#  Environmental Health Promotion: Mercury in Fish Campaign

# 2006 - 2007 

#  Environmental Public Health Leadership Institute Fellow:

#  Dhitinut Ratnapradipa, Ph.D., CHES

*Environmental Health Program Manager;* Rhode Island Department of
Health

*Office of Environmental Health Risk Assessment*

*Division of Environmental Health*

*3 Capitol Hill Room 201*

*Providence, RI 02908*

# Mentor:

### **Richard Gelting, Ph.D., PE**

*Environmental Engineer,* Centers for Disease Control and Prevention

## Environmental Health Services Branch

## Division of Emergency and Environmental Health Services 

## National Center for Environmental Health

# Acknowledgements:

##### Robert Vanderslice, Ph.D., and Staff

*Chief*, Rhode Island Department of Health

Office of Environmental Health Risk Assessment,

> ![](media/image1.jpeg){width="1.3756944444444446in"
> height="0.6368055555555555in"}

# EXECUTIVE SUMMARY:

Methymercury is a neurotoxin that bioaccumulates in fish. The Rhode
Island Department of Health (RIDOH), working with the RI Department of
Environmental Management (RIDEM), has recognized the need to inform
people about mercury levels in some fish, and has developed a brochure
to raise awareness so people can make better choices in their eating
habits. The message of the brochure is that "Fish is Good, Mercury is
Bad." RIDOH has limited resources and has not, in all cases, had an
outreach strategy that is geared for non-English speaking
constituencies, which make up significant portions of the target
population. The goal of this project is to bring together various
interest groups to promote healthy fish consumption and decrease
mercury-in-fish exposures in Rhode Island.

A logic model was employed to create a flowchart to identify potential
partners/resources, as well as to outline activities necessary to form a
viable workgroup to explore this issue more comprehensively. Identified
stakeholders include federal and state government agencies, commercial
interest groups, higher education institutions, the medical community,
and environmental advocacy groups. An initial process meeting with
potential stakeholders was held, and additional interest groups were
identified. The University of Rhode Island Cooperative Extension
Education Program serves as a point of contact, having credibility with
diverse groups. Stakeholders began discussing resource limitations and
possible solutions. Follow-up meetings are needed to continue to find
common ground between diverse interests with limited resources.

Shared long-term vision and effective communication are keys to future
project implementation. Bringing together various interest groups with
different concerns and definitions of success/failure will require open
communication. In addition, community-based studies, such as the
Biomonitoring Cordblood Pilot Study, could motivate stakeholders to
increase educational outreach efforts by illustrating the magnitude of
the local problem. The study, not directly a part of this project, seeks
to establish a baseline of exposure to selected heavy metals in pregnant
women by testing umbilical cord blood.

# INTRODUCTION/BACKGROUND:

Methymercury is a neurotoxin that bioaccumulates in fish. Since the
Minimata Bay (Japan) contamination in the 1950s, government agencies,
environmental advocacy groups, and researchers have worked to increase
public awareness of the health hazards resulting from mercury exposure.
Fish consumption advisories primarily warn women of childbearing age and
young children that some species of fish routinely contain hazardous
levels of methylmercury that could harm a child's developing nervous
system or lead to other adverse health impacts.

RIDOH has recognized the need to inform people about mercury levels in
some fish, and it has developed a brochure to raise awareness so people
can make better choices in their eating habits. The message of the
brochure is that mercury is bad, but eating the right kinds of fish is
good. RIDOH and RIDEM have limited resources and have not, in all cases,
had an outreach strategy that is geared for non-English speaking
constituencies.

Rhode Island coastal waters have an abundance of swordfish, tuna and
shark that contain high levels of mercury. Local commercial fishing
operations are largely family-owned, intergenerational businesses that
have been hurt in recent years by increasing catch limits as well as
polluted fishing grounds. Representatives of these commercial fishing
interests have expressed concern that additional economic pressure could
cause many to go out of business. In addition, due to the industrial
nature of Rhode Island, a number of fresh water rivers and ponds are
sources of mercury that accumulate in the tissues of fish. This affects
recreational fisheries.

In October 2004, the Environmental Council of Rhode Island (ECRI) and
twenty five signatories petitioned RIDOH to use its existing authority
to write regulations that would require all fish retailers to post signs
about the dangers of mercury in fish. Signs would warn women of
childbearing age and young children that particularly swordfish, shark,
and albacore tuna routinely contain hazardous levels of methymercury
that could harm a child's developing nervous system or lead to other
adverse health impacts.

