialeffects in communities near hazardous waste sites.The actions to be taken include the following:

1. Produce a proceedings of this expert panelworkshop;

2. Publish articles in the scientific literatureregarding the psychosocial effects in communi-ties near hazardous waste sites;

3. Write a training handbook for local and statepublic health officials on ways to minimize stressin communities exposed to hazardous substances;

4. Develop direct interventions in communitiesfaced with exposures to hazardous substancesbased on disaster relief strategies; and

5. Develop and implement public health strategiesdesigned to mitigate the psychosocial stresses thatcan be found in communities exposed to hazard-ous substances.

Since the expert panel workshop, ATSDR hasmoved forward with the development of a psycho-logical effects program. Since September 1995, theagency has designed a public health strategy thatcombines enhancement of the public healthsystem�s capacity to respond by developing andimplementing a training program for public healthpartners. Additionally, the agency has deliveredseveral direct interventions in communities.

ATSDR developed a training module for healthassessors and public health officers; this module isdesigned to enhance their awareness of the psycho-logical responses that accompany exposures to

hazardous substances. The first training courseusing that module was presented on February 3�7,1997. Several training sessions for county healthofficials have been conducted through the agency�spartnership with the National Association ofCounty and City Health Officials. Also, training hasbeen held for staff in state health departments.

There have been several different projects withcommunities. This has involved sponsoring a 1996educational workshop regarding ways of reducingstress caused by acute exposures to a hazardoussubstance and a subsequent sudden evacuation for arelocated community. A series of workshops forresidents of a community permanently relocatedbecause of environmental contamination was givenon February 26�28, 1997. The series of workshopsgave the residents basic information on how tocope with the stress of a relocation related toenvironmental contamination. Additionally, training onhow to help temporarily relocated residents was givento social workers involved with the hundreds ofdisplaced people during the methyl parathionresponse on the Gulf Coast. Also, expert opinionwas provided to an EPA task force that is looking atthe issue of how to handle environmental reloca-tions.

ATSDR continued to advance the public healthscience on this topic though a September 10 and 11,1997, expert panel workshop entitled �The Feasibilityof Measuring Stress Related to Hazardous Waste.�The workshop convened in Atlanta, Georgia. Theproceedings from that workshop are forthcoming.

In 1998, ATSDR worked with the MissouriDepartment of Health and ATSDR�s Office ofRegional Operations to develop a needs assessment

60

for public health personnel to use to determine thedesires and needs of a community when coping withthe psychological effects of exposure to hazardoussubstances.

Most recently, ATSDR and EPA have joined in aninitiative, ATSDR-EPA Initiative Regarding CommunityStress Related to Hazardous Substances, to train EPApersonnel in the area of community stress. Theinitiative will increase awareness and improve staffability to respond to communities facing exposureto a hazardous substance. Public health responses

will be piloted at three sites over the next 3 years.During 1999, a community support network involv-ing social workers will assist a community facingboth permanent and temporary relocations due toenvironmental contamination.

A handbook, Training Handbook on PsychologicalResponses to Hazardous Substances, is expected to becompleted by September 1999 and published in FY2000.


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Defining the Problem: Biomedical and Psycho-physiological Effects. Composed of neurobiologicalscientists such as psychologists with expertise on thepsychophysiology of chronic stress and resultinghealth effects, neurobehavioral toxicologists,neuropsychologists, and psychiatric/psychologicalepidemiologists.

Charge: To examine what is known about thepotential effects on public health of the chronicstress response that some studies have documented incommunities near hazardous waste sites. Focus areasinclude the pattern of stress that may occur athazardous waste sites (i.e., acute or chronic, or both);the effects of psychological stress on physiologicalresponses to exposure; and whether neurobehavioraldisorders caused by neurotoxicants, which maymanifest as psychological disorders, are ever a publichealth phenomenon near hazardous waste sites.

Topics to be addressed by Panel One include thefollowing:

APPENDIX ABACKGROUND DOCUMENTS FROM THE EXPERT

PANEL WORKSHOP ON THE PSYCHOLOGICAL

RESPONSES TO HAZARDOUS SUBSTANCES

APPENDICES

1 . What is known about the long-term healtheffects of chronically increased stress amongindividuals living near hazardous waste sites?

2. Are there certain neurobehavioral effects foundin individuals living near hazardous waste sitesthat, if detected, could constitute sentinelhealth events at these sites? If they exist, cantheir early detection be used as an interventionscreening tool?

3. What is known clinically about how to differen-tiate between organic behavioral disorderscaused by exposure to certain neurotoxicantsand purely psychologic responses to possibleexposures? This discussion will considermethodological questions such as testing forstress and neurobehavioral effects as well asother issues.

4. Given what is known regarding the psychobiol-ogy of stress, are there interactions betweenchronic stress and exposure to neurotoxicantsthat could change the dose-response curve for

Panel One.Biomedical and Psychophysiological Effects

64

neurotoxins?

5. What is known about those individuals who aremost sensitive to this stressor (i.e., the uncer-tainty of possible exposures)? This includesconsideration of medically, psychologically, andphysiologically sensitive populations.

Overarching Issues For Discussion ByAll Three Panels:

Overarching Issue 1: Evaluate information aboutsusceptible populations. This may include: a)preexisting conditions (i.e., medical, psychological),b) individual variability in reactions to stress,c) cultural patterns of reaction to stress, and

d) interventions targeted to vulnerable populations.

Overarching Issue 2: Examine the reports ofincreased incidence of psychological disorders inthese communities and make recommendationsregarding the direction for future strategies.

Overarching Issue 3: Address ethical concernspertinent to dealing with the psychological re-sponses to hazardous substances. This addresses theappropriateness of various intervention strategies.

