Earth Island Institute Continuing Education for US Health Care Providers National Resources to Identify Environmental Exposure Risk Utilizing EPA EJSCREEN 1 Emily L. Harris, MPH Public Health Educator a project of Earth Island Institute

ALERT: A Locally Empowered Response Team Goal: Making Healthy People and Healthy Communities Part of Our Energy Future ALERT works to develop environmental justice leadership by working collaboratively to reduce toxic exposures from oil-chemical activities in at-risk communities. ALERT provides free scientific-based educational tools that are accessible and replicable, and engages the community through peer-led trainings. ALERT is an acronym for A Locally Empowered Response Team . ALERT develops environmental justice leadership by working collaboratively to reduce toxic exposures from oil-chemical activities in at-risk communities. Free scientific-based educational tools are accessible and replicable, and engage the community through peer-led trainings.

Earth Island Institute TOXIC TRESPASS 2. ALERT ( A Locally Empowered Response Team) provides free training to community members with the Toxic Trespass Series. The first training in the series is the introductory training to “Toxic Trespass”. Toxic Trespass Training addresses health concerns with Oil-Chemical activities and is a teaching tool created by and for people most at risk of toxic exposures. Participants learn to: 1) identify types of Oil-Chemical hazards in the environment and how exposures occur; 2) explain how these exposures affect health; and 3) recognize Oil-Chemical exposure symptoms and be able to describe them to a doctor or health care provider. You may find more information and downloadable curriculum at the ALERT website. If you would like to schedule a community training in your area please contact us at AREJN.HARRIS@gmail.com a project of Earth Island Institute

USDHHS- ODPHP The United States Department of Health and Human Services through their office of Disease Prevention and Health Promotion releases 10 year health objectives for our Nation via the Health People program . 2. The United States Dept. of Health and Human Service through their office of Disease Prevention and Health Promotion releases 10 year health objectives for our Nation via the Health People program .

USDHHS- ODPHP: Healthy People For three decades Healthy People has provided Science-based, 10-year national objectives for improving the health of all Americans. Encourage collaborations across communities and sectors. Empower individuals toward making informed health decisions. Measure the impact of prevention activities. 3. The USDHHS program for “Healthy People” provides science-based, 10-year national objectives for improving the health of all Americans. For 3 decades, Healthy People has established benchmarks and monitored progress over time in order to: Encourage collaborations across communities and sectors. Empower individuals toward making informed health decisions. Measure the impact of prevention activities. https://www.healthypeople.gov/

Healthy People 2020 Vision: A society in which all people live long, healthy lives. Overarching Goals: Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages. 4. Healthy People 2020 continues in this tradition with the launch on December 2, 2010 of its ambitious, yet achievable, 10-year agenda for improving the Nation’s health. Healthy People 2020 is the result of a multiyear process that reflects input from a diverse group of individuals and organizations. The HP 2020 Vision: A society in which all people live long, healthy lives. The HP 2020 Mission strives to: Identify nationwide health improvement priorities. Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress. Provide measurable objectives and goals that are applicable at the national, State, and local levels. Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge. Identify critical research, evaluation, and data collection needs. This course supports the Healthy People 2020 four overarching goals for the decade. The four Overarching Goals that help guide HP 2020 activities are: Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages. https://www.healthypeople.gov/2020/About-Healthy-People

Healthy People 2020 Approach to Social Determinants of Health 5. Goal three of the four HP 2020 goals highlights this. “Create social and physical environments that promote good health for all”. One way in which HP 2020 addresses the potential for the environment to impact our health and well being is through the importance of addressing the social determinants of health. This emphasis on social determinants of health are shared by the World Health Organization, whose Commission on Social Determinants of Health in 2008 published the report, “Closing the gap in a generation: Health equity through action on the social determinants of health.” 2 The emphasis is also shared by other U.S. health initiatives such as the National Partnership for Action to End Health Disparities 3 and the National Prevention and Health Promotion Strategy.4 https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

HP 2020 “Place-based” Organizing Framework HP 2020 utilizes a “place-based” organizing framework, reflecting five (5) key areas of social determinants of health (SDOH): Economic Stability Education Social and Community Context Health and Health Care Neighborhood and Built Environment .The Social Determinants of Health topic area within Healthy People 2020 is designed to identify ways to create social and physical environments that promote good health for all. All Americans deserve an equal opportunity to make the choices that lead to good health. But to ensure that all Americans have that opportunity, advances are needed not only in health care but also in fields such as education, childcare, housing, business, law, media, community planning, transportation, agriculture and environmental protection. Health starts in our homes, schools, workplaces, neighborhoods, and communities. We know that taking care of ourselves by eating well and staying active, not smoking, getting the recommended immunizations and screening tests, and seeing a doctor when we are sick all influence our health. Our health is also determined in part by access to social and economic opportunities; the resources and supports available in our homes, neighborhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships. The conditions in which we live explain in part why some Americans are healthier than others and why Americans more generally are not as healthy as they could be

Community Voices on Environmental Justice https://www.youtube-nocookie.com/embed/9hE3SyXr9bw?rel=0 CLICK TO VEIW

EJ Facts: People who live, work and play in America's most polluted environments are commonly poor people of color. 4. The environmental justice movement addresses a statistical fact: people who live, work and play in America's most polluted environments are commonly people of color and the poor. Environmental justice advocates have shown that this is no accident. Communities of color, which are often poor, are routinely targeted to host facilities that have negative environmental impacts -- say, a landfill, dirty industrial plant or truck depot. The statistics provide clear evidence of what the movement rightly calls "environmental racism." Communities of color have been battling this injustice for decades PHOTO CREDIT: Community and Environmental Groups Herald Improvements in New Oil Refinery Pollution Standards | Earthjustice earthjustice.org800 × 600Search by image Chrisangel Nieto, 3, rides his tricycle in Hartman Park, the Manchester neighborhood of Houston, Texas. The Valero refinery looms in the background and releases over 114,000 lbs. of toxic air pollutants annually

National Attention to Environmental Justice American Bar Association Civil Rights and Social Justice Committee

Civil Rights and EJ Civil Rights and Environmental Justice are based on many of the same founding principles: Social Justice Equal Protection An End to Institutional Discrimination The Environmental Justice movement and the Civil Rights Movement have many commonalities. At their core, the goals of movements are the same: "social justice, equal protection, and an end to institutional discrimination."

