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Emergency medical services (EMS) personnel treat 22 million patients a year in the United States, yet little is known of their injury risks.To describe the epidemiology of occupational injuries among EMS personnel, calculate injury rates, and compare the findings with those for other occupational groups.This was a retrospective review of injury records kept by two urban agencies. The agencies submitted all 617 case reports for three periods between January 1, 1998, and July 15, 2002. The agency personnel worked an estimated 2,829,906 hours during the study periods. Cases were coded according to U.S. Department of Labor (DOL) criteria.Four hundred eighty-nine cases met the DOL inclusion criteria. The overall injury rate was 34.6 per 100 full-time (FT) workers per year (95% confidence interval [CI] 31.5-37.6). "Sprains, strains, and tears" was the leading category of injury; the back was the body part most often injured. Of the 489 cases, 277 (57%) resulted in lost workdays, resulting in a rate of 19.6 (95% CI 17.3-21.9) per 100 FT workers; in comparison, the relative risks for EMS workers were 1.5 (95% CI 1.35-1.72) compared with firefighters, 5.8 (95% CI 5.12-6.49) compared with health services personnel, and 7.0 (95% CI 6.22-7.87) compared with the national average.The injury rates for EMS workers are higher than rates reported by DOL for any industry in 2000. Funding and additional research are critical to further defining the high risks to EMS workers and developing interventions to mitigate this serious problem.

The objective of this project is to create awareness among parents and healthcare providers on asthma and asthma management through a model of centers for excellence, Pediatric Environmental Health Specialty Units (PEHSU). PEHSUs are centers for education and community outreach on child health and the environment located in every federal region. Although the exact program of each PEHSU differs, they are all mandated to provide educational programs to parents and health practitioners. We describe activities of a representative PEHSU, the Mid-Atlantic Center for Children's Health and the Environment (MACCHE), and the compatibility and potential of PEHSU activities for asthma education. Since its inception, MACCHE has educated physicians in over 20 hospitals during grand rounds on asthma and molds. MACCHE obtained 80% participation at its first conference on Children's Health and the Environment in 2002, Washington, D.C. PEHSUs, in partnership with practitioners treating asthma, can help identify tri...

Background Although stainless steel has been produced for more than a hundred years, exposure-related mortality data for production workers are limited. Aims To describe cause-specific mortality in Finnish ferrochromium and stainless steel workers. Methods We studied Finnish stainless steel production chain workers employed between 1967 and 2004, from chromite mining to cold rolling of stainless steel, divided into sub-cohorts by production units with specific exposure patterns. We obtained causes of death for the years 1971–2012 from Statistics Finland. We calculated standardized mortality ratios (SMRs) as ratios of observed and expected numbers of deaths based on population mortality rates of the same region. Results Among 8088 workers studied, overall mortality was significantly decreased (SMR 0.77; 95% confidence interval [CI] 0.70–0.84), largely due to low mortality from diseases of the circulatory system (SMR 0.71; 95% CI 0.61–0.81). In chromite mine, stainless steel melting shop and metallurgical laboratory workers, the SMR for circulatory disease was below 0.4 (SMR 0.33; 95% CI 0.07–0.95, SMR 0.22; 95% CI 0.05–0.65 and SMR 0.16; 95% CI 0.00–0.90, respectively). Mortality from accidents (SMR 0.84; 95% CI 0.67–1.04) and suicides (SMR 0.72; 95% CI 0.56–0.91) was also lower than in the reference population. Conclusions Working in the Finnish ferrochromium and stainless steel industry appears not to be associated with increased mortality.