Overarching Issue 4: Identify future directions forinvestigation of the biopsychosocial effects frompossible exposures to hazardous waste sites.

Panel Two.Community and Social Science Perspectives

Defining the Problem: Community and SocialScience Perspectives. Composed of community andsocial psychologists, sociologists, anthropologists,political scientists, and community members.

Charge: To review what is known about the psycho-social responses in communities living near hazard-ous waste sites and make recommendations regard-ing ways to interact with communities, outlineproblems in need of further investigation, andsuggest possible psychosocial interventions toreduce stress.

Topics to be addressed by the second panel include:

1 . Factors (both internal and external to a commu-nity) that might make some communitiessusceptible to the stress of living near a hazard-ous waste site. This discussion will include:

Individual and community dynamics,

� Cultural factors affecting responses,

� Type of community (e.g., marginalized),

� Community�s response (i.e., duration ofexposures, socioeconomic and demographicfactors, and unique community factors).

2. The human response to uncertainty may lead todifferent understandings of a possible exposureto hazardous substances and its relation to

psychological responses, such as learned help-lessness.

3. Some of the psychosocial responses that com-munities have given to the stress of living near ahazardous waste site and the results from theseresponses.

Overarching Issues for Discussion byAll Three Panels

Overarching Issue 1: Evaluate information aboutsusceptible populations. This may include a)preexisting conditions (medical, psychological), b)individual variability in reactions to stress, c)cultural patterns of reaction to stress, and d)interventions targeted to vulnerable populations.

Overarching Issue 2: Examine the reports ofincreased incidence of psychological disorders inthese communities and make recommendationsregarding the direction for future strategies.


Overarching issue 4: Identify future directions forinvestigation of the biopsychosocial effects frompossible exposures to hazardous waste sites.


Overarching Issues for Discussion byAll Three Panels

Overarching Issue 1: Evaluate information aboutsusceptible populations. This may include a) preexist-ing conditions (i.e., medical, psychological), b)individual variability in reactions to stress, c)cultural patterns of reaction to stress, and d)interventions targeted to vulnerable populations.

Overarching Issue 2: Examine the reports ofincreased incidence of psychological disorders inthese communities and make recommendationsregarding the directions for future strategies.


Overarching issue 4: Identify future directions forinvestigation of the biopsychosocial effects frompossible exposures to hazardous waste sites.

Responding to the Problem: Protecting andpromoting psychosocial health. Composed ofclinical psychologists, psychiatrists, occupationalmedicine physicians, disaster relief specialists, andcommunity members.

Charge: To develop public health strategies toprevent and control long-term, stress-related healthproblems in communities near hazardous waste sites.

Topics to be addressed by the third panel include:

1. Assessing the extent of the psychosocial effectsand possible public health impacts in thesecommunities to date.

2. Previous prevention and therapeutic strategiesthat have been used in these communities.What were the results of these interventions andwhat issues did they raise?

3. The most effective methods for preventing theacute stress of learning of the existence of ahazardous waste site from becoming chronic inadults and children.

4. The best methods to prevent demoralizationfrom occurring in these communities.

5. Identification and appropriate referral ofsusceptible persons in these communities.

6. The best methods for increasing public andprofessional capacity to respond effectively topsychological issues related to hazardous wastesites.

Panel Three.Protecting and Promoting Psychosocial Health


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Baum A, Fleming I, Israel A, O�Keeffe MK. Symptoms ofchronic stress following a natural disaster and discovery of ahuman-made hazard. Environ Behav 1992 May;24(3):347-65.

Baum A, Fleming R, Davidson LM. Natural disaster andtechnological catastrophe. Environ Behav 1983 May;15(3):333-54.

Baum A, Fleming R, Singer J. Coping with victimization bytechnological disaster. J Soc Issues 1983;39(2):117-38.

Baum A, Gatchel RJ, Schaeffer MA. Emotional, behavioral,and physiologic effects of chronic stress at Three MileIsland. J Consult Clin Psychol 1983;54(4):565-72.

Baum A, Singer JE, Baum CS. Stress and the environment.J Soc Issues 1981;37(1):4-35.

Baxter RH. Some public attitudes about health and theenvironment. Environ Health Perspect 1990;86:261-9.

Beck U. From industrial society to risk society: questionsof survival, social structure, and ecological enlightenment.Theory, Culture, and Society 1992;9:97-123.

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Berman SH, Wandersman A. Fear of cancer and knowledgeof cancer: a review and proposed relevance to hazardouswaste sites. Soc Sci Med 1990;31:81-90.

APPENDIX BBIBLIOGRAPHY FOR THE

PSYCHOLOGICAL EFFECTS PROGRAM

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Mary and Joseph have vivid childhood memories of life in America during the great depression and later on ofWorld War II struggles. It was after his discharge from military service that he took Mary for his bride in 1949.Together with millions of other young couples they began their quest for the post-war American dream.

Their story is shared with the hope that it will help others to help themselves and those around them.

�THERE IS NO AWAY!!�

by

Mary Minor, SFO1

This presentation combines an autobiographical narrative and published results of clinical research tocompare the symptoms of post-traumatic stress disorder to those symptoms evidenced by the survivors ofTechnological Disasters (TDs).

The chronic psychophysiological trauma often experienced by people living near toxic and hazardous wastedisposal sites is presented in a personalized account. Deficiencies in government and institutional and commu-nity victim-assistance programs are discussed. Alternative approaches for providing this assistance and topromote emotional healing are described.

THE TRUTH IS

Technological Disasters & Resulting Psychophysiological Victimization Happen.

Let�s Run Away!!