1994 Pres. Clinton’s EJ Executive Order 12898 All Federal agencies to Assess Environmental Health Risks by: Race Income http://www.ejnet.org/ej/execorder.html In 1994 President Clinton signed the Environmental Justice executive order 12898 directing all federal agencies to address community environmental health risks by race and income. “FEDERAL ACTIONS TO ADDRESS ENVIRONMENTAL JUSTICE IN MINORITY POPULATIONS AND LOW-INCOME POPULATIONS”. http://www.ejnet.org/ej/execorder.html This was done because research clearly shows that poor communities of color suffer from the greatest environmental risk and harm. https://www.youtube-nocookie.com/embed/Sx93yKLxSyk?rel=0 Click on the link to watch the short video “ Environmental Justice-The Road to Executive Order 12898. https://www.youtube.com/watch?v=Sx93yKLxSyk&feature=youtu.be

EJ at EPA EPA has an EJ hotline available during regular daytime hours ; 9-5 EST. Arkansas is in Region 6. Each region has a Regional EJ contact person. Israel Anderson for Region 6 is in the processing of retiring. All regions are posted on the EPA EJ Website. https://www.epa.gov/environmentaljustice/forms/contact-us-about-environmental-justice#local https://www.epa.gov/environmentaljustice/forms/contact-us-about-environmental-justice#local

Meaningful Involvement Equal Protection from Hazards EJ at EPA Fair Treatment Meaningful Involvement Equal Protection from Hazards Access to the Decision-Making Process Environmental justice is the fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income, with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies. EPA has this goal for all communities and persons across this nation. It will be achieved when everyone enjoys: the same degree of protection from environmental and health hazards, and equal access to the decision-making process to have a healthy environment in which to live, learn, and work.

EJ 2020 ACTION AGENDA Vision: By 2020, we envision an EPA that integrates environmental justice into everything we do, cultivates strong partnerships to improve on-the-ground results, and charts a path forward for achieving better environmental outcomes and reducing disparities in the nation’s most overburdened communities. Achieving this vision will help to make our vulnerable, environmentally burdened, and economically disadvantaged communities healthier, cleaner and more sustainable places in which to live, work, play and learn.

EJ 2020 ACTION AGENDA

Community Voices on Environmental Justice https://www.youtube-nocookie.com/embed/llawFopHjQA?rel=0

National Environmental Justice Advisory Committee (NEJC) Independent Federal Advisory Committee Provides Recommendations Broad Spectrum of Stakeholders Integrating EJ in all Policies & Programs https://www.epa.gov/sites/production/files/2015-02/documents/fact-sheet-nejac_0.pdf In 1993, EPA established the National Environmental Justice Advisory Council (NEJAC) in order to obtain independent, consensus advice and recommendations from a broad spectrum of stakeholders involved in environmental justice. As a federal advisory committee, the NEJAC was chartered to provide the Administrator with advice and recommendations on integrating environmental justice considerations into the agency’s programs, policies, and day-to-day activities. The NEJAC consists of representatives of community-based groups, business and industry, academic and educational institutions, state and local governments, tribal governments and indigenous organizations, and non-governmental and environmental groups. The NEJAC provides an environment for all parties to express their viewpoints and to formulate independent, clear and timely consensus advice and recommendations to EPA about major public policy issues. https://www.epa.gov/sites/production/files/2015-02/documents/fact-sheet-nejac_0.pdf

NEJC Plan EJ 2014 9 elements designed to: Strengthen EJ inclusion in decision making across all federal agencies Support community organizations Create a nationally consistent screening and mapping tool The National Environmental Justice Advisory Committee (NEJAC) created a national plan for environmental justice that was released in 2014 and includes 9 elements that are designed to strengthen EJ inclusion in decision making across all federal agencies, support community organization efforts and create a nationally consistent screening and mapping tool.

EPA EJ SCREEN Plan EJ 2014 Documented Need: Nationally Consistent Screening Tool User Friendly Free Access High Quality Maps Printable Standard Reports EPA EJ SCREEN was created based on the Plan EJ 2014 documented need for a nationally consistent screening tool. This tool is freely accessible on the EPA’s website with no cost to the user. There is no password needed or approval necessary to access the tool. EJ Screen is user friendly and provides high quality maps and printable standard reports. The US Census Bureau's American Community Survey provides automatic yearly updates to the tool based on the most current collected data. Multiple active links are included with the EJ Screen tool, so users can click to see where the data comes from and how to get even more information if needed.

EPA EJ SCREEN The United States Environmental Protection Agency (EPA) is charged with protecting human health and the environment for all Americans. In order to better meet the Agency’s responsibilities related to the protection of public health and the environment, EPA has developed a new environmental justice (EJ) screening tool, called EJSCREEN. In some ways, EJSCREEN is similar to prior screening or mapping tools. As a new tool, however, it offers improvements such as easy web-based access to powerful mapping and data reporting tools, a wide range of updated demographic information, environmental indicators addressing more topics, and higher resolution maps covering the entire nation. EJSCREEN also provides standard reports that bring together environmental and demographic data in the form of EJ indexes. These are summarized as percentiles to put the information in perspective and facilitate comparisons between locations. EJ screening tools may be used to explore one location using a data report, or to look across a wide area using maps. EJ tools have been used in a wide variety of circumstances, and EJSCREEN can support a similarly broad range of applications. EJSCREEN provides useful data and indicators, and highlights places that may be candidates for further review, including additional consideration, analysis or outreach.