Disposal of used tires has been a major problem in solid waste management. New uses will have to be found to consume recycled tire products. One such proposed use is as ground cover in playgrounds. However, concern has been expressed regarding exposure of children to hazardous chemicals and the environmental impact of such chemicals. We designed a comprehensive hazard assessment to evaluate and address potential human health and environmental concerns associated with the use of tire crumb in playgrounds. Human health concerns were addressed using conventional hazard analyses, mutagenicity assays, and aquatic toxicity tests of extracted tire crumb. Hazard to children appears to be minimal. Toxicity to all aquatic organisms (bacteria, invertebrates, fish, and green algae) was observed; however, this activity disappeared with aging of the tire crumb for three months in place in the playground. We conclude that the use of tire crumb in playgrounds results in minimal hazard to children and the receiving environment.

Human health studies emphasize the link between the human body and the immediate influences upon it. Ecosystem health studies (defined by David Rapport et al., this volume) has, as its primary objective, the relationships and system characteristics of viable ecosystems. As a practical application, ecosystem health studies describe the mechanisms and assesses the potential to threaten or enhance human health. Keywords: Air quality, Ecology, Greenhouse effect, Linkages, Public health

The dispersion of air pollutants from all 231 licensed sour-gas processing plants in Alberta, Canada, was modeled on a monthly basis over a 10-year period (1985-1994). Exposure estimates for sulfur dioxide (SO(2)-used as a surrogate for exposure to combusted emissions) then were assigned to 1382 provincial dairy farms using a geographical-information system. Individual average and peak exposure for periods prior to each of 15 months of age and conception (four exposure-averaging periods for each of two dispersion models) were estimated for 163,988 primiparous female dairy-cattle between 1986 and 1994. Monthly or annual average farm-site exposure estimates likewise were assigned to associated herd-level data sets for the biologically relevant period of interest for each of three additional reproductive outcomes: monthly herd-average calving interval, stillbirth risk, and twinning risk. In one of the main-effects models, the maximum (i.e., peak) monthly sour-gas exposure experienced by individual-animals from birth to conception was associated with an increased time to first-calving in the very-highest exposure category (hazard ratio=0.86, 95% CI=0.80, 0.92). This equates to a decreased hazard (lambda) of calving (in each month subsequent to 22 months of age) for the highest-exposure animals (lambda=0.170) versus the zero-exposure animals (lambda=0.198) in a model with referent values for agro-ecological region and season of birth. The dose-response was not consistent across the full range of exposure categories. There was significant (P=0.003) interaction of emissions with agro-ecological region. After accounting for the interaction, a more-consistent dose-response was evident for some (but not all) agro-ecological regions. This suggests that any effect of emissions on dairy-heifer reproduction is subject to modification by features of soil type, vegetative cover, and/or climate. The increase in monthly herd-average calving interval on farms exposed to the very-highest levels of emissions appeared quite small and of limited practical importance within the range of expected exposures. There was no association between exposure and the risk for twinning. Herds exposed to higher emissions exhibited a slight decrease in risk for stillbirth.

Workers' compensation systems attempt to evaluate claims for occupational disease on an individual basis using the best guidelines available to them. This may be difficult when there is more than one risk factor associated with the outcome, such as asbestos and cigarette smoking, and the occupational exposures is not clearly responsible for the disease. Apportionment is an approach that involves an assessment of the relative contribution of work-related exposures to the risk of the disease or to the final impairment that arises for the disease. This article discusses the concept of apportionment and applies it to asbestos-associated disease. Lung cancer is not subject to a simple tradeoff between asbestos exposure and smoking because of the powerful biological interaction between the two exposures. Among nonsmokers, lung cancer is sufficiently rare that an association with asbestos can be assumed if exposure has occurred. Available data suggest that asbestos exposure almost invariably contributes to risk among smokers to the extent that a relationship to work can be presumed. Thus, comparisons of magnitude of risk between smokers and nonsmokers are irrelevant for this purpose. Indicators of sufficient exposure to cause lung cancer are useful for purposes of establishing eligibility and screening claims. These may include a chest film classified by the ILO system as 1/0 or greater (although 0/1 does not rule out an association) or a history of exposure roughly equal to or greater than 40 fibres/cm3 x y. (In Germany, 25 fibres/cm3 x y is used.) The mere presence of pleural plaques is not sufficient. Mesothelioma is almost always associated with asbestos exposure and the association should be considered presumed until proven otherwise in the individual case. These are situations in which only risk of a disease is apportioned because the impairment would be the same given the disease whatever the cause. Asbestosis, if the diagnosis is correct, is by definition an occupational disease unless there is some source of massive environmental exposure; it is always presumed to be work-related unless proven otherwise. Chronic obstructive airways disease (COAD) accompanies asbestosis but may also occur in the context of minimal parenchymal fibrosis and may contribute to accelerated loss of pulmonary function. In some patients, particularly those with smoking-induced emphysema, this may contribute significantly to functional impairment. An exposure history of 10 fibre x years is suggested as the minimum associated with a demonstrable effect on impairment, given available data. Equity issues associated with apportionment include the different criteria that must be applied to different disorders for apportionment to work, the management of future risk (eg. risk of lung cancer for those who have asbestosis), and the narrow range in which apportionment is really useful in asbestos-associated disorders. Apportionment, attractive as it may be as an approach to the adjudication of asbestos-related disease, is difficult to apply in practice. Even so, these models may serve as a general guide to the assessment of asbestos-related disease outcomes for purposes of compensation.