APPENDIX CTHERE IS NO AWAY!

(Following is the manuscript of a talk given by Mary Minor in 1995at the International Congress on Hazardous Waste.)

1SFO = Secular Franciscan Order. Mrs. Minor is a professed member of the SFO, which is an organization that worksfor social justice and the resolution of other issues according to the dictates of their faith.

76

The day had finally come. After nearly 16 years ofsaving and dreaming, we set eyes and feet on the landwhere we would learn the true meaning of �steward-ship.�

We found our dream home in 1966. It was an oldfarm house with 16 acres in the foothills of themountains. We wanted our three girls to be able tohear only the wind in the trees. We wanted clean air,peace, and good water. The girls were all grown upand away before a Technological Disaster (TD) struckin 1983.

Please call me Mary. Dorothea is my middlename. It means �gift of God.� It is my belief thatsince I�ve been given the gift of life, I must offersomething in return. So, what I do with my life is mygift to God and to society.

I am finding a measure of peace in doing �mypart� and hoping to inspire others to do likewise. Thebad news is that I did experience exposure to toxicsreleased into our environment by technologicalfailures or TDs. The good news for me is that I amhealing. Victims of TDs, like myself, suffer in avariety of ways as a result of exposure to hazardoussubstances in our communities. Chronic exposure totoxic substances at never to be known levels is part ofthe trauma. Stress related health effects are a majorconcern along with other toxic exposure effects. Worstof all is the unknown; the invisible . . . and that neverends! And, if adverse physical effects to toxic expo-sure don�t �get you,� dealing with our regulatory, legal,and government systems will.

Some individuals never admit the problem�theysimply have another viewpoint. Others become (dueto loss of control of certain aspects of their lives)totally frustrated, filled with guilt, (how could aperson let this happen to him or herself?), with a lossof confidence in government, a loss of value andmeaning in life. They deal with present and futurehealth concerns; physical illnesses; depression; anxiety;impotency; a sense of helplessness and violation;damage to property; self-blame; victimization; feelingsof being trapped; alterations in family, social, andwork relations; daily physical hassles (such as haulingdrinking water); difficult economic situations; alter-ations in attitudes and feelings; serious generalizedpsychopathology; and impaired functioning levels.

These are not irrational hysterical reactions, butare rational�given the unnatural and threateningcircumstances. The invisibility of hazardous sub-stances is a large part of the dilemma. When youcan�t see an invisible enemy, how can life be pro-tected? When and where will it strike? This isstressful! You cannot know, unless you experiencetrying to protect your children and yourself in such asituation.

Stress is a global disease. Stress and the mindand body�s response to it can shatter individuals,communities, entire societies. We see now thegrowing breakdown of our society�things aregetting out of control. Frustrations, anger, andviolence are everywhere!

No one in the world can escape stress. Even inthe best and less stressed segments of society, stress-related health effects are known to occur. You andyour loved ones may be coping with whatever lifesituation you are in and taking it all �in stride.�

What would happen to you and your children ifyou suddenly were faced with poisonous chemicals inyour local drinking water supply? Imagine the levelsof lead (considered safe by the U.S. EnvironmentalProtection Agency [EPA] 50 µg/Liter [µg/L]) foundat 49 µg/L in the water coming from Helen�s faucet.Helen knew that 50.1 µg/L is considered by the EPAto be �unsafe� for her children. Helen and Al learnedthat their water is not yet contaminated enough at 49µg/L. They were expected by government environ-mental regulators to just stay there and wait withtheir family for the toxic level to rise. In another yearor two the water may again be tested to see if thefamily was yet poisoned enough for action to betaken. What would your reaction be? Think about it!Bottled water, filtering the system, testing the wateryourself (it can cost thousands of dollars). Many paythe price to protect their families. Researching publicrecords, acting to ensure regulations are beingupheld, traveling to the state capitol and to Washing-ton, D.C. to interact with elected officials to ensurethat little �Sue�s� and �Willie�s� present and futureconstitutional rights are upheld are all part ofcitizens� responsible response to community TD�s.

Try to imagine yourself in Al and Helen�s shoes.What could you do? Fathers have to go to work. For


that matter, so do wives. Now what about that littlebaby in its mother�s womb? Enough? Get thepicture? This is the world of the victims of TDs.Some of your neighbors, your own facility members,your state and federal departments of environmentalprotection may insist this should not worry you.Maybe you wouldn�t �some people don�t. Countlessinformed and realistic responsible parents thinkbetter of believing you can hand your child a glass ofwater with 49 µg/L of a toxin and not worry because50 µg/L is the level considered �safe� for consump-tion by the EPA.

There are people who choose to remain in TDcommunities and work to better the situation. Forsome families experiencing TDs, the trauma has noend. Parents and children stay on and on in thecontaminated community. Maybe they would like toleave. But, who would buy their home? Theyshould reveal the presence of the TD in any realestate contract offer. This is only fair to prospectivebuyers. Informing buyers is the only ethical way tooffer such properties for sale. Information madeavailable allows for informed decisions aboutpurchase and appropriate decisions for any protec-tive measures needed. Will sellers get fair marketvalue? Not likely.

Not all individuals admit the environmental andhuman threats in communities that experience TDsand hazardous substances releases. In ascribing toother perceptions of the threat to human health andwelfare to their community, they also may denythemselves the opportunity to become better edu-cated; thus they may not consider the risks or makeinformed decisions as to whether or not to take stepsto protect their person and/or children and lovedones. There are those who may remain close mindedand ignorant of continuing available information,which could be beneficial to their health and well-being. It must be remembered that these TDs aremost often chronic and ongoing in nature. This maymake it impossible for individuals to heal from theadverse effects of a TD

Dealing with agencies and institutions who havepower over people and who are most often nonre-sponsive or inefficient only exacerbates the stress.