RIDOH recognizes that the petitioners' concerns are legitimate and that
RIDOH's outreach and education efforts concerning this issue might not
have been adequate to achieve widespread awareness of the hazards of
mercury exposures.

RIDOH worked with the Rhode Island Foods Dealer Association (RIFDA) and
its members to determine if posting advisories in retail food
establishments is an effective tool to educate consumers about mercury
in fish. A survey was conducted which consisted of an eleven (11)
question pre-and post survey design to target consumers at local grocery
stores as they prepared to exit stores. This survey was designed to
gather information from consumers regarding their knowledge, attitudes
and channels of communication about mercury in fish.

The survey results provided little support for regulations requiring
posting of fish advisories at retail point of sale, although most
consumers were aware of the mercury in fish issue. The recommendations
were to continue to work with the community partners to promote
voluntary consumer education. Also, RIDOH and community partners should
continue to evaluate existing mercury educational resources, determine
the best ways to distribute them to target populations and develop
additional outreach materials as necessary. Evaluation of these efforts
can serves as the basis for determining the need for any future
regulatory requirements.

Moreover, RIDOH in collaboration with Memorial Hospital of Rhode Island,
is conducting a Biomonitoring Cordblood Study to establish baseline
measurements of mercury and other selected chemicals for pregnant women
in Rhode Island at the time of delivery. The selected chemicals, when
present in above-normal levels, have been shown to adversely affect
prenatal development. This study is a continuation of the CDC/NCEH
Biomonitoring Planning Grant awarded to RIDOH from 2001-2003. Knowing
the baseline levels of these chemicals may help public health officials
determine the extent of the mercury and other chemicals exposure
problems.

####### 

####### ***Problem Statement:*** 

Is there common ground for mercury in fish issue? If so, what is it and
how can we use it to promote healthy fish consumption?

####### ***Behavior Over Time Graph:***

The extent of testing for mercury contamination for different species of
fish varies over time. RIDEM has not tested local fish for several years
due to funding issues. States often rely on Environmental Protection
Agency (EPA) test results when issuing local fish advisories. Private
funding from advocacy groups sometimes pays for independent testing, but
results often cannot be generalized.

Another variable is fish origin. Local supermarkets routinely sell fish
caught from a variety of locations based on international fish markets.
Some waters are more polluted than others, leading to increased
contamination of fish from those areas. Testing locally-caught fish does
not provide an accurate assessment of potential contamination from
consuming fish purchased at local retail outlets.

Special interest groups can have competing demands, with political
influence waxing and waning over time. Some groups support research into
the health benefits of consuming fish (healthy heart, Omega-3 fatty
acids, etc.) while others focus on the negative health impacts (mercury,
PCBs, etc.) or environmental pollution issues. Therefore, the impact of
these special interest groups depends largely on the amount and type of
publicity they receive and their ability to influence policy.

## **Trend** Actual risk

Perception of risk

Fish consumption

## **Variables**

Fish industry economics

**Time**

Although mercury risk is of most concern during prenatal development,
for the purposes of this discussion we are assuming that mercury
bioaccumulates, and the risk of adverse health effects increases over
time. Assuming that risk perception relates to the extent of knowledge
that an individual has about the relative health benefits vs. risks of
eating fish, once someone has had an initial exposure to information
about the topic (from a healthcare provider, educational brochure, media
source, etc) and begins to perceive risk, that person will seek
additional information. The more informed a person becomes, the greater
the likelihood that the individual will have increased risk perceptions.
In addition, older individuals tend to be more concerned about mercury
exposure from old thermometers.

Overall fish consumption tends to remain fairly static over time,
although it may have seasonal variation due to religious/cultural
practices. Likewise, the local fishing industry tends to be stable. The
local industry is largely intergenerational, family-owned and operated.

####### ***Causal Loop Diagrams and applicable archetypes:***

Although many stakeholders seem to acknowledge the scientific
community's findings about the negative health impact of mercury, they
do not agree about how to communicate this health risk message.
Commercial interests do not appear to see any benefit to signs and other
risk communication initiatives and actually fear negative repercussions
(i.e. loss of revenue) from any changes to the status quo. RIDOH and
RIDEM see benefits in a better-informed public about fish nutrition vs.
mercury risks. The environmental advocacy groups see the benefits of
change in a healthier public through policy reform. Costs of not
changing include possible mercury poisoning in at-risk groups.