EJ SCREEN USES Maps & reports display Exposure Risk Data via Environmental and Demographic Indicators Highlights geographic areas and the need for further review, additional consideration, analysis or outreach Better understanding of the community and environmental stressors Improve patient/HCP communication through a means to document and share exposure risk concerns Assist in diagnosis and care planning Tracking changes in the environment Screening tools can be appropriately put toward a wide variety of uses. EJ mapping and screening tools combine environmental and demographic indicators in maps and reports. This information can help to highlight geographic areas and the extent to which they may be candidates for further review, including additional consideration, analysis or outreach. The tools also allow users to explore locations at a detailed geographic level, across broad areas or across the entire nation. Environmental indicators typically are direct or proxy estimates of risk, pollution levels or potential exposure (e.g., due to nearby facilities). Demographic indicators are often used as proxies for a community’s health status and potential susceptibility to pollution. Environmental and demographic data and indicators may be viewed separately or in combination. This type of screening information may be of interest to health care providers, their service area communities, and many other stakeholders as EJ SCREEN supports a wide range of research and policy goals. In general, EPA’s and Health Care Provider efforts are more effective and efficient if they are informed by an understanding of where the impacts of existing pollution may be greatest. Screening tools can also help ensure that such areas are not overlooked, and receive appropriate consideration, analysis or outreach. . EPA has used existing internal EJ screening tools in aspects of enforcement, compliance, the Superfund program, permitting, and voluntary programs.

EJ SCREEN Limitations Demographic and Environmental Data involve substantial uncertainty Data are available only for some relevant issues HCP training & experience are necessary in conjunction with local wisdom for diagnosis and treatment Does not require HCP, EPA or other’s to act EJ Communities should not be labeled as such EJ SCREEN limitations must be noted. This tool cannot make decisions. Health care provider training and experience in conjunction with local wisdom, knowledge and leadership must be included in overall understanding, as it would be impossible for the tool to include all information. This tool alone cannot diagnose a patient with an environmental exposure related illness and should not ever be used to label any community as an EJ Community. Although the Presidential Executive Order 12898 directs federal agencies to consider EJ in their activities, this tool and the act do not require health care providers or those agencies to act. EJSCREEN, as a screening tool, is more limited than a detailed analysis in two key ways. First, it has data on only some of the relevant issues, and second, there is uncertainty in the data it does have. It is important to understand each of these limitations. The first limitation arises because a screening tool cannot capture all the relevant issues that should be considered (e.g., other local environmental concerns). Any national screening tool must balance a desire for data quality and national coverage against the goal of including as many important environmental factors as feasible given resource constraints. Many environmental concerns are not yet included in comprehensive, nationwide databases. For example, data on environmental factors such as local drinking water quality and indoor air quality were not available with adequate quality, coverage and/or resolution to be included in this national screening tool. EJSCREEN cannot provide data on every environmental impact and demographic factor that may be important to any location. The second important limitation is that EJSCREEN relies on demographic and environmental estimates that involve substantial uncertainty. This is especially true when looking at a small geographic area, such as a single Census block group. A single block group is often small and has uncertain estimates. A buffer that is roughly the same size as a block group or smaller will introduce additional uncertainty because it has to approximate the locations of residences. Therefore, it is typically very useful to summarize EJSCREEN data for a larger area, covering several block groups, in what is called a “buffer” report, as explained later in this document. There is a tradeoff between resolution and precision: Detailed maps at high resolution can suggest the presence of a local “hotpot,” but are uncertain. Estimates based on larger areas will provide more confidence and precision, but may overlook local “hotpots” if not supplemented with detailed maps.

EJ Screen Indicators & Indexes Just like the dashboard in a car, EJ Screen Indicators & Indexes help us to better understand the situation. Just like the dashboard in a car, EJ Screen provides access to Indicators & Indexes help us to better understand the situation However. EJSCREEN is a pre-decisional screening tool, and was not designed to be the sole basis for decision making or determinations regarding the existence or absence of Environmental exposure risk and concerns. It also should never be used to identify or label an area as an “EJ Community.” Instead, EJSCREEN is designed as a starting point, to highlight the extent to which certain locations may be candidates for further review or outreach. EJSCREEN’s initial results should be supplemented with additional information and local knowledge whenever appropriate, for a more complete picture of a location. Additional considerations and data, such as national, regional, or local information and concerns, along with appropriate patient examination, laboratory analysis, and other diagnostic procedures should form the basis for any health care decisions.

EJ Screen Indicators & Indexes 2 types of Indicators: Demographic - describe the people Environmental - describe the issues 1 combined E J Index: Describe community member susceptibility to environmental issues Help identify Environmental Exposure Risk. EJ Screen gives us 2 types of Indicators: Demographic- which describe the people and Environmental- which describe the issues. E J Screen also provides Indexes which describe community member susceptibility to environmental issues and help identify Environmental Exposure Risks.

Indicators and Indexes: Enable us to compare measurements Indicators & Indexes Indicators and Indexes: Enable us to compare measurements about the people that live in a community and their environmental stresses. EJ Screen makes use of Indicators and Indexes to enable us to compare measurements about the people that live in a community and their environmental stresses.

Census Block Group An area defined by the Census Bureau that usually has in the range of 600-3,000 people living in it. The US is divided into more than 200,000 block groups. It is important to understand that a census block group is how the information about the community is gathered and analyzed. A Census Block Group is an area defined by the Census Bureau that usually has in the range of 600-3,000 people living in it. The US is divided into more than 200,000 block groups.

EJ INDEX EJ INDEX Environmental Indicator Demographic Indicator EJ Indexes are created based on a statistical process that combines Demographic Indicators and Environmental Indicators that produce EJ Indexes for each block group.