Method for diagnosing evaporative losses from a fuel tank of an internal combustion engine; the method of diagnosis consisting of: isolating the tank; pressurizing/depressurizing the tank by means of a pneumatic machine driven by an electric motor; measuring the time profile of at least one characteristic value of the electric motor; and diagnosing the rate of evaporative loss from the tank as a function of the frequency range of the characteristic value of the electric motor.

Building Health Sciences, Inc. (BHS), investigated environmental conditions by many modalities in 71 discreet areas of 12 buildings in a government building complex that had experienced persistent occupant complaints despite correction of deficiencies following a prior survey. An online health survey was completed by 7,637 building occupants (49% response rate), a subset of whom voluntarily wore personal sampling apparatus and underwent medical evaluation. Building environmental measures were within current standards and guidelines, with few outliers. Four environmental factors were consistently associated with group-level building-related health complaints: physical comfort/discomfort, odor, job stress, and glare. Several other factors were frequently commented on by participants, including cleanliness, renovation and construction activities, and noise. Low relative humidity was significantly associated with lower respiratory and "sick building syndrome"-type symptoms. No other environmental conditions (including formaldehyde, PM10 [particulate matter with an aerodynamic diameter

Context: Determination of the occupational risk of hepatitis B and C to public safety workers is important in identifying prevention opportunities and has significant legal and policy implications. Objectives: Characterize the risk of occupationally acquired infection: (1) risk of exposure to blood and body fluids, (2) seroprevalence of hepatitis B and C in the source population, and (3) risk of infection after exposure. Data Sources: Electronic search of MEDLINE (1991–1999), HealthStar (1982–1999), and CINAHL (1975–1999) supplemented by selected reference citations and correspondence with authors of relevant articles. Study Selection: Peer-reviewed journal articles (N=702) that addressed the transmission of hepatitis B and C in law enforcement, correctional, fire, emergency medical services, and healthcare personnel were identified. One hundred five (15.0%) articles were selected for full-text retrieval; 72 (68.6%) were selected for inclusion. Data Abstraction: Articles selected for inclusion were abstracted by two reviewers and checked by a third reviewer, using a standard reporting form. Data Synthesis: Evidence tables were constructed, using the standardized abstracts. The tables were designed to summarize data for the key elements of the risk analysis. Conclusions: Data suggest that emergency medical service (EMS) providers are at increased risk of contracting hepatitis B, but data have failed to show an increased prevalence of hepatitis C. EMS providers have exposure risks similar to those of hospital-based healthcare workers. Other public safety workers appear to have lower rates of exposure. Urban areas have much higher prevalence of disease, and public safety workers in those areas are likely to experience a higher incidence of exposure events.