In this Shifting the Burden archetype, government regulation could cause
a decline in the fishing industry due to a "scary health message."
Consumers might interpret regulation as cause to be concerned about
eating fish, resulting in decreased consumption. This could in turn lead
to decreased benefits of healthy fish consumption as well as negative
financial impact on the fishing industry and retail outlets.

The Long-term Fix (a Balancing Loop) could be a feasible alternative, in
which a joint campaign to promote moderate fish consumption could result
in a viable, sustainable fishing industry while limiting consumption of
high-mercury fish. This health education campaign would be most
effective when supported by advocacy groups, health professionals, and
the media, as well as retail outlets and the fishing industry itself.
RIDOH and RIDEM have allocated resources to meet with key stakeholders
to promote a shared vision.

####### ***10 Essential Environmental Health Services:***

This project primarily seeks to fulfill two of the 10 Essential
Environmental Health Services:

-   Inform, Educate, and Empower: This project is essentially an attempt
    to expand the state's health education outreach on the mercury/fish
    consumption issue. Knowledge is power, and educating vulnerable
    populations is essential to empowering them to make wise choices
    about their fish consumption and overall health.

-   Mobilize Community Partnerships: Collaborative work between
    government and non- government sectors would open additional
    channels of communication, thereby making health educational
    materials more accessible to the public.

####### ***National Goals Supported***

Mainly, this project seeks to support the Institute of Medicine report,
CDC's Health Protection Goal of "Healthy People in Every Stage of Life,"
with the following focus areas:

-   Start Strong: The campaign for healthy fish consumption focuses on
    the "Fish is Good, Mercury is Bad" slogan being directed primarily
    to women of childbearing age and young children, because mercury can
    affect neural development. Fish still provide important nutrition
    for healthy pregnancy, birth, and beyond, so the focus is to
    encourage individuals to select fish with lower levels of mercury.

-   Live a Healthy, Productive, and Satisfying Life: Promoting the
    consumption of low-mercury fish to the general public, pregnant
    women, and children sets the stage for healthy eating habits
    throughout the life cycle.

This project also supports the goals and initiatives of the National
Strategy to Revitalize Environmental Public Health Services in the
following areas:

## **Goal IV: Communicate and Market**

One of the key components of this mercury in fish campaign project is to
improve communication with stakeholders and thereby broaden the channels
of communication to the public. Raising awareness of mercury as a
harmful chemical, and marketing the message of promoting low mercury
fish consumption is the overall goal of the project.

Goal VI: Create Strategic Partnerships

Many stakeholders were included in this project, to include
representatives from government, education, healthcare, commercial
interests, and community advocacy groups. Broad-based collaboration is
important because socio-political-economic factors all intersect in
promoting the message "Fish is Good, Mercury is Bad" by fostering mutual
understanding and clear communication among stakeholders.

#######  {#section-2 .unnumbered}

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

####### ***Program Goal***

To bring together various interest groups to promote healthy fish
consumption and decrease mercury-in-fish exposures in RI

####### ***Health Problem***

Fish consumption advisories primarily warn women of childbearing age and
young children that some species of fish routinely contain hazardous
levels of methylmercury that could harm a child's developing nervous
system or lead to other adverse health impacts.

####### ***Outcome Objective***

By December 31, 2010, the number of elevated mercury levels in pregnant
women in RI will decrease by 10%.

####### ***Determinant***

Biomonitoring Pilot Study -- measurement of mercury in cord blood, to
set baseline for Rhode Island by Summer 2007.

####### ***Impact Objective***

By December 31, 2006, RIDOH will collaborate with at least two partners
to support the fish advisory campaign.

####### ***Contributing Factors***

-   Lack of proactive partners supporting fish advisory campaign

-   Socio-economic factors, making fish with potentially high levels of
    mercury a relatively inexpensive and/or culturally supported food
    source

-   Scientific uncertainty and unclear policy relating to mercury
    contamination

####### ***Process Objective***

Identify groups who have an interest in the RI fish advisory campaign.

