# Call to introduce environmental preventive medicine courses to the medical curriculum. An initial experience of an education program at the Faculty of Medicine of Nice, University of Côte d'Azur

Patrick Fénichel, Emiko Todaka, Ruth Etzel, Chang-Chuan Chan, Robert Barouki, Nicolas Chevalier, Jean-Baptiste Fini, Kirsten Poore, Kou Sakabe, Valérie Siroux, et al.

► To cite this version:

Patrick Fénichel, Emiko Todaka, Ruth Etzel, Chang-Chuan Chan, Robert Barouki, et al. Call to introduce environmental preventive medicine courses to the medical curriculum. An initial experience of an education program at the Faculty of Medicine of Nice, University of Côte d'Azur. Frontiers in Medicine, 2025, 11, pp.109308. 10.3389/fmed.2024.1412674. hal-05111985

HAL Id: hal-05111985

https://hal.science/hal-05111985v1

Submitted on 13 Jun 2025

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
<figure><img src="image_2.png" /></figure>

Check for updates

## OPEN ACCESS

**EDITED BY**
Jacqueline G. Bloomfield,
The University of Sydney, Australia

**REVIEWED BY**
Jason W. Marion,
Eastern Kentucky University, United States
Hannah Covert,
University of Pittsburgh, United States
Mona Arora,
University of Arizona, United States

**\*CORRESPONDENCE**

Patrick Fénichel

patrick.fenichel@univ-cotedazur.fr

RECEIVED 08 April 2024

ACCEPTED 12 November 2024

PUBLISHED 09 January 2025

## CITATION

Fénichel P, Todaka E, Etzel RA, Chan C-C, Barouki R, Chevalier N, Fini J-B, Poore KR, Sakabe K, Siroux V, Yamamoto M and Mori C (2025) Call to introduce environmental preventive medicine courses to the medical curriculum. An initial experience of an education program at the Faculty of Medicine of Nice, University of Côte d'Azur. *Front. Med.* 11:1412674.
doi: 10.3389/fmed.2024.1412674

## COPYRIGHT

© 2025 Fénichel, Todaka, Etzel, Chan, Barouki, Chevalier, Fini, Poore, Sakabe, Siroux, Yamamoto and Mori. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

# Call to introduce environmental preventive medicine courses to the medical curriculum. An initial experience of an education program at the Faculty of Medicine of Nice, University of Côte d'Azur

Patrick Fénichel<fnref n="1" />*, Emiko Todaka², Ruth A. Etzel³, Chang-Chuan Chan⁴, Robert Barouki⁵, Nicolas Chevalier<fnref n="1" />, Jean-Baptiste Fini⁶, Kirsten R. Poore⁷, Kou Sakabe², Valerie Siroux⁸, Midori Yamamoto² and Chisato Mori²

## KEYWORDS

environmental medicine, education program, medical schools, endocrine disruptors, preventive medicine

## Introduction

Non-communicable diseases, including neuro-developmental, reproductive, metabolic, cardiovascular, oncologic, allergic/immune, and neurodegenerative diseases, have become more frequent worldwide than infectious diseases (1). Since 1990, there has been a marked shift in the global burden due to years lived with disability from communicable diseases to non-communicable diseases and injuries (2). Non-communicable diseases kill 41 million people each year, equivalent to 74% of all deaths globally (3). Adults with NCDs had an increased risk of death during the COVID-19 pandemic and could be similarly at risk during future epidemics (4). Diseases of pure genetic origin with single germlinal mutations are found only in a very small proportion of chronic diseases. Currently, chronic, non-communicable diseases are considered to result from a combination of genetic susceptibility and a variety of environmental exposures. Among these environmental exposures, air and chemical pollution play a major role, but lifestyle factors, nutrition, psychological stress, and socioeconomic conditions are also involved. To improve environmental exposure assessment, Christopher Wild proposed the concept of the exposome in 2005: "At its most complete, the exposome encompasses life-course environmental exposures (including lifestyle factors), from the prenatal period

<footnote n="1">¹Department of Endocrinology, Diabetology and Reproduction, University of Côte d'Azur, Nice, France, ²Center for Preventive Medical Sciences, Chiba University, Chiba, Japan, ³Milken Institute School of Public Health, George Washington University, Washington, DC, United States, ⁴College of Public Health, National Taiwan University, Taipei, Taiwan, ⁵Inserm UMRS-1124 Université de Paris, Paris, France, ⁶Laboratoire PHYMA, MNHN, UMR 7221, Paris, France, ⁷Faculty of Medicine, University of Southampton, Southampton, United Kingdom, ⁸Inserm U1209 CNRS UMR 5309 Team of Environmental Epidemiology Applied to the Development and Respiratory, Health Institute for Advanced Biosciences, Université Grenoble Alpes, La Tronche, France</footnote>
onwards” (5). The rapid environmental changes in the Anthropocene have caused harm to both human and veterinary health, which can no longer be isolated from the harms to Earth’s environment, including air (6), chemical (7), and ocean (8) pollution, as well as the decline in biodiversity and climate change—issues that are addressed through the “One Health” approach (9).