Background Polyvinyl chloride plastics (PVC), made flexible through the addition of di-2-ethylhexyl phthalate (DEHP), are used in the production of a wide array of medical devices. From the late 1960s, leaching of DEHP from PVC medical devices and ultimate tissue deposition have been documented. Methods A critical review of DEHP exposure, metabolism, and toxicity data from human and animals studies was undertaken. A brief analysis of alternatives to DEHP-plasticized PVC for use in medical device manufacture was completed. Results DEHP leaches in varying concentrations into solutions stored in PVC medical devices. Certain populations, including dialysis patients and hemophiliacs may have long-term exposures to clinically important doses of DEHP, while others, such as neonates and the developing fetus, may have exposures at critical points in development. In vivo and in vitro research links DEHP or its metabolites to a range of adverse effects in the liver, reproductive tract, kidneys, lungs, and heart. Developing animals are particularly susceptible to effects on the reproductive system. Some adverse effects in animal studies occur at levels of exposure experienced by patients in certain clinical settings. DEHP appears to pose a relatively low risk of hepatic cancer in humans. However, given lingering uncertainties about the relevance of the mechanism of action of carcinogenic effects in rodents for humans and interindividual variability, the possibility of DEHP-related carcinogenic responses in humans cannot be ruled out. Conclusions The observed toxicity of DEHP and availability of alternatives to many DEHP-containing PVC medical devices presents a compelling argument for moving assertively, but carefully, to the substitution of other materials for PVC in medical devices. The substitution of other materials for PVC would have an added worker and community health benefit of reducing population exposures to DEHP, reducing the creation of dioxin from PVC production and disposal, and reducing risks from vinyl chloride monomer exposure. Am. J. Ind. Med. 39:100–111, 2001. © 2001 Wiley-Liss, Inc.

Acute exposure to hydrogen sulfide (H2S) causes 4 dose-dependent responses: hyperpnea, unconsciousness or knockdown, apnea, and death. At present, scientific mechanisms for these effects are unknown, but inhibition of cytochrome oxidase in the central nervous system (CNS) by sulfide has been suggested. In this study, the premise of brain as target is examined by comparing peripheral with direct delivery of sulfide to brain. NaHS was administered to anesthetized Sprague-Dawley male rats, by femoral intravenous, or carotid intra-arterial injection. With apnea as the test, ED100 values of 0.6 and 3.0 mg kg(-1) were found for peripheral and direct delivery to brain, respectively. Peripheral delivery is 5 times as effective as direct delivery to the brain, and greater if the relative dilution factors are considered. Lidocaine, applied to the vagus, prevented apnea, so lung-brain transmission was essential. It was therefore concluded that the lung is the peripheral site of action. Hyperpnea increased in duration with dose. The carotid body, located distal to the arterial catheter, sensed the high doses of NaHS but did not trigger apnea. Intravenous infusion or intraperitoneal injection with NaHCO3 prevented hyperpnea, apnea, and death. The following conclusions are drawn: the carotid body is not implicated in NaHS-induced apnea, the lung and not brain harbors the primary site of action of H2S, and an afferent neural signal from the lung via the vagus induces the apnea. Finally, NaHCO3 appears to prevent toxicity from sulfide, and therefore H2S, by some unexplained mechanism. Practical emergency treatment for acute toxicity in the field may be possible.

Background: Inhalational exposure to zinc oxide fumes is associated with metal fume fever a self-limited but very uncomfortable condition closely resembling influenza. Very little is known regarding the toxicokinetics of inhaled zinc, making the interpretation of zinc measurements in serum and urine problematic. Methods: Twenty workers in a zinc foundry in Baiyin, Peoples' Republic of China, were investigated with serial examinations by a physician, chest radiographs, and spirometry. Exposure assessment consisted of the measurement of zinc in serum, urine, and personal air samples. Results: No cases of metal fume fever were observed during the study period despite exposures to as high as 36.3 mg/m(3) over less than 4 hr. In addition, no radiographic or functional changes were noted. Serum zinc levels of all workers were within the reference range and did not correlate with external exposure measurements. However, elevations were noted in urinary zinc levels, which showed a significant association (Spearman's correlation coefficient = 0.47, P = 0.04) between exposure to zinc and urine zinc. Conclusions: These results provide exposure measurements for zinc at which workers demonstrate tolerance to the development of metal fume fever. Furthermore, they suggest that urine may be the preferred biological medium for the assessment of zinc exposure. Am. J. Ind. Med. 35:574-580, 1999. (C) 1999 Wiley-Liss, Inc.