# METHODOLOGY:

####### ***Events***

Meeting with the stakeholders to request establishing a consumer fish
education campaign

####### ***Activities***

-   Contact the potential partners

-   Review current research/scientific basis for concern

-   Convene and share information with partners/participants

-   Solicit inputs and brainstorm options

-   Enumerate all concerns

-   Answer questions

-   Create a working group

# RESULTS:

The impact objective was accomplished by enlisting the RIFDA to
facilitate the printing of 10,000 copies of the "Fish is Good, Mercury
is Bad" brochure. RIDEM and several health care facilities have agreed
to help distribute the brochures to their constituencies.

# NEXT STEPS:

This mercury in fish planning project is a work in progress. The primary
challenge is to form community partnerships and get the stakeholders on
board. The next steps include:

-   Bring more partners to share ideas with the group so that they can
    be informed about the issue

-   Seek specific commitments from stakeholders as to their level of
    involvement

-   Explore environmental advocacy strategies such as policy,
    enforcement, education, social marketing, and media, etc.

-   Utilize information from any available data on fish

-   Utilize information from biomonitoring cordblood pilot study when it
    becomes available

-   Seek a credible spokesperson as a project liaison

# EXPECTED OUTCOMES:

It is hoped that when the biomonitoring study's baseline results are
released in Summer 2007, that the scope of the local problem will become
clear. This will aid stakeholders in determining their level of
commitment to participation in the mercury in fish campaign. The
campaign's unifying goal is to promote healthy fish consumption among
the general populace, with awareness activities sponsored by various
interest groups.

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

####### ***Dhitinut Ratnapradipa***

I am thankful to the CDC/NCEH/ATSDR for its commitment to providing
advanced leadership, resources and funding for environmental health
professional development.

It has been time well spent for me. National Environmental Public Health
Leadership Institute (EPHLI) was well organized, from logistics to
curriculum. The curriculum was comprehensive in that it introduced
several different leadership and psychological models and provided
guided application of them to a single project. The competency-based
approach of applying the various models and receiving continuing
feedback as it related to my project provided me with a wide range of
tools for future development projects. In addition, by participating in
this institute, I have refined my knowledge of my own personal
leadership strengths and challenges.

EPHLI has been very intensive in terms of time commitment and structured
assignments. Although I was aware of the basic components of this
leadership training opportunity, I didn't realize how comprehensively
the project would integrate the training materials. At times I struggled
with my project, trying to see how the different models applied to a
project that depended so much on the contributions of external
participants.

The people also made the program a success. Mentors were dedicated to
providing support to fellows as needed. The role of mentor was valuable
particularly in fostering my project development and enhancing the
learning experience. Cohort and smaller team interactions created an
atmosphere conducive to developing long-lasting networks and will
continued to be highly valued.

# ABOUT THE EPHLI FELLOW

Dr. Dhitinut Ratnapradipa has worked for the Office of Environmental
Health Risk Assessment, Environmental Health Division, Rhode Island
Department of Health, since 2002. He coordinates environmental health
risk programs related to mercury exposures in Rhode Island including
Biomonitoring, Poison Control Center, and Fish Advisories. He is an
investigator for Biomonitoring -- Cord Blood Study, and for Southeast
Asian Community Fish Ingestion Study. Dr. Ratnapradipa is a Clinical
Assistant Professor of Community Medicine at Brown University School of
Medicine. He has served as a Co-Chair of Health Science and Biology
Divisions for the Utah Academy of Sciences, Arts, and Letters, and
editorial board member of the Journal of the Utah Academy. He was a
member of the review board for the SOPHE/CDC/ATSDR Graduate Fellowship.

Dhitinut Ratnapradipa was trained as a environmental biologist. His BS
(Biology) and MS (Environmental Technology) focused on the toxicity of
*Bacillus Sphrearicus* to non- target organisms. He received BA in
Economics and MPA in Organizational Behavior. His Ph.D. from the
University of Utah was focused on safe food-handling practices among
immigrants.

**REFERENCES**

1.  Osaki, Carl. *Essential Services of Environmental Health.* Northwest
    Center for Public Health Practice, University of Washington School
    of Public Health and Community Medicine, Seattle, WA. July 2004.

2.  CDC Health Protection Goals,
    <http://www.cdc.gov/about/goals/default.htm>.

3.  National Strategy to Revitalize Environmental Public Health
    Services,
    <http://www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf>.