As one who has become �expert� at living with

chronic exposure to trauma in an EPA Superfundsite community and through extensive review ofscientific studies and personal contact with othervictims, I believe:

� People living with chronic stress in TD commu-nities may acquire a syndrome which is similar to(but is not in fact) POST Traumatic StressDisorder (PTSD)

� Most symptoms exhibited by some residents inthese communities are the same as those seen inPTSD.

� How does the syndrome seen in TD areas (forchronically exposed persons) differ from PTSD?A significant portion of our entire local area hasbeen affected by the TD in our local township�Pennsylvania Landfill Superfund Site. Thefollowing material is an excerpt from the Interna-tional Handbook of Traumatic Stress Syndrome: 1993:

Posttraumatic Stress Disorder

The person has experienced an event that isoutside the range of ususal human experienceand that would be markedly distressing to almostanyone (e.g., serious threat to one�s life orphysical integrity; serious threat of harm to one�schildren, spouse, or other close relatives andfriends...).

The traumatic event is persistently reexperi-enced in at least one of the following ways:

� Recurrent and intrusive distressing recollec-tions of the event (in young children,repetitive play in which themes or aspects ofthe trauma are expressed).

� Recurrent distressing dreams of the event.

� Sudden acting or feeling as if the traumaticevent were recurring (includes a sense ofreliving the experience, illusions, hallucina-tions, and dissociative [flashback] episodes,even those that occur upon awakening orwhen intoxicated).

� Intense psychological distress at exposure toevents that symbolize or resemble an aspectof the traumatic event, including anniversa-ries or the trauma.

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Our trauma is not POST?

� It is a never-ending process! - It is NOT a POSTTraumatic Stress Disorder experience for affectedpersons in TD communities. The toxins do notgo away and dealings with government officialsand others are continual.

� TDs such as leaking landfills may not always becleaned up; containment of toxics may be theonly solution. Continued monitoring andvigilance is required.

� What is the syndrome? Acquired Toxic ExposureSyndrome (ATES).

� The disorder is something which one acquires asa reaction to the knowledge of toxins (usuallyman-caused) released into one�s environment andthe potential exposure for self and family andneighbors.

� ATES victims may suffer physically, psychologi-cally, socially, economically (e.g., through localbusinesses, in the tax base) when people becomeaware of potential for toxic exposure from a TDin a community.

In an interview with Stephen R. Couch, PhD,Department of Sociology, Penn State University, I wastold that I am remarkably consistent in my TD andrelated trauma experience with all others he hasstudied. He added that the difference in my responseto this life altering TD experience made my storyunique. How different? The question is a new onefor me. There are likely to be multiple answers.

The first that comes to mind is that my naturalconcerns for myself and my own family immediatelyfocused on the children�s environmental educationlimitations. For me, the needs of the little ones in myown family and other communities soon becamemultiplied by the millions of exposed, victimized,and helpless children. They needed to be educatedabout technological failures and human victimiza-tion so they could make better and more informeddecisions than we did.

The technological disaster impacting our com-munity in south central Pennsylvania is a landfillthat is leaking toxic substances into local groundwater, drinking water, and streams. The children in

my family and community soon came to me person-ally to ask their questions and voice their concernswhen the area�s four recognized TDs (Superfundsites) in our county were making the headlines.That�s natural. I�m a caring grandmother. Laura, alocal high school student, was the first to ask me tocome and talk to her biology class. We began to talkabout the environment because I asked her to wrapmy order in foil instead of Styrofoam at the carryout restaurant where she was employed part time.

I spoke to her class in a sensitive, factual, andinformative way. Our children already know there is alot wrong with their world. They are curious aboutenvironmental dangers, especially when it happens intheir own or a friend�s backyard. They want to learn:what, how, why, and who did it (sometimes). Mostlywhat�s important to them is not who�s responsiblebut how do we change things and stop doing what-ever caused the disaster in the first place. And theyare working to make those changes as we show ourwillingness to admit the problems and seek solutionstogether with them.

My personal healing process began thanks to thechildren. How could I, a mother, a grandmother, anexample setter, remain frozen for an extended time ina state of apprehension and impotency? I couldn�tand did not. Immediately, I sought the best informa-tion and moved forward to assess the communities�environmental concerns about the TD. We were alllooking for a return to our normal family life andsocial conditions in our beautiful rural neighbor-hood.

Did it happen? No! Often, I dream of the timewhen we trusted that the two small landfills in ourcounty would be run safely to protect the health,safety, and welfare of local citizens. But it was only adream. Do I wish to go back? Not really. But thereality was that things had to change. We needed thepublic officials to listen to us. We now knew thelandfill was damaging our community, mind, body,and soul, and we knew it could have been preventedif only the public officials on any level, city, county,state, or federal, had intervened or gotten involved atthe first hint of an environmental health threat. Wewanted and needed our concerns and interests to bemet; our health to be protected. But that�s not the


way it was. Not many of us would want to turn backthe clock in our township. Prior to 1983, as a localbusinessman described our situation: We were to be�sacrificial lambs� in this issue. This was written in aFebruary 1988 letter to our Governor of Pennsylvania.The local businessman had been �naive enough totrust . . . elected representatives . . . will not sell usout.....� He soon lost this trust.

We�re all part of the problems that brought forththese growing number of TDs. All of us should takeon the burden of HEALING for other communitiesand individuals, before being personally affected. Weneed common assessments, common goals, and thebest solutions for us all; HEALING for millions ofTD victims depends on our collective efforts onbehalf of society and the safety of our environment.In 1995, there were at least 41 million people livingwithin a 4-mile radius of Superfund sites in theUnited States according to the EPA (today, thisnumber is 71 million). Remember, TDs can happenanywhere. Your community could be next.