COMPLEX RELATIONSHIPS Demographics, Exposure and Susceptibility Greater personal exposure despite same ambient pollution levels EX: Children breath faster and ingest more lead dust than adults. Susceptibility increases because of a greater percentage increase in health risk for a given exposure, e.g., “effect modification” or “multiplicative interaction” may occur. EX: Cumulative previous exposure means a group is more likely to be closer to a threshold for adverse effects, or where greater stress/allostatic load increases susceptibility through inflammatory or other pathways. The relationships between demographics, exposure, and susceptibility are complex. For example, demographics may be associated with susceptibility to pollutants in any of the following ways: Greater personal exposure despite the same ambient level of pollutant. For example, children have higher breathing rates or ingest more lead dust than adults (U.S. EPA, 2011a), Susceptibility because of a greater percentage increase in health risk for a given exposure, e.g., “effect modification” or “multiplicative interaction” may occur. An example would be where cumulative previous exposure means a group is more likely to be closer to a threshold for adverse effects, or where greater stress/allostatic load increases susceptibility through inflammatory or other pathways. Several examples of effect modification relevant to EJ and PM2.5 are referenced by Bell & Ebisu, 2012 and in a review of subgroups susceptible to ozone (Bell, Zanobetti, & Dominici, 2014). A growing body of research has documented interactions of psychosocial stress and environmental exposures.

COMPLEX RELATIONSHIPS Demographics, Exposure and Susceptibility Susceptibility increases with a higher baseline risk or rates of pre-existing diseases An equal percent increase in mortality risk has a larger impact on absolute risk if baseline risk is higher An initial health risk (e.g. because of less ability to recover due to lack of health care or resources) EX: low income or minority individuals, or those with less than a high school education are far less likely to have health insurance. Susceptibility because of higher baseline risk or rates of pre-existing diseases. The same percent increase in mortality risk has a larger impact on absolute risk if baseline risk is Higher • Susceptibility because of increased overall burden resulting from an initial health risk (e.g., because of less ability to recover due to lack of health care or resources). For example, low income or minority individuals, or those with less than a high school education, are far less likely to have health insurance (Cohen & Martinez, 2011).

Demographic Indicators Describe the people living in the community Demography is the statistical study of populations- especially humans. from prefix demo- from Ancient Greek meaning "the people", and -graphy, implies "writing, description or measurement. Demographic Indicators describe the people living in the community . Demography is the statistical study of populations- especially humans. from prefix demo- from Ancient Greek meaning "the people", and -graphy, implies "writing, description or measurement EJSCREEN uses demographic indicators as very general indicators of a community’s potential susceptibility to the types of environmental exposures included in this screening tool. Impacts of pollutants depend on a combination of exposure and susceptibility to those exposures. Demographic factors may be related to both of these. Therefore, it is very useful to distinguish between 1) the fact that some demographics are associated with higher exposure, and 2) the fact that demographics are useful in predicting susceptibility to those exposures. To indicate potential exposures, EJSCREEN uses environmental indicators, not demographics. EJSCREEN uses demographics to indicate potential susceptibility. EJSCREEN then combines the exposure and susceptibility indicators in the form of an EJ Index. The demographic indicators in EJSCREEN are a way to indicate which communities may be more susceptible to a given level of exposure to environmental pollutants. For example, individuals may be more susceptible when they are already in poor health, have reduced access to care, lack resources or language skills or education that would help them avoid exposures or obtain treatment, or are at susceptible life stages. Nationwide direct measures of health status are not available for all block groups or even tracts – such data are typically compiled by county in national databases. Demographics, however, are available for every block group, and are correlated with health status and these other susceptibility factors, making them useful screening-level indicators of potential susceptibility at the local level.

Demographics Indicate Potential Susceptibility EJ SCREEN uses demographic indicators as very general indicators of a community’s potential susceptibility to the types of environmental exposures included in the screening tool. Demographic Indicators describe the people living in the community . Demography is the statistical study of populations- especially humans. from prefix demo- from Ancient Greek meaning "the people", and -graphy, implies "writing, description or measurement EJSCREEN uses demographic indicators as very general indicators of a community’s potential susceptibility to the types of environmental exposures included in this screening tool. Impacts of pollutants depend on a combination of exposure and susceptibility to those exposures. Demographic factors may be related to both of these. Therefore, it is very useful to distinguish between 1) the fact that some demographics are associated with higher exposure, and 2) the fact that demographics are useful in predicting susceptibility to those exposures. To indicate potential exposures, EJSCREEN uses environmental indicators, not demographics. EJSCREEN uses demographics to indicate potential susceptibility. EJSCREEN then combines the exposure and susceptibility indicators in the form of an EJ Index. The demographic indicators in EJSCREEN are a way to indicate which communities may be more susceptible to a given level of exposure to environmental pollutants. For example, individuals may be more susceptible when they are already in poor health, have reduced access to care, lack resources or language skills or education that would help them avoid exposures or obtain treatment, or are at susceptible life stages. Nationwide direct measures of health status are not available for all block groups or even tracts – such data are typically compiled by county in national databases. Demographics, however, are available for every block group, and are correlated with health status and these other susceptibility factors, making them useful screening-level indicators of potential susceptibility at the local level.

Demographics Indicate Potential Susceptibility Impacts of pollutants depend on a combination of exposure and susceptibility to those exposures. Demographic factors may be related to both of these. Therefore, it is very useful to distinguish between the fact that some demographics are associated with higher exposure, and the fact that demographics are useful in predicting susceptibility to those exposures. Demographic Indicators describe the people living in the community . Demography is the statistical study of populations- especially humans. from prefix demo- from Ancient Greek meaning "the people", and -graphy, implies "writing, description or measurement EJSCREEN uses demographic indicators as very general indicators of a community’s potential susceptibility to the types of environmental exposures included in this screening tool. Impacts of pollutants depend on a combination of exposure and susceptibility to those exposures. Demographic factors may be related to both of these. Therefore, it is very useful to distinguish between 1) the fact that some demographics are associated with higher exposure, and 2) the fact that demographics are useful in predicting susceptibility to those exposures. To indicate potential exposures, EJSCREEN uses environmental indicators, not demographics. EJSCREEN uses demographics to indicate potential susceptibility. EJSCREEN then combines the exposure and susceptibility indicators in the form of an EJ Index.

