**Developing a Health Education Program to Address Liver Cancer in a
Community Impacted by Environmental Contamination**

# 2007 - 2008 

# 

# Environmental Public Health Leadership Institute Fellow:

# Melanie J. Rodriguez; MPH

*Epidemiology Program Manager*

Public Center for Environmental Health, San Antonio Metropolitan Health
District

*2513 Kennedy Circle, Ste. 105, Brooks City-Base, TX 78235, (210)
532-5765*

*melanie.rodriguez@sanantonio.gov*

# Mentor:

### **Martin A. Kalis; MA**

*Public Health Advisor*

Emergency Preparedness and Response

Environmental Health Services Branch

Division of Emergency and Environmental Health Services

National Center for Environmental Health

Centers for Disease Control and Prevention

# Acknowledgements:

### **Kyle Cunningham; RS**

*Health Program Manager*

Public Center for Environmental Health, San Antonio Metropolitan Health
District

##### Linda Kaufman; MSN, RN, CS

## Environmental Health Nursing Program Manager

Environmental Health and Wellness Center, San Antonio Metropolitan
Health District

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

# EXECUTIVE SUMMARY:

Before its closure in 2001, Kelly Air Force Base (AFB) in San Antonio,
Texas was the oldest, continuously active air base in the United States.
Past operations at the base resulted in releases of industrial chemical
contaminants into the environment. Investigations revealed a shallow
groundwater plume of volatile organic compounds extending beyond the
base boundary and lying under approximately 20,000 homes. While the
health consequences attributable to this contamination are not
confirmed, environmental exposures may have contributed to adverse
health effects within the community.

The consistently high rate of liver cancer is just one environmental
health concern in the Kelly community. Efforts to address this issue
have included assuring exposures are not presently occurring, monitoring
temporal trends, and conducting investigations to identify the causes.
The application of systems thinking to the problem led to a supplemental
strategy for responding to the elevated incidence of liver cancer.
Through partnerships with key stakeholders, an environmental health
education and risk communication program will be developed and
implemented within the community.

The perception that risk emanates primarily from the environmental
contamination at Kelly AFB overshadows the reality that other factors
also contribute to the development of liver cancer. Personal behaviors
potentially may have the greatest impact on health. Community health
workers will be recruited to empower groups of community members in
reducing their cancer risks and promoting wellness. The anticipated
outcomes of the program will be a greater understanding of risk and the
adoption of healthier lifestyles, ultimately reducing the incidence of
liver cancer and improving the overall health of the community.

# INTRODUCTION/BACKGROUND:

Kelly Air Force Base was established in 1916 as the first military air
base in Texas.^1^ Before its closure in 2001, the base covered nearly
4,000 acres and was the largest single employer in San Antonio.^2^
During its 85-year history, Kelly AFB served as a pilot training
facility, air cargo center, and jet engine repair shop. After World War
II, an increased emphasis was placed on the base's depot-level
maintenance activities. Kelly AFB managed more than 75 percent of the
aircraft and auxiliary engines for the entire United States Air
Force.^3^ Thousands of gallons of fuels, oils, solvents, and other
petroleum products were utilized in support of the base's mission.

Past operations and waste management practices at Kelly AFB resulted in
releases of industrial chemical contaminants into the soil and
groundwater at the base.^3,4^ The most common contaminants were
chlorinated solvents, primarily perchloroethylene (PCE) and
trichloroethylene (TCE), which were used to degrease engine parts. The
contaminants migrated off-base through the shallow groundwater. In 1988,
a City of San Antonio Public Works crew encountered underground jet fuel
during a street construction project in a neighborhood adjacent to the
base. This was the first indication that contamination from Kelly AFB
had gone beyond the base boundary.