Despite calls from researchers (10), the curriculum of most medical schools in the world does not yet incorporate concepts concerning the impact of the environment on human health and the consequences for public health policy and preventive medical practice (11). Medical students themselves have recognized this, as recently reported in a French national survey, which showed they considered the topic of preventive and environmental medicine to be insufficiently taught (12). While there have been some student-led initiatives (13), we aimed to establish a faculty-led education program on environmental preventive medicine in the medical school curriculum. This medical field includes individual patient care, population health management, and non-medical risk management interventions, such as product substitution and patient education. The field draws on both One Health (9) and Planetary Health (14) concepts (15). We report here our positive experience in enhancing students’ understanding of environmental preventive medicine.

## Background to the environmental preventive medicine program

An official collaboration between Chiba University in Japan and the University of Côte d'Azur in Nice, France, was established in 2016, following initial meetings between the teams of Professor Chisato Mori, Director of the Center for Preventive Medical Sciences at Chiba University, and Professor Patrick Fénichel, Director of the Endocrine and Reproductive Medicine Department of the University Hospital of Nice (University of Côte d'Azur). After initially collaborating around the theme of human exposure to endocrine-disrupting chemicals, this expanded to a wider goal of exchanging scientific research and educating students about preventive environmental medicine, both in Nice and beyond. An education course was designed after extensive discussions that would cover topics that newly trained doctors would likely face in their practices, all core to the practice of environmental preventive medicine (16). There was a particular focus on the effect of environmental exposures during critical periods of early life as a foundation to reduce the lifetime risk of non-communicable disease.

Two initial iterations of this course took place in 2017 and 2018 at the University Hospital of Nice, which included a small group of students from Chiba University and a larger cohort of approximately 80 Year 3–5 medical students from the University of Côte d'Azur, who attended on a voluntary basis. In 2018, a brief student evaluation of the course was undertaken that showed it was positively received (overall approval rating of 4.4 out of 5, n = 26 respondents).

Informed by these initial iterations of the education course, since 2022, all students at the University of Côte d'Azur's Faculty of Medicine have benefited from environmental health teaching.

In their first year, students complete 6 h of teaching covering global concepts such as One Health, major health issues linked to environmental issues, methodologies for quantifying hazards and risks, and the concept of endocrine disruptors. In Year 3, students receive 12 h of teaching focused on environmental health and climate change. These efforts have been shaped by a requirement within the French national program for medical faculties to include environmental medicine in Year 2 of the curriculum.

## Environmental preventive medicine course in 2023

The most recent edition of the environmental preventive medicine course took place in November 2023 at the Faculty of Medicine of the University of Côte d'Azur in Nice. This course was designed for final year (Year 6) students, who thus had a strong background of scientific knowledge and were better equipped to embed environmental medicine into their clinical experience. In addition, following a proposal from the Faculty of Medicine's Dean, the course was made mandatory, with students registering their attendance twice a day before each half-day session. Those who were not able to attend were required to take a test after watching a recording of the course. Students completing the course were at an advantage in the final competition, which determines their specialty choice for the future. A cohort of 180 students, along with 10 invited students from Chiba University, attended the course, which was given in English with simultaneous translation to French throughout.