6 Demographic Indicators & Definitions Low Income- % of people at or below twice the federal “poverty level”. Minority- all people other than non-Hispanic white. Less than high school education- % of people age 25 or older without a high school diploma. Linguistic isolation- % people in household in which all members over 14 years speak English “very well”. Individuals under age 5- % of people under age 5. Individuals over the age 64- % of people over 64. EJ Screen uses 6 demographic indicators that are based on estimates from the American Community Survey data collected between 2008 and 2012. The demographic indicators are calculated on the census block level and their descriptions are here. Low income- the percent of people at or below twice the federal “poverty level”. Minority- all people other than non-Hispanic white alone individuals. Less than high school education- the percent of people age 25 or older without a high school diploma. Linguistic isolation- the percent of people in household in which all members over 14 years speak English “very well”. Individuals under age 5- the percent of people under the age of 5. Individuals over the age 64- the percent of people over the age of 64. T

Demographics Indicate Potential Susceptibility Nationwide direct measures of health status are not available for all block groups or even tracts – such data are typically compiled by county in national databases. Demographics, however, are available for every block group, and are correlated with health status and these other susceptibility factors, making them useful screening-level indicators of potential susceptibility at the local level. Nationwide direct measures of health status are not available for all block groups or even tracts – such data are typically compiled by county in national databases. Demographics, however, are available for every block group, and are correlated with health status and these other susceptibility factors, making them useful screening-level indicators of potential susceptibility at the local level.

Demographics Indicate Potential Susceptibility Individuals may be more susceptible when: They are already in poor health, Have reduced access to health care, Lack resources, language skills, or education that would help them avoid exposures or obtain treatment, or are at susceptible life stages. The demographic indicators in EJSCREEN are a way to indicate which communities may be more susceptible to a given level of exposure to environmental pollutants. For example, individuals may be more susceptible when they are already in poor health, have reduced access to care, lack resources or language skills or education that would help them avoid exposures or obtain treatment, or are at susceptible life stages.

Types of susceptible people 11 Types of susceptible people The demographic indicators in EJSCREEN are a way to indicate which community members may be more susceptible to a given level of exposure to environmental pollutants. For example, individuals may be more susceptible when they are already in poor health, have reduced access to care, lack resources or language skills or education that would help them avoid exposures or obtain treatment, or are at susceptible life stages. Nationwide direct measures of health status are not available for all block groups or even tracts – such data are typically compiled by county in national databases. Demographics, however, are available for every block group, and are correlated with health status and these other susceptibility factors, making them useful screening-level indicators of potential susceptibility at the local level. Note that EJSCREEN documentation uses the term susceptibility in a qualitative, general sense, to refer to what various authors have called susceptibility and/or vulnerability. Susceptibility in this report means greater “impact” for a given environmental indicator value. The terms vulnerability and susceptibility sometimes are used interchangeably, although various other reports and programs have made distinctions between these terms.10 Types of susceptible people pictured include those with respiratory or chronic diseases, workers, kids, pregnant women and the elderly. Graphic: Riki Ott

Environmental Indicators Describe the estimate of risk to community members based upon: Air quality measurements Roads and the amount of traffic The age of homes Superfund sites Chemical plants Hazardous waste management facilities Facilities permitted to make major water discharges industry, facilities, Direct or proxy estimates of risk, pollution levels or potential exposure from nearby facilities Environmental Indicators describe the estimate of risk to community members based upon air quality measurements, nearby roads and the amount of traffic, the age of homes in the community, and how many and how close are the superfund sites, chemical plants, hazardous waste management facilities, and facilities permitted to make major water discharges. EPA and other agencies keep large data bases with this information that is displayed in EJSCREEN on maps, graphs and charts. Some of these environmental indicators quantify proximity to and the numbers of certain types of potential sources of exposure to environmental pollutants, such as nearby hazardous waste sites or traffic. The lead paint indicator indicates the presence of older housing, which often, but not always, indicates the presence of lead paint, and therefore the possibility of exposure. In some cases, the term "exposure" is used very broadly here to refer to the potential for exposure. Others indicators in EJSCREEN are estimates of ambient levels of air pollutants, such as PM2.5, ozone and diesel particulate matter. Still others are actual estimates of air toxics-related cancer risk or a hazard index, which summarizes the ratios of ambient air toxics levels to health-based reference concentrations. In other words, these environmental indicators vary widely in what they indicate.

Environmental Indicators Considerations for selection: Resolution: Screening level data are available (or could be readily developed) at the block group level (or at least close to this resolution). Coverage: Screening level data are available (or could be readily developed) for the entire United States (or with nearly complete coverage). Some environmental indicators used in EJSCREEN quantify proximity to and the numbers of certain types of potential sources of exposure to environmental pollutants, such as nearby hazardous waste sites or traffic. The lead paint indicator indicates the presence of older housing, which often, but not always, indicates the presence of lead paint, and therefore the possibility of exposure. In some cases, the term “exposure” is used very broadly here to refer to the potential for exposure. Others indicators in EJSCREEN are estimates of ambient levels of air pollutants, such as PM2.5, ozone, and diesel particulate matter. Still others are actual estimates of air toxics-related cancer risk, or a hazard index, which summarizes the ratios of ambient air toxics levels to health-based reference concentrations. In other words, these environmental indicators vary widely in what they indicate, as discussed further below. A variety of considerations has informed the selection of these environmental indicators; in general, the selected indicators exhibit the following characteristics: • Resolution: Screening level data are available (or could be readily developed) at the block group level (or at least close to this resolution). • Coverage: Screening level data are available (or could be readily developed) for the entire United States (or with nearly complete coverage).