In response to community health concerns relating to the environmental
contamination at the former Kelly AFB, the United States Air Force
entered into a cooperative agreement with the City of San Antonio in
2001 to establish and fund the Public Center for Environmental Health
(PCEH). This division of the San Antonio Metropolitan Health District
(Metro Health) is responsible for investigating and addressing health
concerns related to environmental contamination at the former base.
Working in collaboration with PCEH, the Environmental Health and
Wellness Center, another division of Metro Health, is responsible for
screening community members and former Kelly AFB workers for
environmental exposures and documenting health outcomes.

The Kelly community faces a number of unresolved environmental health
issues, most notably the TCE-contaminated shallow groundwater plume that
extends beyond the former base's boundary and lies under approximately
20,000 homes. While the health consequences attributable to this
contamination, if any, are not clearly defined, community members
continue to express concern that past environmental releases at the
former base, as well as the remaining contamination, have contributed to
adverse health effects, including liver cancer.

Known risk factors for liver cancer include chronic infection with
hepatitis B virus or hepatitis C virus; cirrhosis of the liver;
diabetes; obesity; long-term exposure to aflatoxin; exposure to vinyl
chloride, thorium dioxide, anabolic steroids, and arsenic in drinking
water; tobacco use; family history; age; and male gender.^5,\ 6^ Most of
these risk factors are either preventable or modifiable.

***Problem Statement:*** Considering that many factors that contribute
to the development of liver cancer are preventable and/or modifiable,
why has a comprehensive environmental health education and risk
communication program addressing these risk factors not been implemented
within the Kelly community?

***Behavior Over Time Graph:***

####### ![](media/image2.wmf){width="4.738888888888889in" height="3.265972222222222in"} 

**Liver cancer** **incidence** has consistently remained elevated in the
Kelly community. In 1999, after receiving a petition to perform a public
health assessment on neighborhoods around the former Kelly AFB, the
Agency for Toxic Substances and Disease Registry (ATSDR) requested the
Texas Department of State Health Services Texas Cancer Registry (TCR) to
evaluate the occurrence of cancers, including liver cancer, in three ZIP
code areas around the base. An excess of liver cancer incidence was
observed for two of the three ZIP code areas.^7^ Due to the increased
occurrence of liver cancer in the initial three ZIP code areas, ATSDR
requested an evaluation of liver cancer in ten additional ZIP code
areas. Excess liver cancer was observed for three.^7^

In response to ATSDR's recommendation to re-evaluate cancer as more data
became available, the TCR updated the analyses of liver cancer in August
2003. None of the 18 ZIP code areas evaluated showed an excess of liver
cancer. However, liver cancer mortality was elevated in three ZIP code
areas.^8^ Liver cancer incidence was further evaluated in February 2005
using data from 1995 to 2001. An elevation of liver cancer was again
observed for two of the three ZIP code areas.^9^

The **contaminated groundwater plume** lies 10 to 30 feet beneath the
surface, and once extended four miles east-southeast of the base under
20,000 homes in the community. In 1999, the Air Force Real Property
Agency (AFRPA) assumed management of the environmental restoration
program, begun in 1982, at the then still active base. In 2006, the Air
Force completed installation of off-base cleanup systems, including
three permeable reactive barriers to treat the groundwater.^4^

Metro Health has conducted a number of **environmental investigations**
and **health studies** in response to the contamination at Kelly AFB and
the health consequences that may have resulted from potential
environmental exposures. Liver cancer studies and investigations
focusing on possible exposures from the contaminated groundwater are
summarized below.

**Drinking Water**

San Antonio's primary source of drinking water is the Edwards Aquifer, a
deep aquifer separated from the shallow groundwater by approximately
1,000 feet of clay, marl, limestone, and shale.^7^ Although municipal
water has been supplied to the Kelly community since the 1950s, shallow
groundwater wells were present in the community and used most recently
for gardening and lawn care. PCEH, the Air Force, and the San Antonio
Water System (SAWS) have located and plugged 75 of these private
abandoned wells.