�Pollution causes violent crimes,� according to aDartmouth College scientist, Roger D. Masters. Hisstudy used �Federal Bureau of Investigation and EPAdatabases.� Such crimes and violence can be pre-vented if we intervene in our public health practices.Let�s begin to intervene.

How can you help? Care enough to becomeinformed. Learn about the communities and peoplewho are burdened with TDs. If you don�t come toknow us and the nature of our disastrous experi-ences, you will not be able to understand and takeaction. Much is now known about the seriousness ofstress-related and toxic exposure effects on humanlife and well-being of persons living in TD communi-ties. When technology fails, environments may becontaminated and everyone can suffer (e.g., humanhealth, nature, personal and business economy,growth potential).

A tremendous amount of information is avail-able. I have included below a beginning list ofreferences. To find information on how to deal withcommunity issues regarding TDs and their long-termeffects the following text is essential:

International Handbook of Traumatic Stress Syndrome,Edited by John P. Wilson (Cleveland State

University, Cleveland, Ohio) and Beverley Raphael(University of Queensland, Herston, Australia),publisher: Plenum Press - New York and Lon-don: 1993.

Contents of Interest

� Biological Response to Psychic Trauma

� Posttraumatic Stress and Adjustment Disor-ders

� Posttraumatic Stress...Common Themes

� Technological Hazards: Social Responses asTraumatic Stressors

� Intervention Considerations in Working withVictims of Disasters

� Posttraumatic Stress Disorder in NaturalDisasters and Technological Accidents

� Chernobyl

� Responses to Children and Adolescents toDisasters

� Children...Stresses of Unrest and Oppression

� Coping with Disaster

References for Psychosocial Effectsof Hazardous Waste Sites

Baum, A. Stress, intrusive imagery, and chronic distress.Health Psychol 1990;9(6):653-75.

Baum A, Fleming R, Singer J. Coping with victimizationby technological disaster. J Soc Issues 1983;39(2):117-38.

Baum A, Gatchel RJ, Schaeffer MA. Emotional, behav-ioral, and physiologic effects of chronic stress at Three MileIsland. J Consult Clin Psychol 1983;54(4): 565-72.

Couch SR, Kroll-Smith JS, editors. Communities at Risk:Collective Responses to Technological Hazards. New York: PeterLang; 1991.

Couch SR, Kroll-Smith JS. Patterns of victimization andthe chronic technological disaster. In: EC Viano, editor.The Victimology Handbook. New York: Garland Publishers;1991.

Edelstein MR. Contaminated Communities: The Social andPsychological Impact of Residential Toxic Exposure. Boulder, Co:Westview Press; 1988.

Gatchel RJ, Newberry B. Psychophysiological effects of toxicchemical contamination exposure: a community field study.J Appl Soc Psychol 1991;21(24):1961-76.

Gibbs M. Psychopathology in victims of toxic exposure.

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Environmental Issues: Today�s Challenges for the Future:Fourth National Environmental Health Conference; 1989June 20-23; San Antonio, Texas; p 257-64.

Glendinning C. When Technology Wounds: The HumanConsequences of Progress. New York: William Morrow andCompany, Inc.; 1990.

Masters RD. Dartmouth College Public Records: U.S.Government (EPA), Pennsylvania (DER), & Local.

Montague P. Rachel�s Environmental Health Weekly.

Kroll-Smith S. As if exposure to toxins were not enough:the social and cultural system as a secondary stressor.Environ Health Perspect 1991;95:61-6.

Sherman JD. Chemical Exposure and Disease: Diagnostic andInvestigative Techniques. Princeton, NJ: Princeton ScientificPublishing Co., Inc.

Vyner HM. Invisible Trauma: Psychosocial Effects of InvisibleEnvironmental Contaminants. Lexington, MA: D.C. Health &Co.; 1988.

Citizens Urge Rescue of the Environment (CURE) Library

Being informed and alert allows us to make thebest choices and changes needed to protect our futureand that of our children.

You may not be aware of how close you and yourown loved ones are to becoming names on the listsof victims (growing by the minute) in the govern-ment registries of persons exposed to toxic substancesresulting from TDs.

This is serious business. Some of these hazard-ous substances enter the human body and take uppermanent residence in tissues and organs. For thoseindividuals in toxic pathways, �there is no away�;nowhere to run. Exposed persons may carrybioaccumulating toxins in their bodies indefinitely.Victimization is more of a concern today thanyesterday. How can we protect ourselves and ourchildren?

Education. Educate ourselves, our children, thebureaucracy, and appointed and elected publicservants. We will never be aware of all toxins presentor released in our environment. Pure is gone forever.We can admit we have a serious problem; a flawedsystem of priorities. Choosing what we need andtrying to do the best to our ability to make and use

the things we consume safely will help. How can weparticipate in fostering the end to unnecessary use oftechnologies which are known to fail and bringdisaster to human life? What we want and what weneed can be very different. Better choices are inorder for society, because millions are sufferingunnecessarily. We want too many things which we donot need and now that we have them do not knowwhat to do with them. Conserving energy couldprevent the need for more nuclear power plants likeThree Mile Island or Chernobyl. As we tender careto the present victims of TDs could we not practiceconservatism and lessen tomorrow�s growingregistry of exposed persons? Finding a better waythan throw away is a must for a safer environment.�Away� is a place we will have to try and clean upsomeday; like the leaking landfill in my community.