Environmental Indicators Considerations for selection (con’t): Relevance to EJ: Pollutants or impacts are relevant to EJ (e.g., differences between groups have been indicated in exposures, susceptibility, or health endpoints associated with the exposures) Public health significance: Pollutants or impacts are potentially important in the United States (e.g., notable impacts estimated or significant concerns have been expressed, at least locally, or exposure has been linked to health endpoints with substantial impacts nationwide). Some environmental indicators used in EJSCREEN quantify proximity to and the numbers of certain types of potential sources of exposure to environmental pollutants, such as nearby hazardous waste sites or traffic. The lead paint indicator indicates the presence of older housing, which often, but not always, indicates the presence of lead paint, and therefore the possibility of exposure. In some cases, the term “exposure” is used very broadly here to refer to the potential for exposure. Others indicators in EJSCREEN are estimates of ambient levels of air pollutants, such as PM2.5, ozone, and diesel particulate matter. Still others are actual estimates of air toxics-related cancer risk, or a hazard index, which summarizes the ratios of ambient air toxics levels to health-based reference concentrations. In other words, these environmental indicators vary widely in what they indicate, as discussed further below. A variety of considerations has informed the selection of these environmental indicators; in general, the selected indicators exhibit the following characteristics: • Resolution: Screening level data are available (or could be readily developed) at the block group level (or at least close to this resolution). • Coverage: Screening level data are available (or could be readily developed) for the entire United States (or with nearly complete coverage).

Environmental Indicators The first seven Environmental Indicators are displayed here along with their definition. It is important to remember that these indicators vary in how relevant they are to actual estimated risks to health or welfare, and how significant those impacts may be. These indicators represent a spectrum in terms of the quality of information about potential impacts, ranging from direct estimates of risk to rough indicators of proximity or exposure to pollution or other environmental hazards. This table provides detail on how closely each environmental indicator in EJSCREEN approximates actual estimated risk. (https://www.epa.gov/sites/production/files/2015-05/documents/ejscreen_technical_document_20150505.pdf#page=13) National Air Toxics Assessment (NATA) Air Toxics Cancer Risk is calculated based upon the Lifetime inhalation cancer risk. National Air Toxics Assessment (NATA) Respiratory Hazard Index calculated based upon the Ratio of exposure concentration to the Reference concentration from EPA’s Integrated Risk Information System (RfC). National Air Toxics Assessment (NATA) Neurological Hazard Index calculated based upon Ratio of exposure concentration to the Reference concentration from EPA’s Integrated Risk Information System (RfC). National Air Toxics Assessment (NATA) Diesel PM (DPM) calculated in micrograms per cubic meter (µg/m3). Particulate Matter (PM 2.5) Annual average of micrograms per cubic meter (µg/m3). Ozone Summer seasonal average of daily maximum 8- hour concentration in air (ppb) Lead Paint Indicator Percentage of Housing units built before 1960. https://www.epa.gov/sites/production/files/2015-05/documents/ejscreen_technical_document_20150505.pdf#page=13

Environmental Indicators The remaining five Environmental Indicators and their definitions are displayed here. Traffic Proximity and Volume: Count of vehicles (average annual daily traffic) at major roads within 500 meters, divided by distance in kilometers (km) Proximity to Risk Management Plan (RMP) Sites Count of facilities within 5 km, divided by distance Proximity to Hazardous waste Treatment, Storage and Disposal Facilities (TSDF)s Count of major TSDFs within 5 km, divided by distance Proximity to National Priorities List, Superfund Program (NPL) Sites Count of proposed and listed NPL sites within 5 km, divided by distance Proximity to Major Direct Water Dischargers Count of National Pollution Discharge Elimination System (NPDES) major facilities within 5 km, divided by distance It is also important to note that each proximity indicator focuses on one category of facility or site (e.g.,NPL), but the category’s facilities or sites vary in the degree to which they could actually pose risks. They vary in the amount of emissions (if any), the possibility of exposure to any pollutants released, the size of the facility or site, and toxicity of the pollutants or severity of the impacts that might occur. As a screening tool, EJSCREEN generally does not distinguish based on these factors in proximity indicators (although NATA indicators do account for such information). Any closer review of a particular location would have to consider these important differences. All of these indicators are focused on potential impact at residential locations (e.g., proximity of residence to traffic), and therefore only address some of the exposures that individuals may face. Data are generally insufficient to readily estimate exposures away from the home, particularly in a screening tool. Exposures that occur away from the home, such as at work, at school or during a commute, are not captured in EJSCREEN unless those exposures are near the home or in other locations that happen to have the same level of exposure.

EJ INDEX EJSCREEN uses maps and reports to present three kinds of information: Environmental Indicators Demographic Indicators EJ Indexes An EJ Index summarizes how an environmental indicator and demographics come together in the same location. EJ INDEX -- EJSCREEN uses maps and reports to present three kinds of information: Environmental indicators, demographic indicators and EJ Indexes. An EJ Index summarizes how an environmental indicator and demographics come together in the same location.

EJ INDEX Mathematically, the EJ Index is constructed as the product of three items, multiplied together as follows: To calculate a single EJ Index, EJSCREEN combines a single environmental indicator with demographic information. It considers the extent to which the local demographics are above the national average. It does this by looking at the difference between the demographic composition of the block group, as measured by the Demographic Index, and the national average (which is approximately 35%). It also considers the population of the block group. Mathematically, the EJ Index is constructed as the product of three items, multiplied together as follows: This formula for the EJ Index is useful because for each environmental indicator it finds the block groups that contribute the most toward the national disparity in that environmental indicator. By “disparity” in this case we mean the difference between the environmental indicator’s average value among certain demographic groups and the average in the US population.

