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Ecology and Public Health
Spring 2008  
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h Tolbert's research includes the largest study to date examining the relationship between Atlanta emergency room visits and air pollution. h

Ecology and Public Health
How humans treat the planet is changing how the Department of Environmental and Occupational Health approaches the environment
By Sherry Baker and Pam Auchmutey

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On far too many hot, muggy Atlanta days, the view from Paige Tolbert's corner office at the RSPH is obscured by haze. It's a reminder of one of Tolbert's research passions—how air quality affects health. And in a larger context, it also illustrates the challenges the Department of Environmental and Occupational Health (EOH) faces as the city and the planet move toward a future where public health is increasingly affected by climate change, growing environmental degradation, and urban sprawl.
     "Classical environmental health looks at chemical exposures and very specific health outcomes. It's what a lot of us do and what the department will continue to do," says Tolbert, who became EOH chair last fall. "But we are broadening our thinking about the impact of all human activities, such as deforestation and polluting our water and air around the globe. As the department moves forward, we'll be hiring new faculty who focus on these wider areas."
     Public health ecology—how planetary changes resulting from human behavior affect health—is the wave of the future in environmental studies. Climate change and deforestation, for example, influence health as new patterns for disease emerge.
     "If you think about a shift of one degree and what that means globally, it changes the entire distribution of a number of infectious diseases that are vector-borne," says Tolbert. That includes diseases like West Nile virus and malaria. "As the climate warms, the distribution of the mosquito population changes. Similarly, deforestation can impact vector-borne illnesses."
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Paige Tolbert
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h For Paige Tolbert, Atlanta is the perfect laboratory for studying the effects of air quality on health. The city has the highest number of vehicle miles driven per day in the nation. h
  Atlanta as laboratory

What humans do to the air they breathe and the effects on health have long fascinated Tolbert. Atlanta is an ideal laboratory for studying air quality and health, given the often-visible haze produced by emissions from vehicles and coal-burning power plants. Tolbert's research includes the largest study to date examining the relationship between emergency room visits and air pollution. Funded by the nih and the U.S. Environmental Protection Agency (EPA), her study uses some of the most detailed pollution data ever collected using measurements taken by the Georgia Institute of Technology and other partners. RSPH researchers Mitch Klein, Jeremy Sarnat, Stefanie Eblet Sarnat, Dan Flanders, and Lance Waller also are collaborating on the study.
     "We went to each Atlanta-area hospital and collected data on more than 10 million emergency department (ED) visits," says Tolbert. "This research has never been done before, and it provides us with an incredible resource that I think of as ‘natural experiments' going on around us that we can study."
     The Study of Particles and Health in Atlanta (SOPHIA) examines the associations between daily air quality and daily ED visits for heart and respiratory problems, based on data from 41 hospitals dating back to 1994. The study looks at outcomes such as ischemic heart disease, cardiac arrhythmias, congestive heart failure, asthma, chronic obstructive pulmonary disease, upper respiratory infections, and pneumonia.
     "It is well established that particulate pollution is related to these outcomes. This study allows us to extend our understanding and look at questions about what aspects of particulate matter appear to be the most hazardous," Tolbert says. "We're using detailed air quality data that a number of researchers are developing, including our Georgia Tech collaborators. It allows us to go beyond what previous studies have done, which generally relied on routine air quality monitoring of the usual air pollutants that the EPA regulates."
     For instance, study evidence implicates particles from motor vehicle exhaust as being important for cardiac outcomes. "The sheer size of the study allows more robust assessment of the dose-response relationships of interest," she adds.
     While there is a strong body of evidence linking air pollution with cardio-respiratory problems, the links between air pollution and other health outcomes are less clear. In other work relating to SOPHIA, Tolbert, epidemiology professor Michele Marcus, and CDC researchers are looking at birth outcomes, including pre-term births, small for gestational age birth defects, and cardiac birth defects. Jonathan Langberg, director of cardiac electrophysiology at Emory University Hospital, is analyzing data from people implanted with heart defibrillators to determine if heart arrhythmias increase when air pollution is high. Emergency medicine physician Jeremy Hess has a special interest in the heat index and how it can be used to project the health impact of climate change. In another SOPHIA offshoot, RSPH sanitation expert Christine Moe is looking at gastrointestinal illness from the ED data in relation to Atlanta's drinking water.
     As the SOPHIA study progresses, so will the body of evidence to further shape environmental policy. "Our study is a key contributor to the EPA's development of air quality standards," says Tolbert. "The agency comes to us for our latest results because they provide key evidence. So our studies are contributing to the development of changes in air quality standards."
     The department recently turned its attention to the repercussions of China's vast environmental transformation. As part of a new collaboration with China, Tolbert and other EOH researchers will study how living near major roadways may lead to development of asthma. The study, to be funded by Emory's Global Health Institute, is just one arm of a continuing 20-year study involving hundreds of thousands of people and led by Chinese and CDC researchers. This study will set the stage for more work on the impacts of the environmental changes taking place in China.
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      Poised for growth

Given the scope of her research, Tolbert already had a full plate when she became acting chair of EOH in 2005. But the leadership role soon opened her eyes to the department's potential and what needed to be done to achieve that potential.
     Atlanta's appeal as a hub for studying environmental and occupational health and the school's plans to open a second building with state-of-the-art laboratory space make the department and the RSPH ripe for growth. The department plans to double its faculty from 10 to 20, bringing in experts to build on existing strengths and create new ones. Current strengths range from the global to the molecular, with expertise in pesticide exposure, toxicology, occupational cancer, air pollution and urban sprawl, and global environmental health issues. Plans call for broadening expertise in laboratory-based mechanistic work, including biomarkers and gene-environment research, and adding faculty who specialize in public health ecology, the built environment, children's environmental health, environmental medicine, geographic information systems, and more.
     The opportunity for collaborative research is a strong drawing card. "For faculty involved in climate change work, collaboration with Georgia Tech researchers, who are already looking at projections of severe weather events in the future, is a great advantage," says Tolbert.
     Students stand to benefit in other ways. EOH plans to offer a PhD program in environmental health sciences beginning in the fall of 2009. The program will raise the profile of the department and the school and enhance recruitment and retention of faculty.
     Global Environmental Health, a joint program between EOH and the Hubert Department of Global Health, attracts students interested in global environmental questions. "We are in need of mentors who can identify and supervise projects for these students and offer them additional courses," says Tolbert. "That's another strong motivation for bringing in more faculty and for building our doctoral program."
     Together, Tolbert and Uriel Kitron, the new chair of environmental studies in Emory College, are launching a five-year bs/mph program this fall. Students will complete their undergraduate studies and begin taking public health courses during the first four years and complete their studies in EOH during the last year.
     Last fall, the department introduced an interdisciplinary course on the built environment and public health. "This is another emerging area," says Tolbert. "We are interested in expanding our research about issues such as urban sprawl, the benefits of green space, and the health impacts of land use—which can range from the very acute (motor vehicle trauma) to the long term (obesity, cancer, heart disease)."
     What else does the future of EOH hold? Student interests reveal part of the answer. "They are increasingly concerned and excited about the big planetary issues. Instead of feeling hopeless and helpless about the future, there is a movement toward taking action on a personal level in addition to striving to change policies at the national and international level," Tolbert says. "And there is an understanding that at the local level we have to plan responses and adaptation to problems like climate change.
     "More and more, environmental health is being recognized as multi-level, from local to global, in terms of the kinds of action that need to happen. It's a very important time—and very exciting time—to be part of this work and this department."
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