The program of the course is shown in Table 1 and includes 30-min lecture-style presentations followed by 15 min of questions and discussion with the students. A pre- and post-course knowledge quiz was delivered via an online platform (Vevox) based on the topics in each presentation (12 multiple-choice questions) at the start and end of the course. The learning outcomes of the course were to ensure students understood several environmental preventive medicine concepts, including a complete environmental history, environmental injustice, the Developmental Origins of Health and Disease (DOHaD) (17), the role of epigenetics in the occurrence of chronic diseases, epidemiological transition, exposome (18), and mechanisms of endocrine disrupting chemicals (19). All the topics were supported by epidemiological and experimental studies and were delivered by a multidisciplinary team of clinicians and scientists. Our objective was to help students understand the physio-pathological origins of non-communicable diseases, the concepts of One Health and planetary health, and the importance of education and prevention at critical periods of development (20, 21). This involved a discussion of the individual and collective public health responsibilities, as well as the role of general practitioners as public health actors at the preventive medical level (22). The expert international speakers provided students with a practical understanding of the environmental health problems experienced by different cultures and societies and the common threats to human health caused by environmental changes. This allowed the students to think more broadly than through their cultural lens. We believe this approach is necessary to give students the cultural sensitivity to understand environmental
<table><caption>TABLE 1 Program of the "Third International Education Course on Environmental Preventive Medicine" co-organized by Chiba University and University of Côte d'Azur (Faculty of Medicine of Nice) 22–23 November 2023.</caption><thead><tr><th>Session title</th><th>Invited speaker</th></tr></thead><tbody><tr><td colspan="2"><strong>Day 1</strong></td></tr><tr><td colspan="2">Greetings from Prof. Jean Dellamonica, the Dean of the Faculty of Medicine, University of Côte d'Azur</td></tr><tr><td colspan="2">Greetings from Dr. Richard Chemla, Deputy City Mayor of Nice</td></tr><tr><td colspan="2">Opening remarks by Prof. Chisato Mori, Center for Preventive Medical Sciences, Chiba University</td></tr><tr><td>Online quiz of student knowledge before the course</td><td>Dr. Kirsten Poore</td></tr><tr><td colspan="2"><strong>Session 1: "Early life environmental determinants of health in later life"</strong></td></tr><tr><td>"Developmental Origins of Health and Disease (DOHaD) and Epigenetics"</td><td>Dr. Kirsten Poore</td></tr><tr><td>"Children are not little adults"</td><td>Prof. Ruth Etzel</td></tr><tr><td colspan="2"><strong>Session 2: "Pollutants and human health"</strong></td></tr><tr><td>"Learning from historical disaster and tragic events: Minamata Disease, Seveso, etc."</td><td>Prof. Emiko Todaka</td></tr><tr><td>"Endocrine Disrupting Chemicals (EDCs)"</td><td>Prof. Robert Barouki</td></tr><tr><td>"Agricultural pesticides and human health"</td><td>Prof. You Sakabe</td></tr><tr><td colspan="2"><strong>Session 3: "Modern issues of human health"</strong></td></tr><tr><td>"Neurodevelopmental diseases"</td><td>Prof. Jean-Baptiste Fini</td></tr><tr><td>"Recent increase of metabolic syndrome including obesity and diabetes"</td><td>Prof. Nicolas Chevalier</td></tr><tr><td>"Air Pollution and Health"</td><td>Prof. Chang-Chuan Chan</td></tr><tr><td colspan="2"><strong>Day 2</strong></td></tr><tr><td colspan="2"><strong>Session 4: "Emerging health issues and environmental exposures I"</strong></td></tr><tr><td>"Environmental Epidemiology, Exposome and Biomarkers"</td><td>Prof. Valerie Siroux</td></tr><tr><td>"One Health"</td><td>Prof. Ruth Etzel</td></tr><tr><td>"Plastic pollution and human health"</td><td>Prof. Patrick Fénichel</td></tr><tr><td colspan="2"><strong>Session 5: "Emerging health issues and environmental exposure II"</strong></td></tr><tr><td>"Climate change and health"</td><td>Prof. Ruth Etzel</td></tr><tr><td>"Chemical sensitivity"</td><td>Prof. Kou Sakabe</td></tr><tr><td>"Japan Environment and Children's Study by the Ministry of the Environment of Japan"</td><td>Dr. Midori Yamamoto</td></tr><tr><td colspan="2"><strong>Session 6: "Prevention and intervention" discussion by all the participants</strong></td></tr><tr><td>"How to prevent parental-fetal exposure to endocrine disruptors? The pre-conception consultation"</td><td>Prof. Patrick Fénichel</td></tr><tr><td colspan="2"><strong>Final discussion by all the lecturers and students</strong></td></tr><tr><td>Online quiz of student knowledge after the course</td><td>Dr. Kirsten Poore</td></tr><tr><td>Student online evaluation of the course</td><td>Dr. Kirsten Poore</td></tr><tr><td>Closing remarks</td><td>Prof. Chisato Mori</td></tr></tbody></table>

injustice across generations, race, wealth, and poverty, in the Global North and Global South.