EJ INDEX & Potentially Susceptible Individuals Represented by the Demographic Index times the population count in a block group Essentially the average of the count of minorities and the count of low-income individuals The demographic portions of the EJ Index can be thought of as the additional number of susceptible individuals in the block group, beyond what you would expect for a block group with this size total population. EJ Index = (Environmental Indicator) X (Demographic Index for Block Group –Demographic Index for US) X (Population count for Block Group) “Susceptible” or “potentially susceptible individuals” are used informally in these examples, as a way to think of the Demographic Index times the population count in a block group, which is essentially the average of the count of minorities and count of low-income individuals. It is easiest to think of the average of these counts as “the susceptible individuals” in these examples.

12 EJ Indexes Particulate Matter (PM2.5) Ozone National Scale Air Toxics Assessment Air Toxics Cancer Risk* National Scale Air Toxics Assessment Respiratory Hazard Index* National Scale Air Toxics Assessment Neurological Hazard Index* National Scale Air Toxics Assessment Diesel PM (DPM)* Lead Paint Indicator Traffic Proximity and Volume Proximity to Risk Management Plan Sites Proximity to Treatment Storage and Disposal Facilities Proximity to National Priorities List Sites Proximity to Major Direct Water Dischargers The EJ index is a combination of environmental and demographic information. There are twelve EJ Indexes in EJSCREEN reflecting the 12 environmental indicators. The pale gray indicators 3 through 6 on the list are awaiting release. The 12 EJ Index names are: National Scale Air Toxics Assessment Air Toxics Cancer Risk* National Scale Air Toxics Assessment Respiratory Hazard Index* National Scale Air Toxics Assessment Neurological Hazard Index* National Scale Air Toxics Assessment Diesel PM (DPM)* Particulate Matter (PM2.5) Ozone Lead Paint Indicator Traffic Proximity and Volume Proximity to Risk Management Plan Sites Proximity to Treatment Storage and Disposal Facilities Proximity to National Priorities List Sites Proximity to Major Direct Water Dischargers

EJ Screen Indicators & Indexes Displayed in the reports by using colors on maps and in charts to show the way the situation in each community compares with the state, the EPA region, and the entire nation. Indicators & Indexes are displayed in reports with different colors on maps and in charts to show the way the situation in each community compares with the state, the EPA region, and the entire nation.

The EJ screening tool, helpful user guides and supporting documentation can be found at http://www.epa.gov/ejscreen.

Scrolling down to the bottom of the page reveals more useful information and additional links.

Interpreting the Standard Report With an internet connection you can access this less than 5 minute video that walks one through the process. https://www.youtube.com/watch?v=eZ8-9Mx8UgI&feature=youtu.be

Percent (%) A percentage is an absolute term. If you received 80% on a test of one hundred questions you had 80 correct answers. Understanding the way in which information is given in the standard report is important. A percentage is an absolute term. If you received 80% on a test of one hundred questions you had 80 correct answers

Percentiles A percentile is a relative term, and tells you how you have done on the test in comparison to the others who took the test. A percentile of 80 means that you scored equal to or better than 80% of people who took the test. Many of the indicators and indexes may be displayed as a percentile. A percentile is a relative term, and tells you how you have done on the test in comparison to the others who took the test. A percentile of 80 means that you scored equal to or better than 80% of people who took the test

EJ SCREEN Perspective on Percentiles Each indicator or index value are put into perspective by reporting the value as a percentile. EJ SCREEN percentiles approximates what percent of the US population lives in a block group that has a lower value. Percentiles are considered to be a reasonable interpretation. EJSCREEN puts each indicator or index value in perspective by reporting the value as a percentile. For example, an area may show 60% of housing was built prior to 1960. It may not be obvious whether this is a relatively high or low value, compared to the rest of the nation or in the state. Therefore, EJSCREEN also reports that 60% pre-1960 puts this area at the 80th percentile nationwide. For a place at the 80th percentile nationwide, that means 20% of the US population has a higher value. A percentile in EJSCREEN tells us roughly what percent of the US population lives in a block group that has a lower value (or in some cases, a tied value). This means that 100 minus the percentile tells us roughly what percent of the US population has a higher value. This is generally a reasonable interpretation because for most indicators there are not many exact ties between places and not many places with missing data.

EJ SCREEN Standard Report Contents Mapping color codes are used to clearly and easily distinguish between percentile levels. YELLOW = > 80th percentile & < 90th ORANGE = > 90th percentile & < 95th RED = > 95th percentile Locations at least at the 80th percentile but less than the 90th are shown in yellow on EJSCREEN maps, while those at the 90th percentile but less than 95th percentile are orange on the maps, and those at the 95th percentile or above are shown in red on maps and reports. These colors call attention to certain locations as a very simple way to communicate relative screening results. There is no official policy significance assigned to each individual color on the maps, but the choice of these categories or “bins” is noteworthy because it signifies that certain ranges of percentiles may merit closer attention. Percentiles at or above the 95th percentile are shown in red on the EJSCREEN standard report. This is a way to call particular attention to those cases where the value is in the top 5% of the nation (or region or state). Indicator or index values in the top 5% tend to be much higher than those in the next 5-10%, so they may merit close attention. This is especially true for the indicators with highly skewed distributions, such as the traffic proximity indicator (see Appendix D, Table 6 and Figure 1). For example, block groups in the top 5% (shown in red on maps and reports) have traffic, NPL, and TSDF proximity indicators on average that are about three times as high as in the next 5% (shown in orange on the maps). These differences are far less extreme in the cases of PM2.5 and lead paint indicators, which don’t vary as much across block groups. In general, though, indicator or index values above the 95th percentile represent much higher demographic, environmental, or EJ Index values than those at lower percentiles. The maps also identify areas in the 90th to 95th percentiles as orange, and those at the 80th to 90th as yellow. These additional categories highlight larger groups of locations that have indicator or index values well above the national mean or median for the given indicator or index. The actual values are lower than those in the top 5%, typically much lower, but they are still in the top 10 to 20% of values for the US population overall.