If you have been a TD victim, I know your pain.I weep with you for your adversely affected quality oflife. Your sleepless nights are understood by me. Youunderstand me. I know your frustrations. On theother hand, I am experiencing a measure of HEAL-ING with my family and community. What encour-agement! There were times when I saw very little�light at the end of the tunnel.� Will I ever com-pletely HEAL? Maybe. Maybe not. I am joyful formy degree of wellness today. I look for a bettertomorrow. Scientific studies have shown that TDvictims may show serious psychopathological dys-function. The public has the right to know thatgroups studied were adversely affected and that �forabout half the subjects (studied), functioning levelswere seriously impaired (Gibbs, Margaret, 1989).�With the aid of such studies, we can predict theaffects of TDs. If we can predict such disastrousaffects, we can and should move to prevent them. Wecannot afford NOT to adopt preventative measuresfor the common good.

Such groups of victimized persons are not healthsegments of society. Unhealthy people means humansuffering and economic loss, which affects us all.

If your life has not been shattered by a TD andrelated exposure, I am happy for you. I hope it neverhappens to you.

For the victims and those yet untouched, I say weneed to continue to look for solutions to environmen-


tal contamination and preventive measures and actto implement them. TDs do not have to happen.

Because of you who know and share my lossesand those of you who care enough to come to ouraid in communities which need help in HEALING, Iwrite this paper.

In the HEALING experience the helped and thehelpers will benefit. We can lessen future victimiza-tion by acting to change our system. We shouldfurther study and acknowledge general psychopathol-ogy as an effect of TDs. The EPA, the United StatesDepartment of Health and Human Services, andother government institutions have historically beenlargely in the �dark� on this subject. Shall we �turnon the light� and show the need for health interven-tion for these �wounded millions.�

Only if society admits the present lie about thevictimization resulting from TDs and the vast numberof suffering individuals can the process of HEAL-ING expand to include all. If this does not happensoon, will the breakdown of our country be beyondrepair? I was taught from childhood that a peacefuland healthy mind is a must for a healthy body.

I share this story because of you who can helpand those who need help. You have read it. Do youbelieve? Do you care enough to help? I have learnedand am doing my part. May readers learn theirs.

Peace be with you.

Mary

�Remember - for evil to triumph, it is necessaryonly for good men to do nothing.�

- Edmund Burke

Note: Except for the author and her family, names of

individualshave been changed.

UPDATE

Since December 1993, a multidisciplinary researchteam has been investigating stress within our commu-nity. Sociologist, Stephen R. Couch, PhD, and psy-chologist, Jeffrey D. Kindler, PhD, are exploringcommunity interventions to pilot in our community.

In April 1995, at the invitation of the Agency for

Toxic Substances and Disease Registry (ATSDR)and the Keystone Landfill Task Force (SteeringCommittee), the ATSDR began to investigate a newagency involvement approach with out community.The 2-day procedure included 2 covered dishdinners and informal dialogue. ATSDR came andlistened to our concerns in detail. These concernsled to the development of new objectives and aresurgence of cautious hope among communityparticipants.

The author, with her husband, three daughters andelderly mother, lived in rural Pennsylvania in the areaof a landfill leaking toxic substances (an EPASuperfund site). She served as president of CitizensUrge Rescue of the Environment (CURE), theVictim�s Academic Network (VAN) and CITIZEN; amember of the Union Township Planning Commis-sion, the Keystone Landfill Task Force (TF), PeopleAgainst Contamination of the Environment (PACE),and Union Township RESOURCE Committee, andother community service. She is also a certifiedPennsylvania Municipal Landfill Inspector.

May 23, 1995Quote on blood disorders nearsuperfund sitesFollowing is a portion of the testimony of Barry L.Johnson, PhD, Assistant Surgeon General, AssistantAdministrator for ATSDR, Public Health Service, U.S.Department of Health and Human Services, givenbefore the Subcommittee on Commerce, Trade, andHazardous Material Committee on Commerce, U.S.House of Representatives:

Cancer and Immune System Function

�Blood samples from approximately 6,000 personswho live near 10 hazardous waste sites showed anincreased rate of an unusual production of abnormalblood cells that has been associated with chroniclymphocytic leukemia. Thus far these observationshave been predominantly among people who werepotentially exposed to volatile organic compounds.�

May 17, 1995Polycythemia vera (a rare blood disorder)Mary�s husband, Joseph, had been diagnosed withpolycythemia vera (PV). He has begun chemotherapy(drugs to kill extra blood cells in the body) and

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presently the disease is in �control.� Doctors saythere will be no remission. More research needs tobe done.

Joseph and Mary had thought to live out theirdays in their dream house. In May 1996, 30 yearslater, they left their dream home to another family:Roy, Elizabeth, and son Noah. They finally had hadto downsize to a small stone house not far awaybecause of age, ill health, and economic circum-stances. Stewardship of their beloved �Minor�sFolly� (named by their three daughters in 1966) wasgiven over by old friends to new friends who sharein common devotions to responsible stewardship ofcreation and commitment to county service.

We need to remember the Keystone SanitationLandfill disaster to better define our system�s weak-nesses and strengths. The children will always need tosuch stories. Their informed choices depend onkeeping the memory of struggles for justice alive.Joseph and Mary experienced technological disastersand resulting economic devastation. They are gratefulto serve and are devoted to helping others avoid suchexperiences.

CURE Adopts Education Committee(Victim’s Academic Network [VAN])

VAN Mission Statement

The Victim�s Academic Network was formed inresponse to the need for the education of citizens,governments, and other institutions to bring aboutawareness of the dangers of environmental contami-nation. This group is networking with others toimplement educational programs and presentations.