In response to citizen's concerns that contaminants may have reached the
Edwards Aquifer, PCEH routinely tests drinking water samples for
volatile organic compounds (VOCs). Sampling sites are selected from
areas with the highest concentrations of groundwater contamination and
include schools, day care centers, restaurants, and homes. Furthermore,
the two public water purveyors in the community are required by the
Texas Commission on Environmental Quality to test drinking water for the
chemicals of concern (i.e., TCE, PCE, 1,2-dichloroethylene, and vinyl
chloride). Reports have confirmed that the COCs are not present within
the public drinking water supply.

**Homegrown Produce**

Residents were concerned that homegrown produce may have been impacted
through absorption of the COCs from the shallow groundwater plume. In
response, PCEH analyzed samples of seasonal fruits, vegetables, and nuts
grown in residential areas over the plume. None of the 150 samples
tested positive for any of the COCs.

**Vapor Intrusion**

PCEH conducted sub-slab soil vapor monitoring at sites on or near Kelly
AFB in response to concerns that VOCs were accumulating beneath building
foundations at levels that could potentially result in vapor migration
into indoor air space. COCs were not detected in any of the soil gas
samples. Further vapor intrusion investigations are planned for Fiscal
Year 08.

**Liver Cancer Studies**

A liver cancer case series and feasibility study was conducted within 14
ZIP code areas surrounding the former base to identify personal risk
factors for liver cancer from interviews with liver cancer patients or
their next-of-kin. A secondary goal of the study was to determine the
feasibility of a case-control study. The study corroborated previous
findings of increased liver cancer and concluded that individual case
follow-up would be very difficult.

Presently, PCEH is collaborating with two state universities in
performing a study to identify contributing causes of liver cancer in
the Kelly community. Participants are asked to complete a short
questionnaire about their diet, lifestyle factors (e.g., alcohol and
tobacco use), medical history, and known exposures to chemicals. Liver
function tests are completed on blood samples, as are screenings for
hepatitis B and hepatitis C viruses. Blood and urine samples are also
tested for recent exposures to aflatoxins, mycotoxins produced by
species of the *Aspergillus* fungus that commonly contaminate foods such
as corn, rice, and peanuts. This study is expected to be completed in
Spring 2008.

Although most of these investigations and studies incorporated
educational components, a comprehensive **environmental health
education** and **risk communication** program tailored to the community
has not been implemented.

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

####### ![](media/image3.wmf)

Figure 1: Shifting the Burden Archetype

####### The archetype chosen for this project is shown in Figure 1. Metro Health has an obligation to continue monitoring for potential environmental exposures and investigating the causes of elevated liver cancer in the Kelly community so that appropriate actions can be taken to reduce the community's risks from environmental sources. However, these investigations and studies intensify the community's health concerns, which may lead to distrust and lack of community support. Without the community's cooperation and participation, Metro Health cannot accurately assess, and respond to, the health needs of the community. The implementation of an environmental health education program will supplement the current efforts of Metro Health to reduce the incidence of liver cancer in the Kelly community by educating the community about environmental risks and empowering residents to take responsibility for their health by reducing risks through modified lifestyles. 

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

This project addresses the core function of policy development by
focusing on the environmental health services of (1) informing,
educating, and empowering the community about health issues and (2)
mobilizing community partnerships (See Figure 2). During a health
roundtable meeting sponsored by the Kelly Area Collaboration in
September 2006, participants identified promotion of healthy lifestyles
and health education and outreach services as necessary actions for
improving the health status of the Kelly community. This need for
appropriate health information specific to the environmental challenges
confronting the Kelly community will be met with an environmental health
education and risk communication program developed in collaboration with
key stakeholders, including community-based organizations, government
agencies, and educational institutions.

![](media/image4.png){width="3.75in" height="3.8125in"}

Figure 2: The Essential Environmental Health Services,

Source: Public Health Functions Steering Committee

#######  

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

**CDC Health Protection Goals**^10^

> Healthy People in Every Stage of Life -- All people, and especially
> those at greater risk of health disparities, will achieve their
> optimal lifespan with the best possible quality of health in every
> stage of life.