The effects of exposure to carbon disulphide have been studied mostly among workers in the viscous rayon industry, where the usual exposure profile has been relatively steady exposure over work shifts. We investigated 13 workers in a small chemical company who were exposed to low levels, peaking intermittently to relatively high levels in the range of 100-200 ppm at the end of the work shift, a pattern that may change the risk profile. Our investigation was part of a compliance order that was fought by the company and our access and follow-up was limited. Two workers had burns on their bodies associated with exposure to caustic. Four had elevations in total serum cholesterol, one had elevated serum triglycerides and three had elevations in fasting blood glucose - two of them were known to be diabetics before employment and one had a history of unexplained peripheral neuropathy. No consistent pattern suggestive of a defined lipoprotein abnormality was obvious but several atherogenic profiles were observed. Five had abnormalities on electrocardiogram, four of whom appeared to be among the most heavily exposed. The presence of these changes taken together in this context may suggest accelerated atherosclerotic changes. Tests of liver and kidney function were within the normal range for all workers, as was a complete blood count. Four of the workers had evidence of a bilateral reduction in hearing threshold at 4,000 Hz. A complete set of recommendations was forwarded to the employer, emphasizing further control of exposure to carbon disulphide, personal protection requirements and a cardiovascular risk reduction programme. Conditions improved in the plant following modifications introduced in response to a stop work order from the provincial government's occupational health and safety agency. However, a fire in 1998 put the company out of business and ended further follow-up or interventions. We conclude that these findings, while difficult to interpret because of the circumstances of the investigation, are compatible with an atherogenic effect of exposure to peaking levels of carbon disulphide. The observation should be tested in a larger population with fewer confounding factors and greater control over the investigation.

Particulates not otherwise classified (PNOC) and particulates not otherwise regulated (PNOR) are the terms used by the American Conference of Governmental Industrial Hygienists and by the Occupational Safety and Health Administration (OSHA), respectively, for those dusts not already identified and covered by a specific OSHA standard, as listed in 29 CFR 1910.1000. The rubric of PNOC/R therefore covers the vast majority of dusts likely to be encountered in the workplace. However, these dusts are associated with only a small number of claims for workers' compensation or reports of occupational disease. Pneumoconioses caused by these dusts are uncommon and usually confer little functional impairment compared with the fibrogenic dusts such as asbestos, silica, and coal dust. The attribution of airways disease to nonfibrogenic dusts has been highly controversial. It is common practice, in the absence of a clear guideline to the contrary in the clinical literature, to consider exposure to nonfibrogenic...

Physicians and public health professionals working with the U.S. Environmental Protection Agency’s Region 8 Pediatric Environmental Health Specialty Unit (PEHSU) received several telephone calls requesting information regarding the safety of recycled tire crumb as a playground surface constituent placed below children’s play structures. There were no reported symptoms or adverse health effects in exposed children. The literature available on the safety and risk of exposure to crumb rubber constituents was limited and revealed no information quantifying exposures associated with product use. Callers were informed by the PEHSU that no evidence existed suggesting harm from intended use of the product, but gaps in knowledge about the product were identified and communicated. Here the case of crumb rubber on playgrounds is used as a model to present an approach to similar environmental medicine questions. From defining the question, to surveying traditional and nontraditional resources for information, synthesis of findings, and risk communication, the case provides a model to approach similar questions.