IN MEMORIAM:

Marianna CatesNew Paltz, New York, died on June 21, 1995. Shewas co-chair of CURE and VAN Education Com-mittee, and Foundress and Executive Director of theCancer Awareness Coalition.

Herbert Lee GreenFairfield, Pennsylvania, died suddenly on March 16,1995. He was mentor and friend of CURE andcountless other citizens who sought environmentaljustice. He was a former employee of the Pennsylva-

nia Department of Environmental Resources.

We mourn our loss and continue to work,inspired by their example.

�Justice will not come . . .until those who are not injured

are as indignant as those who are.�- Thucydides

Following is a list of some things we can do:

� Take action and encourage others to aid victims ofTDs.

� Support timely, multidisciplinary mitigation actionsfor TD communities.

� Intervene by caring, sharing, planning, implement-ing, teaching, guiding, learning about experiencesfor victims.

� Promote a better way than throw away.

� Reduce use of toxic substances.

� Admit the facts about TD victimization

� Insist on honest health, chemical, and environmen-tal reporting.

� Love those affected by TDs enough to act socially,

politically, economically.

� Support scientific reviews of existing studies and

support further health studies.

� Help victims who have lost control of theirenvironment regain power.

� Recognize that victims of TDs may need self-implemented solutions to help with the healingprocess.

� Acknowledge the normalcy and predictability of

people�s actions in light of their stressed lives.

� Work for social change to educate ourselves and

our children about TDs and environmental

degradation and victimization.

� Stop acceleration of TDs and resulting victim-

zation, societal breakdown, and environmental

degradation.

Let the shared task of HEALING begin!

� Commit to personal action.

� Hope that others see the change and take actionto facilitate it.


Most recently, the Agency for Toxic Substances andDisease Registry (ATSDR), the U.S. EnvironmentalProtection Agency (EPA), the Citizens Urge Rescue ofthe Environment (CURE), and representatives fromPenn State University met in Arlington, Virginia,November 16, 1998, to discuss the Keystonecommunity�s ongoing concerns about stress related tothe Keystone Sanitation Landfill Superfund Site.Presentations were made by Mary Minor, CURE, andReverend Julian Hall, Trinity United Church of Christ,on the community perspective of living near aSuperfund site; by Stephen Couch, PhD, Penn StateUniversity, Center for Environment and Community,on the predictability of adverse effects to humanhealth and quality of life in chronic technologicaldisasters, human and economic costs, ideas on how tomitigate trauma to communities, and communityempowerment; by Maureen Lichtveld, MD, MPH,ATSDR, on ATSDR�s Psychological Effects Initiative;and Pam Tucker, MD, ATSDR, on the psychobiologi-cal effects of stress, the current state of science anddata gaps, case studies and lessons learned, and atraining module developed for public health officials.

The one-day meeting included Mary Minorretelling the story of the Keystone Landfill disaster.Following this introduction, an open multiperspectivediscussion ensued on outreach, education, and pro-active intervention on the stress-related health effects,as well as the social dimensions, for communitieslocated near Superfund sites. The science of stress-related effects was shared and a dialogue was begunon stress and the development of partnerships to helpimplement stress-intervention programs. New goalswere set for relieving the chronic problems of theKeystone Landfill and reducing the chronic stress ofthe Keystone community.

By the end of the meeting, the group had agreedupon a number of �next steps� focused on thecontinued healing of the Keystone Landfill SuperfundSite community. Following is a list of some of thenext steps and a progress report:

� Recognize stress as a major health concern,

� Determine if Keystone is candidate for anATSDR community-based demonstration project,

� Open communication with Mary Minor

concerning her presentation and thecommunity�s participation in the meeting,

� Develop a means to incorporate psychologicalstress into risk assessments and public healthevaluations,

� Identify instruments to measure the success ofprograms,

� Establish a working museum or archive of theKeystone Incident, and

� Complete a community needs assessment.

In addition, the Community Stress Task Force(CSTF) subcommittee was formed, with representa-tives from CURE, Penn State University, EPA, andATSDR, to support the sharing of the story of theKeystone Landfill Disaster to inspire others to takeresponsibility to ensure the well-being of our environ-ment, to provide education, and to raise publicawareness. The CSTF is focusing on the goal to buildand maintain a library/archives, to write documenta-tion and history, to begin outreach efforts and theproduction of educational materials and activities.

During the summer months of 1999, severalmeetings have been held in the community. Theprogram, sponsored by CURE and the CSTF,initiated the organization and preservation of materialscontained in the CURE archives to make them morereadily accessible to community members. Theprogram also developed a plan on how to usearchived materials to develop research and educationalactivities, and continue the implementation of initialeducational activities. A video is planned to documentthe Keystone Incident and give an historical account.Also, through Penn State University, an internshipprogram began in July 1999.


GLOSSARY

Adrenal cortical responsea response of defeat or withdrawal (i.e., helpless-ness) that is biologically gased on cortisol secre-tion by the adrenal cortex.

Adrenal medullary responsea first response to fight or flee when challengedby a threat (e.g., exposure to a hazardous sub-stance) that is biologically based on the sympa-thetic.

Bioaccumulationprocess by which organisms retain chemicalpollution in their tissues at levels that are higherthan those found in the surrounding environ-ment.

Cognitive appraisal

looking at and interpreting the nature of a situation(e.g., a threat).

Demoralizationfeelings of hopelessness and helplessness.

Depressiona disorder of mood characterized by feelings oflow self-esteem, hopelessness about the future, littleactivity and appetite, and sleep disturbance.

Detoxificationthe process of removing a poison or toxin or theeffect of either from an area or individual.

Disempowermentto lose legal capabilities or control, to lose author-ity.