-   Improve behaviors that promote children's health and well-being in
    future life stages.

-   Prevent chronic diseases and their consequences among adults.

-   Improve behaviors among adults that promote health and well-being.

> Healthy People in Healthy Places -- The places where people live,
> work, learn, and play will protect and promote their health and
> safety, especially those at greater risk of health disparities.

-   Support a robust, sustainable capacity to provide access to and
    ensure receipt of essential public health, health promotion, health
    education, and medical services.

-   Promote adoption of behaviors that keep people healthy and safe in
    their homes.

**Healthy People 2010 Objectives**^11^

-   Reduce the number of new cancer cases as well as the illness,
    disability, and death caused by cancer.

-   Increase the quality, availability, and effectiveness of educational
    and community-based programs designed to prevent disease and improve
    health and quality of life.

-   Use communication strategically to improve health.

**National Strategy to Revitalize Environmental Public Health
Services**^12^

-   Support educational approaches and models of best practices to gain
    community support and participation in addressing environmental
    public health service issues, concerns, and best models to organize,
    deliver, and market environmental pubic health services.

**Environmental Health Competency Project: Recommendations for Core
Competencies for Local Environmental Health Practitioners**^13^

-   Collaboration -- The capacity to form partnerships and alliances
    with other individuals and organizations to enhance performance on
    the job.

-   Communicate -- The capacity to effectively communicate risk and
    exchange information with colleagues, other practitioners, clients,
    policy-makers, interest groups, media, and the public through
    routine activities, public speaking, print and electronic media, and
    interpersonal relations.

####### ***Project Logic Model:***

# 

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

####### ***Program Goal:*** To reduce the incidence of liver cancer and improve the overall health of a community confronting multiple environmental health challenges through a culturally appropriate health education and risk communication program.

####### ***Health Problem:*** Historically, liver cancer incidence has been higher within the Kelly Air Force Base community compared to others areas of Bexar County.

####### ***Outcome Objective:*** By December 31, 2011, new liver cancer cases reported to the Texas Cancer Registry will be reduced by at least ten percent from the 2001 baseline.

####### ***Determinant:*** The perception that risk emanates primarily from environmental sources overshadows the reality that other factors, such as genetics, nutrition, infectious agents, and lifestyle choices, also contribute to the development of liver cancer.

####### ***Impact Objective:*** By September 30, 2009, at least 60% of the program participants will have a greater knowledge of risk and the determinants of health; and 35% or more of the participants will adopt healthier lifestyles.

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

1.  A general lack of understanding of health and its determinants.

2.  The difficulty in sorting through and understanding the often
    conflicting health information received through the media, World
    Wide Web, and special interest groups.

3.  The commonly held belief that personal behaviors, in comparison to
    environmental contamination, are less harmful to health.

####### ***Process Objectives:***

####### During FY08 (October 2007 -- September 2008), a comprehensive health education and risk communication program will be developed in collaboration with key stakeholders.

1.  The new program will be implemented in two to four neighborhoods
    within the Kelly community during FY09.

# METHODOLOGY:

**Event:** Develop a comprehensive health education and risk
communication program.

**Activities:**

1.  Develop and submit a project proposal to funding agency.

2.  Meet with key stakeholders to develop program objectives.

3.  Develop curriculum.

4.  Recruit *promotores* to conduct training sessions.

**Event:** Implement the program in several Kelly area neighborhoods.

**Activities:**

1.  Select neighborhoods.

2.  Select training sites and schedule training dates.

3.  Conduct pre-test.

4.  Conduct training sessions.

**Event:** Evaluate the program.

**Activities:**

1.  Develop evaluation materials.

2.  Conduct post-test.

3.  Measure long-term lifestyle changes.

# CONCLUSIONS AND NEXT STEPS:

Using systems thinking, a health education and risk communication
program was identified as a supplemental strategy to address the
elevated liver cancer incidence within the Kelly Air Force Base
community. The perception that risk emanates primarily from the
environmental contamination at Kelly AFB overshadows the reality that
other modifiable factors also contribute to the development of liver
cancer. Personal behaviors potentially may have the greatest impact on
health. Research has suggested that 20 to 50% of cancer deaths are
attributable to diet and another 29 to 31% to tobacco use, whereas only
1 to 5% are attributable to environmental pollution.^14^ Nevertheless,
voluntary risks are perceived to be less harmful compared to imposed
risks, such as environmental pollution.

