Overarching Issues Discussed by All Three Panels

Topic One

Evaluate information about susceptible populations. This information may include preexisting conditions (i.e., medical and/or psychological), as well as individual variability in reactions to stress, cultural patterns of reaction to stress, and targeting interventions to vulnerable populations.

Panel Discussion

Most people cope very well with stress; however, people with preexisting mental or physical health problems, limited coping strengths, or meager family and community support systems may be more vulnerable to psychological stressors than others. For example, the following question was raised: "Can an individual already experiencing depression from other circumstances experience exacerbated depression from the stress associated with living near a hazardous waste site?" An individual's response to stress is multifactorial. Episodes of mood disorders, such as depression, may be triggered by psychosocial stress associated with different situations.

In addition, some age groups appear to be more vulnerable than others, particularly young children and older adults. Children's perceptions of stress and their coping skills differ by developmental level and are not the same as that of adults'. A change in environment, such as that which occurs with relocation, may leave children frightened and insecure. They may display a variety of emotional responses. How a parent reacts to the situation makes a great difference in the child's understanding and recovery. People with children may be a susceptible group themselves because of their concerns over the potential adverse health effect on their children. Older adults may suffer because their familiar routines are disrupted, particularly when there is residential loss and relocation.

In marginalized communities, there is a sense of internalized oppression. This results in incapacitation and loss of self-esteem and efficacy. Drawing site boundaries (e.g., putting a fence around the contaminated area) can create a specific susceptible community by attaching an environmental stigma and changing a community's perception of safety. The trigger for psychosocial effects is perception.

Environmental cues, such as odors associated with waste sites, may make a community more susceptible to the stress associated with exposure. Communities who have suffered changes in threat levels (i.e., being told at first that there is no harm, then that the exposure is a threat, or vice versa) may be more at risk to have increased stress. Communities exposed to multiple contaminants might also be more susceptible to the stress associated with multiple exposures.

Helpers and responders themselves have the potential to become "secondary victims." They may experience "burnout" syndrome-a state of exhaustion, irritability, and fatigue.

Data Gaps and Recommendations

1. Acknowledge the unique problems of Superfund communities.
2. Seek to understand the problem from a community point of view.
3. Train staff of various agencies in recognizing different patterns and types of psychosocial responses to environmental contamination.

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Topic Two

Examine the reports of increased incidence of psychologic disorders in these communities and make recommendations regarding the directions for future strategies.

Panel Discussion

The members of all three panels had very mixed opinions on the adequacy of the literature on psychological disorders from the stress related to hazardous waste sites. Some felt the evidence was adequate to overwhelming; others thought that the literature was sparse and that more studies, including epidemiologic and qualitative methods were needed before drawing any firm, final conclusions.

The first question to be answered by these studies would be to assign statistical causality to the site (i.e., to determine how much of the reaction is caused by the site and how much to a preexisting condition). How do we differentiate effects from different stressors? The suggestion was made that a convergent strategy be used to do this. This convergent strategy would involve using a mix of qualitative (e.g., clinical screenings by neuropsychologists and sociological studies of the factors that influence community responses) and quantitative methods (e.g., psychophysiological research, application of standardized research instruments to measure the psychological disorders in the communities near these sites, and pre- and post-data on how stress levels change in a community affected by hazardous substances). Two important points to remember are that 1) the psychosocial effects of a hazardous waste site change over time and 2) not every community is affected in the same way.

Panel Three suggested rewording the issue to read "psychological distress" rather than "psychological disorders."

Data Gaps and Recommendations

For a specific site, one must first ask whether the site is old or new. For a new site, the relevant issues are prevention and intervention before stress has a chance to build within a community. A recommendation was made to incorporate mental health services into the process of helping victims of an acute technologic disaster (e.g., a spill). Another recommendation was to standardize the psychological assessment tools and to work toward a wider recognition for the need to address psychological responses to hazardous substances, including encouragement of state health departments to incorporate means of addressing these effects.

All panels recommended a need for further study on the topic of psychosocial stress in communities exposed to hazardous substances. Panel Two gave the following set of recommendations for how to conduct further research in these communities:

1. Listen to the concerns of the community.
2. During a community needs assessment, look at census data and demographics for factors such as the male-to-female ratio, number of children and elderly, number of homeowners versus renters, and the minority makeup.
3. Map the community using geographical information systems to assist in tracking health impacts and community psychological and social needs.
4. Have joint fact-finding activities with communities to build trust in the data.

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Topic Three

What ethical concerns need to be addressed in dealing with the psychological responses to hazardous substances? This question addresses the appropriateness of various intervention strategies.

Panel Discussion

The panel concluded that the following are practical questions that will help preserve an ethically balanced and appropriate intervention:

• Do we know enough about the pathophysiology and natural history of the psychological conditions that are present?
• Can we provide effective remedies?
• Who is responsible for the intervention?
• Which organization (e.g., federal, state, or local) is most appropriate to deliver services?
• What is the appropriate way to deal with the question of invasion of privacy?
• How would the situation change if the event were natural?
• What are the appropriate parameters for policy governing the behavior of the media? The principal responsible party? The government agencies?
• Should the principal responsible party be a part of the planning, implementation, and evaluation of the intervention?

Data Gaps and Recommendations

1. Do no harm.
2. Obtain the community's permission and input before designing or implementing any interventions intended to reduce stress in that community.
3. Have experts on the subject, such as bioethicists, explore the issue further.

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Topic Four

Identify future directions for investigation of the biopsychosocial effects from possible exposures to hazardous waste substances.

Panel Discussion and Recommendations

The panel identified four areas in need of greater attention:

Data collection: There is a need to collect more data on psychosocial effects of living near a hazardous waste site. This data collection should include a systematic, community-based study that collects a wide range of psychosocial data, such as the community's level of knowledge and understanding of stress reactions; variations and characteristics of positive coping skills; evaluation of policy responses; and an evaluation of the efficacy of various treatment methods, including early intervention.

Training: Further training on psychosocial effects should be provided to community members and their health care providers to elevate their knowledge and understanding of stress reactions. This should include validation of the community's stress response as a normal reaction to the situation.

Earlier intervention: Early intervention with more community involvement is needed. Noninvolvement and mistrust can be avoided by establishing partnerships early with key stakeholders and treating them as equals. These partnerships should include local officials and respected community members.

Evaluation: The impact of the government response should be evaluated. Do certain policy responses, such as relocation of the community, cause more stress or additional harm? Additional consideration should be given to how information is delivered and understood by the community. Attempts should be made to know what and how the community thinks and feels before delivering the message.

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