EJSCREEN Results In EJSCREEN, if your results indicate that an area is 48% minority and is at the 69th national percentile, this means that 48% of the area’s population is minority, and that is an equal or higher % minority than where 69% of the US population lives. In EJSCREEN, if your results indicate that an area is 48% minority and is at the 69th national percentile, this means that 48% of the area’s population is minority, and that is an equal or higher % minority than where 69% of the US population lives.

Example #1 100% total population of the Census Block 15% Both (for this example 1,000 people) 15% Both Example #1: Suppose that a certain block group of 1000 people, 350 (35%) are minority and 350 (35%) low-income. There might be 200 (20%) who are low-income but not minority, and 200 (20%) who are minority but not low-income. In that case, there would be 150 (15%) who are both, and 450 (45%) who are neither. Therefore, there actually would be 550 (55%) who were either minority, low-income or both. The Demographic Index would use 35% in this case, which falls between the 15% who were both minority and low-income, and the 55% who were in at least one of these groups. These detailed numbers cannot be obtained from the ACS block group. Therefore, to represent both groups in a imple way, the average is used 55% = either low income, minority race, or both 45% = neither

EXTREME EXAMPLE #2 100% Low Income 100% Minority Race Suppose a block group has 1000 people but it is 0% minority and 100% low-income. The demographic index would be 50% or the equivalent of 500 “potentially susceptible individuals” in this case. The same would be true in a block group that was 100% minority but 0% low-income- it would be treated as having the equivalent of 50% (500) “potentially susceptible” for the sake of these examples. 100% = Low Income/ 0% = Minority Race 50% = Index 100% = Minority Race 0% = Low Income 100% = Minority Race 0% = Low Income 50% = INDEX 100% = Low Income 0% = Minority Race 50% = INDEX

EJ Screen’s Standard Report Page 1 (of 3) ALWAYS review title and headings Always review the title and headings to be sure that the description of your community is correct and the approximate population makes sense.

EJ Screen’s Standard Report Page 1 (of 3) ALWAYS review title and headings Always review the title and headings to be sure that the description of your community is correct and the approximate population makes sense.

EJ Screen’s Standard Report Page 1 (of 3) Table Format and Bar Chart of EJ Indexes: 1) EJSCREEN Selected Area 2) State 3) (EPA) Region 4) (US) Nation "Percentiles" are an important part of EJSCREEN. Every indicator in EJSCREEN is put into perspective by showing its associated percentiles. Also on the first of the three page report includes both in a Table Format and a Bar Chart the EJ Indexes for 1) EJSCREEN selected Area 2) State 3) (EPA) Region 4) (US) Nation ."Percentiles" are an important part of EJSCREEN. Every indicator in EJSCREEN is put into perspective by showing its associated percentiles. The US percentile uses the US population as the basis of comparison. The state or regional percentile was calculated based on the population in a given state (or DC) or one of EPA’s 10 regions. 18 The national or state or regional mean value was calculated as the population weighted average of the block groups with data for that indicator, within the respective geographic scope. Note that the US and state percentiles both will rank block groups in exactly the same rank order within the given state. If the goal is just to rank or compare locations within a single state, it does not matter whether the US or state percentile is used. The difference between state and US percentiles becomes apparent mainly in two situations: when comparing places across states, or when comparing results to some pre-determined, specific reference percentile (e.g., 80th percentile)

EJ Screen’s Standard Report Page 2 (of 3) The MAP: Be Aware- the Map will be printed however the report creator is displayed on your screen. You should check the map to be sure: The entire community is included The buffer zone settings include any surrounding areas of concern. On Page 2 of the 3 page report you will find the The MAP: Be Aware- the Map will be printed however the report creator displayed the map on your screen. You should check the map to be sure: The entire community is included and The buffer zone settings include any surrounding areas of concern. Reports may be adjusted many different ways to meet your specific needs.

EJ Screen’s Standard Report Page 3 (of 3) Table Format of Raw Data & Percentiles Environmental & Demographic Indicators 1) EJSCREEN Selected Area 2) State 3) (EPA) Region 4) (US) Nation The last page of the report Page 3 (of 3) provides a Table Format of Raw Data & Percentiles for the Environmental & Demographic Indicators addressing the EJSCREEN selected Area , 2) State, 3) (EPA) Region and the 4) (US) Nation

How to Interpret an EJSCREEN Standard Report https://www.youtube.com/watch?v=eZ8-9Mx8UgI

Utilizing the EJSCREEN Report in HEALTH CARE PRACTICE By having a better understanding of the community and environmental stressors; patient and health care provider communication about exposure risk concerns can be improved. Documenting and sharing of exposure risk concerns are important aspects of a patients permanent medical records. Diagnosis and care planning interventions are supported with evidence based community measures Changes in the environment and potential exposure risk concerns can be tracked over time Screening tools can be appropriately put toward a wide variety of uses in the health care field. By having a better understanding of the community and environmental stressors; patient and health care provider communication about exposure risk concerns can be improved. Documenting and sharing of exposure risk concerns are important aspects of a patients permanent medical records. Diagnosis and care planning interventions are supported with evidence based community measures Changes in the environment and potential exposure risk concerns can be tracked over time

Identify Environmental Exposure Risk Utilizing EPA EJSCREEN TOXIC TRESPASS Continuing Education for US Health Care Providers National Resources to Identify Environmental Exposure Risk Utilizing EPA EJSCREEN Emily L. Harris, MPH AREJN.Harris@gmail.com Dr. Riki Ott riki@alertproject.org Contact Emily Harris or Dr. Riki Ott for more information. Visit the ALERTProject.Org website for additional curriculum offerings and access to resources.