Ecohistoricalthe environmental record or account of an area.

Epidemiologista person who studies how often, in whom, andwhy a disease occurs in a population. An epidemi-ologist looks at the sum of the factors controllingthe presence or absence of a disease and thepossible causes (e.g., coming into contact with ahazardous substance).

Epinephrineadrenaline; a hormone that is released in responseto stress or other stimuli (e.g., a reaction to astressful situation, can raise blood pressure).

Field researcha type of research during which social scientistsrecord their observations of communities (e.g.,communities being affected by possible exposuresto hazardous substances).

Heterogeneous populationa group of people (e.g., in a community) who aredifferent (e.g., in culture, socioeconomic level, age).

Holistic viewa way of looking at something that includes all ofits parts at one time, looking at the whole orcomplete picture (e.g., how humans and theenvironment work together) or how medicine cantreat both the mind and body at the same time.

Homogeneous populationa group of people (e.g., in a community) who aresimilar (e.g., culture, socioeconomic level, or age).

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Interaction analysis researcha way of studying groups of people by looking atthe members� reactions in categorized emotionaland problem-solving responses.

Longitudinal studya study that looks at changes (e.g., in a person orgroup of people) over a long period of time.

Marginalized communitya community that feels disenfranchised, or withoutlegal right or other privileges; a susceptible orvulnerable community (e.g., created by establishingboundaries to indicate environmental contamina-tion).

Mercurialismmercury poisoning. Preclinical signs of mercurypoisoning resulting in tremor and emotional changesoccur at urine mercury levels greater than 500micrograms/Liter.

Nerviosa general state of vulnerability to stressful lifeexperiences and to a syndrome brought on bydifficult life circumstances. This type of distress iscommon among Latinos in the United States andLatin America, with similar concepts of �nerves�among Greeks in North America, nerva.

Neurobehavioral disordera response to an occurrence (e.g., exposure to ahazardous substance) that results symptoms of aneurological (e.g., a tremor) or behavioral (e.g.,mental distress) nature.

Neurotoxinspoisonous substances that can have a negativeeffect on the nervous system.

Nonspecific health outcomesnegative physical responses to a situation or anexposure that do not seem to fit a defined pattern.

Norepinephrinea hormone that is produced before epinephrine(adrenalin) and results in a similar reaction in thebody. (See Epinephrine.)

Occupational stressstrain or tension associated with one�s job. In thecontext of this report, the word refers specificallyto strain or tension associated with working nearor in a hazardous environment or with a hazardsubstance.

Physiological health effectsadverse effects to health resulting from psychologi-cal and social factors.

Pibloctoqan episode of extreme excitement, which lasts up to30 minutes and is often followed by convulsiveseizures and coma lasting up to 12 hours amongAlaskan Eskimos (26).

Post-traumatic stress syndrome (PTSD)a pattern of symptoms (e.g., anxiety, tension,depression, nightmares) that follows a disaster (e.g.,exposure to a hazardous substance).

Psychiatric epidemiologista person who studies how often, in whom, andwhy a mental disorder or disturbance occurs. Apsychiatric epidemiologist looks at the sum of thefactors controlling the presence or absence of amental disorder or stress and the possible cause(e.g., coming into contact with a hazardous sub-stance).

Psychobiologya field of psychology that looks at how an organ-ism (e.g., a human) adapts to its environmentthrough its physical makeup (e.g., the nervoussystem).

Psychosocialthe way a group of people interacts mentally (e.g.,social interaction).

Qualitative methoda means of studying factors that influence aresponse on the basis of attributes that are or aren�tpresent


Quantitative methoda means of studying factors that influence a re-sponse that is measured on a numerical scale ofequal intervals.

Secondary controlan attempt to change one�s self to suit the exist-ing circumstances.

Secondary gaina positive outcome or advantage that occurs as aresult of an incident (e.g., illness results in atten-tion, time off from work).

Secondary victimsworkers or participants who enter a situation tooffer help and who subsequently react with exhaus-tion or irritability.

Sensitivitya state of being responsive to an occurrence orsubstance.

Sensitizationthe process of becoming easily hurt or affected byexposure to or the possibility of being exposed to ahazardous substance.

Sequela(e)an effect that occurs after an illness or injury (e.g.,depression, a constant state of nervousness).

Siting decisionto make the choice to locate a building, facility, orproject in an area that can affect the environment ina number of ways.

Somatichaving to do with the body.

Statistical significancea difference found among groups after a compara-tive randomized investigation that is not likely to becaused by chance alone. The probability of itoccurring by chance alone is often reported asP<0.05.

Stressa state of physical or psychological strain ortension.

Subculturesan ethnic, regional, economic, or social grouphaving patterns of behavior that are specific totheir group.

Subjective phenomenonan occurrence that is seen through the eyes of thebeholder.

Subpopulationsan identifiable part of a larger population (e.g.,health care workers, factory workers).

Sustoa folk illness that is attributed to a frighteningevent. This illness is found among some Latinos inthe United States and among people in Mexico,Central America, and South America.

Syndromea group of symptoms that occur together andindicate a specific health problem.

Target OrgansA part of the internal body, for example, thenervous system, cardiovascular and gastrointestinalsystems, that could be adversely affected by expo-sure to a hazardous substance and resulting stress.

Threatan individual�s awareness of an imminent, wide-spread change in their environment that poses apossible danger (e.g., a large chemical spill).

Trauma inductionthe process by which a person begins to experiencesuffering from a highly stressful event.

Trauma reductionthe process by which an individual�s suffering froma highly stressful event begins to lessen.

ATSDR - Psychological Responses to Hazardous Substances · social responses to toxic exposures and...

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