## Feedback about the environmental preventive medicine course in 2023

The majority of students stayed until the end of the course; they remained attentive and interactive, asking many pertinent questions at the end of each lecture. They explained that they had not received extensive teaching on these topics before. However, we were impressed by their ability to understand,

integrate, and synthesize these new data and concepts and to realize the implications from both individual and collective points of view. When comparing student knowledge before and after the course, the percentage of students answering each question correctly was increased for all questions, showing the effectiveness of the teaching and learning during the course (Table 2).

All students were asked for their evaluation of the course on completion; 38 students provided numerical (on a scale of 1 to 5) and qualitative feedback. Students found the course intellectually stimulating (score 4.4 out of 5) and clinically relevant (score 4.4 out of 5) and would recommend the course to other students
<table><caption>TABLE 2 Effect of the environmental preventive medicine course on student knowledge of topics presented.</caption><thead><tr><td>Question topic</td><td>Pre-course results (% students correct)</td><td>Post-course results (% students correct)</td></tr></thead><tbody><tr><td>Postnatal lung development</td><td>24%</td><td>70%</td></tr><tr><td>Vulnerability of children to air pollution</td><td>86%</td><td>90%</td></tr><tr><td>Cause of Minamata disease</td><td>33%</td><td>92%</td></tr><tr><td>Health outcome associated with childhood exposure to lead</td><td>28%</td><td>46%</td></tr><tr><td>Chemical compound linked to type 2 diabetes</td><td>0.7%</td><td>13%</td></tr><tr><td>Childhood obesity associated with bisphenol A exposure</td><td>23%</td><td>43%</td></tr><tr><td>Health outcome associated with PM2.5 exposure</td><td>34%</td><td>93%</td></tr><tr><td>Worldwide number of deaths from COVID-19</td><td>40%</td><td>41%</td></tr><tr><td>Organizations leading the One Health approach</td><td>29%</td><td>46%</td></tr><tr><td>Alternative sources of power generation</td><td>40%</td><td>80%</td></tr><tr><td>Effect of sea level rise</td><td>39%</td><td>84%</td></tr><tr><td>Importance of folic acid supplementation pre-conception</td><td>36%</td><td>71%</td></tr></tbody></table>

Multiple choice (one best answer) questions were presented to students using an online polling website (Vevox) immediately before (pre-course, without revealing correct answers) and immediately after (post-course, revealing and briefly discussing correct answers) the course. N = 149 participants.

(score 4.7 out of 5). Students clearly understood the aims of the course (score 4.8 out of 5) and found the material covered was appropriate (score 4.6 out of 5), given their prior knowledge as Year 6 students. The overall course rating was 4.6 out of 5 (95% giving a rating of 4 or 5). Crucially, 74% of students who responded agreed that the course would influence their future practice as a doctor.

We believe that bringing French students together with Japanese students for this course helped to create a collaborative learning environment to foster the development of students who will be equipped to respond to global problems through effective collaboration and transdisciplinarity (23). Although some students found the course too intensive at times, with some sessions too long and overly scientific in nature, their level of interaction with the course suggested they were conscious it was important to them as future doctors. We explained to them that we deliberately presented original epidemiological and experimental data during the lectures to support the conclusions, following an evidence-based medicine approach. Students suggested that the course should dedicate more time to providing practical advice and methods to educate their patients. Some students were worried about not being able to advise patients in their medical practice due to a lack of time, practical solutions, and knowledge. We understood that they wanted more practical advice, patient-focused sources of information, questionnaires, applications, and pedagogical methods to use with their patient consultations.

Students were also conscious that the course content was important for their own lives and humanity in general, developing philosophical reflections and questions. Some even questioned whether it was reasonable or pertinent to start a family given the many environmental and climate pressures facing them. They could not understand why politicians and policymakers did not care more about the link between the environment and health.

## Our ongoing education approach

The feedback from the 2023 course and its earlier iterations were overwhelmingly positive, and this is now shaping the future of the medical curriculum at the University of Côte d'Azur's Faculty of Medicine. In addition to content in Years 1-3, in 2024, a social responsibility and the eco-design of healthcare theme has been added to the curriculum (15 h of workshop teaching). In Year 4, students are trained to provide practical advice on the prevention and promotion of environmental health for use with secondary school students and staff in vocational training, directly responding to students' requests for practical advice to help their patients. In addition, the faculty is proposing 6-12 h of teaching on environmental medicine in Year 6, based on the model of our 2023 course, to reinforce specific knowledge they have achieved throughout the curriculum.