Welding produces a variety of substances toxic to the respiratory tract. A thorough occupational history, based on an understanding of the various work processes, is essential to the prompt identification of potential welding-associated hazards. Several key questions can establish if the worker has been exposed to some of the more potent airborne emissions from welding. Although this trade is not associated with extraordinary morbidity and mortality in occupational health statistics, a wide variety of acute and chronic respiratory disorders are recognized. There is considerable overlap in the presentation of several of the acute disorders, frequently posing a diagnostic dilemma. The health hazards of welding are changing with the evolution of increasingly sophisticated technologies. Although exposure to welding fumes in general is associated with a 30% to 40% increased mortality from lung cancer, it remains controversial whether or not stainless steel welders are at heightened risk.

This is the first in a series of surveys conducted in Fort McMurray, Alberta, Canada, as part of the Fort McMurray Demonstration Project in Social Marketing. The Project is a community-based, cooperative program designed to demonstrate and to evaluate the application of social marketing and community animation to health- and safety-promoting interventions. This baseline survey was for the purpose of planning specific interventions and to support evaluation of the impact of these interventions. In 1992, a survey of Fort McMurray residents was conducted by telephone. Respondents to the survey tended to be disproportionately women (60%) and aged 30 to 44 (men 55%, women 54%). Most of the findings reported describe a generally affluent community with good self-reported health status and satisfaction in the quality of life. Occupational and personal health-and safety-related behaviours showed some contradictions. Both hearing protection and eye protection are much more frequently practiced at work tha...

The Network of Centres of Excellence (NCE) in Sustainable Forestry Management is a new research initiative in Canada that examines management practices that protect boreal forest resources while permitting controlled economic development. A critical factor in the viability of such practices is socioeconomic and cultural acceptability in the communities of the region. Health is an essential factor in this dimension of sustainability. The NCE includes a health component that examines issues of human and ecosystem health related to boreal forest communities in western and northern Canada. These may be direct, involving direct health effects on the human body, or indirect, mediated by social mechanisms. Communities in the region are generally small, remote, limited in economic resources, and support a mixed economic development of forest products, oil and gas, and traditional aboriginal activities. The small and dispersed population and the time frame for the study do not permit application of the usual methods of broad-based community health research. Instead, emphasis is placed on four main elements with a variety of robust and sometimes qualitative methods to suit the problems. The four elements are: (1) ”Population health,“ a conceptual model of determinants of health, as interpreted for boreal forest communities; (2) application of the population health model to anticipate and prevent human health problems associated with various scenarios of sustainable forestry management; (3) occupational health and safety issues associated with increased activity in the forest products sector; and (4) large-scale ecosystem change and human health. The NCE presents an unusual opportunity to study both the ecosystem and human health implications of an ecological intervention. Its activities may provide insight into the complex relationship between human and ecosystem health.

Trace element profile analysis detects and quantifies the presence of several metals simultaneously at low concentrations in the body. In occupational medicine, it may be used to monitor exposure or to evaluate suspected toxicity. Clinical interpretation is often difficult because, with the exception of lead and possibly cadmium, there is little firm information on toxicity thresholds. For these tests, the reference ranges typically reflect low levels of exposure in the general population and it is expected that workers handling metals in occupations such as welding and industries such as steelmaking will have higher levels. Interpretation requires some knowledge of the toxicokinetics of the metal of interest and the preferred medium for analysis for each: serum, whole blood or urine (preferably 24-hour collection). Trends are often more informative than concentrations at one time. Trace element values are reported together with a reference range which must be distinguished from the normal range of other clinical tests. As a practical matter, the greatest interpretation problems tend to be found with manganese because serum levels have a poor correlation with both recent exposure and neurological symptoms. Molybdenum and vanadium are often found to be elevated among workers exposed to metals who show no evidence of clinical illness. Interpretation of the trace element profile analysis overall when an elevation occurs generally requires close attention to the pattern of elevation, clinical context, absolute and relative magnitude of the elevation and knowledge of the exposure history.