The intended goal of this project is to reduce the incidence of liver
cancer within the Kelly community. To accomplish this goal, a health
education and risk communication program will be developed and
implemented within several neighborhoods of the community. The program
will consist of health education modules developed in collaboration with
key stakeholders and presented by *promotores*, or community health
workers, in sites throughout the targeted neighborhoods over a period of
six to twelve months. Assessments will be conducted at the beginning of
the program to measure baseline levels of health behaviors, risk
perception, and knowledge of health determinants. The expected outcomes
of the project are a better understanding of risk and reduction of
health risks through the adoption of healthier lifestyles. These
outcomes will be quantified by post-assessments.

The two greatest challenges to this project will be recruiting trained
and experienced community health workers and persuading residents to
participate in the program. Metro Health has identified a
community-based organization already training *promotores* on several
health issues, including cancer prevention, within some areas of the
Kelly community. Partnering with this group will address the first
challenge. As for community buy-in, a community-led effort will provide
for the greatest chance of success. Ownership will be given to the
community. Metro Health will act as facilitator and allow the community
to establish the program objectives. To encourage participation and
retention in the program, non-cash incentives may also be offered.

The next step in implementing this program will be to present the
project plan to the Air Force for funding approval. Additional funding
and support for this project may be sought through the U.S.
Environmental Protection Agency's Community Action for a Renewed
Environment (CARE) grant program. Once funding has been secured, a
series of meetings will be held with key stakeholders to develop program
objectives and select an appropriate curriculum, in addition to
selecting the neighborhoods in which the program will be implemented.

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

####### ***Melanie J. Rodriguez, MPH***

My participation in the Environmental Public Health Leadership Institute
has been a very rewarding and informative experience, the lessons of
which I will repeatedly draw upon and apply during my career in
environmental health. As I have no formal training in environmental
health, learning specifically about the national program goals for
environmental health and the essential environmental health services was
very helpful. The self-assessments were especially revealing, as I
learned not only what my strengths and weaknesses are, but how to use
each to the best advantage. The greatest benefit of the program was the
introduction to organizational learning and systems thinking I received.
These skills will allow me to more effectively respond to the
environmental health problems in my community.

Thanks to all the EPHLI staff, instructors, coaches, and mentors for
sharing their knowledge, experiences, and insights. Thanks also to the
2008 EPHLI fellows. I've learned that San Antonio's environmental health
issues are not merely local challenges, but national ones. I would like
to give special thanks to my mentor, Martin Kalis, who gave generously
of his time guiding me as I developed my project, and to my personal
development coach, David Steffen, who spent hours with me discussing my
MBTI and Skillscope360 to refine my Individual Development Plan. Their
assistance and encouragement is greatly appreciated.

# ABOUT THE EPHLI FELLOW

Melanie J. Rodriguez has served as the Epidemiology Program Manager for
the Public Center for Environmental Health at the San Antonio
Metropolitan Health District in San Antonio, Texas since 2002. The
Center was established through a cooperative agreement between the City
of San Antonio and the United States Air Force to investigate health
impacts from potential exposure to environmental contaminants released
from the former Kelly Air Force Base. She is responsible for analyzing
health data, developing and managing research projects, and providing
technical assistance to staff and the community.

Following completion of her graduate studies in 2001, Melanie was
awarded a fellowship by the Oak Ridge Institute for Science and
Education. As an epidemiology fellow, she began her career in
environmental public health at the Air Force Institute for Operational
Health at Brooks Air Force Base, Texas performing surveillance of
influenza and deployment health hazards.

Melanie received her Master of Public Health degree with a concentration
in Epidemiology and Biostatistics from Texas A&M University System
Health Science Center School of Rural Public Health. She was recently
elected a member of Delta Omega, the national public health honor
society.

**REFERENCES**

1.  Department of the Air Force. *A Brief History of Kelly Air Force
    Base*. Office of History, San Antonio Air Logistics Center, Kelly
    Air Force Base, Texas; 1998.

2.  Hutton, Jim. History spans from dusty aviation field to AF aircraft
    depot. *San Antonio Express-News*. July 8, 2001:2M.

3.  Air Force Real Property Agency. Former Kelly AFB Community Resource
    Guide. Available at:
    http://www.safie.hq.af.mil/shared/media/document/AFD-070613-122.pdf.
    Accessed January 9, 2008.

4.  Air Force Real Property Agency. Community Relations Plan for the
    Former Kelly Air Force Base. Available at:
    http://www.safie.hq.af.mil/shared/media/document/AFD-070924-112.pdf.
    Accessed January 9, 2008.

5.  American Cancer Society. Overview: Liver Cancer. Available at:
    http://www.cancer.org/docroot/CRI/CRI_2_1x.asp?dt=25. Accessed
    January 9, 2008.

6.  U.S. National Institutes of Health, National Cancer Institute. What
    You Need to Know About Liver Cancer. Available at:
    http://www.cancer.gov/cancertopics/wyntk/

> liver. Accessed January 9, 2008.

7.  U.S. Department of Health and Human Services, Agency for Toxic
    Substances and Disease Registry. Public health assessment phase I
    final report, Kelly Air Force Base, San Antonio, Bexar County,
    Texas. 2004.

8.  Texas Department of State Health Services. Texas Cancer Epidemiology
    and Surveillance Branch. Summary of investigation into the
    occurrence of cancer zip codes 78201, 78204, 78205, 78207, 78211,
    78212, 78221, 78224, 78225, 78226, 78227, 78228, 78229, 78237,
    78238, 78242, 78245, and 78252, San Antonio, Bexar County, Texas,
    1992-2001. 2003.

9.  Texas Department of State Health Services, Texas Cancer Epidemiology
    and Surveillance Branch. Summary of investigation into the
    occurrence of cancer zip codes 78211, 78226, 78227, 78228, and
    78237, San Antonio, Bexar County, Texas, 1993-2002. 2005.

10. U.S. Department of Health and Human Services, Centers for Disease
    Control and Prevention. Health Protection Goals*.* Available at:
    http://www.cdc.gov/about/

goals.htm. Accessed January 9, 2008.

11. U.S. Department of Health and Human Services, Office of Disease
    Prevention and Human Services. Healthy People 2010*.* Available at:
    [http://www.healthypeople.gov.]{.underline} Accessed January 9,
    2008.

12. U.S. Department of Health and Human Services, Centers for Disease
    Control and Prevention. A National Strategy to Revitalize
    Environmental Public Health Services*.* Available at
    http://www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf. Accessed
    January 9, 2008.

13. U.S. Department of Health and Human Services, Centers for Disease
    Control and Prevention, National Center for Environmental Health and
    the American Public Health Association. Environmental Health
    Competency Project. Available at:
    http://www.apha.org/NR/rdonlyres/50581D31-E13B-4424-8895-5545A3265C19/0/Env_Comp_Booklet.pdf.
    Accessed January 9, 2008.

14. U.S. Department of Health and Human Services, U.S. National
    Institutes of Health, National Cancer Institute. Understanding
    Cancer Series: Cancer and the Environment. Available at:
    <http://www.cancer.gov/cancertopics/understandingcancer/environment>.

Accessed January 16, 2008.