Occupational medicine in Canada presents many paradoxes and anomalies. This paper outlines the history, status, and current direction of occupational medicine in the country, with an emphasis on the unusual features of the Canadian experience.

(2005). When a Journal Cannot Stand Behind a Published Paper. Archives of Environmental & Occupational Health: Vol. 60, No. 3, pp. 115-117.

Reproductive hazards make many employers uncomfortable. They raise issues of equity and responsibility beyond worker health protection. Fear of liability for adverse birth outcomes, such as miscarr...

Background Workplace violence has become an issue of increasing concern of in public health, in Turkey elsewhere. Healthcare workers are at particular risk of workplace violence. In order to develop prevention policies for workplace violence, the current and objective data should be available. This study aims to provide such data, obtained with a stratified sample representative of the country and a whole. Methods A cross-sectional study was conducted from …

The US Centers for Disease Control and Prevention (CDC) recently announced a change that is not really a change but a change in point of view, accompanied by a new number with the same significance...

Asbestos is a significant occupational carcinogen; it is responsible for a global epidemic of lung cancer and mesothelioma, and other cancers as well, as well as smaller epidemics of nonmalignant r...

The literature specific to respiratory disorders associated with firefighting is expanding with the appearance of new longitudinal studies of responders to the World Trade Center (WTC) tragedy, whi...

Tout comme les programmes de santé publique, les services d'hygiène du milieu diffèrent fondamentalement des autres formes de prestation de services de santé. À une époque où le secteur de la santé se bat pour intégrer ses disciplines, l'incorporation de ces services uniques au système de prestation présente un défi unique pour les décideurs et les administrateurs dans tous le pays. L'université de l'Alberta a récemment terminé une étude exhaustive des services de protection de l'hygiène du milieu gérés et offerts localement en Alberta, et en a proposé une nouvelle conception. Dans cet article, les auteurs décrivent brièvement les questions clés et les caractéristiques particulières à la prestation de services d'hygiène du milieu, et y présentent l'approche proposée par l'équipe de recherche albertaine pour aborder ces questions.

Preventive medicine is an exciting specialty that is often blocked in its progress by internal conflicts and external obstacles. We can all change this state of affairs. I present and compare definitions of important terms to clarify the discussion. Structural problems of the specialty include, among others, fragmentary representation, unfocused academic departments, lack of control over professionalization, and specialty identification, particularly with respect to occupational medicine. A set of suggested solutions to these problems include these actions: (1) federate the leading organizations into a coalition for organizational strength, without sacrificing their individual identities; (2) define the core content of the specialty once and for all by the mechanism of consensus-driven competency-based learning objectives; (3) build stronger bridges to clinical specialties other than family medicine, particularly to internal medicine; (4) restructure academic departments to form a preventive medicine unit as such, encouraging health care research and community medicine to connect principally with family medicine departments; (5) rethink specialty certification, including a model defining a knowledge and skills set in defined modules, which would be combined in various ways to support flexible specialty certification; and (6) integrate occupational medicine with preventive medicine generally by exploring issues of common interest and building closer institutional ties when the opportunity arises. These and other ideas might be discussed by the leadership of the principal public health and prevention organizations at a “summit” meeting, but some group must take the initiative to champion the cause.

This second of two parts continues with the development of a framework for understanding air quality issues and their relationship to human health. Recognized health effects associated with air pollution are described and current controversies regarding ozone and PM10are briefly outlined. Epidemiological methods of investigating air quality effects are discussed, comparing recent landmark studies in Canada. Comparative prevalence studies do not reflect the state of the art in air pollution epidemiology but are frequently cited and conducted in Canada as if they were definitive. The implications of setting air quality standards and objectives on this basis or to meet arbitrary levels of risk of health effects are examined. The current state of the art does not support risk-based air quality standards. A policy of continuous improvement is most protective of both human health and the environment.