All medical schools have a crowded curriculum, and there is considerable competition for time to be allocated to new topics. We argue that future doctors need to be prepared to deal with the health challenges of our changing environment. Including new content about environmental preventive medicine could be done using various methods, such as the course presented here, but need not be burdensome for students. Others have used an "infusion" approach to gently reinforce concepts over many years of study and in a variety of contexts (24). This is aligned with the new approach at the University of Côte d'Azur, which begins in Year 1 and is reinforced in Year 6 following recent national recommendations.

## Conclusion

We conclude that this original and innovative teaching experience should not only be a recommendation but an absolute
necessity to introduce and develop environmental preventive medicine into the curriculum in worldwide medical faculties. We have proposed one model based on a final-year course that has been effective and well-received. This may have three positive general consequences for future healthcare practitioners: (1) to bring more attention to the impact of the environment on health in clinical practice, (2) to give pertinent preventive medical advice to patients, and (3) to enable future specialists in environmental health to inform policymakers on ways to reduce harmful environmental exposures at the local, national, and international levels. We believe this is a universal competence that all medical students need before they enter clinical practice in our increasingly complex and interconnected world.

## Author contributions

PF: Writing – original draft, Writing – review & editing. ET: Writing – original draft, Writing – review & editing. RE: Writing – original draft, Writing – review & editing. C-CC: Writing – original draft, Writing – review & editing. RB: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft. Writing – review & editing. NC: Writing – original draft, Writing – review & editing. J-BF: Writing – original draft, Writing – review & editing. KP: Writing – original draft, Writing – review & editing. KS: Writing – original draft, Writing – review & editing. VS: Writing – original draft, Writing – review & editing. MY: Writing – original draft, Writing – review & editing. CM: Writing – original draft, Writing – review & editing.

## References

1. Bygbjerg IC. Double burden of noncommunicable and infectious diseases in developing countries. *Science*. (2012) 337:1499–501. doi: 10.1126/science.123466

2. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. *Lancet*. (2020) 396:1204–22. doi: 10.1016/S0140-6736(20)30925-9

3. World Health Organization. *Non-Communicable Diseases*. (2023). Available at: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases (accessed 16 September, 2023).

4. Balasuriya L, Briss PA, Twentyman E, Wiltz JL, Richardson LC, Bigman ET, et al. Impacts of the COVID-19 pandemic on nationwide chronic disease prevention and health promotion activities. *Am J Prev Med*. (2023) 64:452–8. doi: 10.1016/j.amepre.2022.09.012

5. Wild CP. Complementing the genome with an “exposome”: the outstanding challenge of environmental exposure measurement in molecular epidemiology. *Cancer Epidemiol Biomarkers Prev*. (2005) 8:1847–50. doi: 10.1158/1055-9965.EPI-05-0456

6. Chen SY, Hwang JS, Chan CC, Wu CF, Wu C, Su TC. Urban Air Pollution and Subclinical Atherosclerosis in Adolescents and Young Adults. *J Adolesc Health*. (2022) 71:233–8. doi: 10.1016/j.jadohealth.2022.03.004

7. Kahn LG, Philippat C, Nakayama SF, Slama R, Trasande L. Endocrine-disrupting chemicals: implications for human health. *Lancet Diabetes Endocrinol*. (2020) 28:703–18. doi: 10.1016/S2213-8587(20)30129-7

8. Landrigan PJ, Raps H, Cropper M, Bald C, Brunner M, Canonizado EM, et al. The Minderoo-Monaco Commission on plastics and human health. *Ann Glob Health*. (2023) 89:23. doi: 10.5334/aogh.4056

## Funding

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. KS was a specially appointed Professor of the Department of Environmental preventive medicine (Yamada Bee Company, Inc.), a corporate endowed course and he received financial support for the research and travel fee to participate at the course.

## Conflict of interest

The authors declare that one author received funding for travel from Yamada Bee Company. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article, or the decision to submit it for publication.

## Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

## Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmed.2024.1412674/full#supplementary-material

9. One Health High-Level Expert Panel (OHHLEP), Adisasmito WB, Almuhairi S, Behravesh CB, Bilivogui P, Bukachi SA, et al. One Health: a new definition for a sustainable and healthy future. *PLoS Pathog*. (2022) 18:e1010537. doi: 10.1371/journal.ppat.1010537

10. Wellbery C, Sheffield P, Timmireddy K, Sarfaty M, Teherani A, Fallar R. It's time for medical schools to introduce climate change into their curricula. *Acad Med*. (2018) 12:1774–7. doi: 10.1097/ACM.0000000000002368

11. Mendes IAC, Ventura CAA, Queiroz AAFLN, de Sousa ÁFL. Global health education programs in the americas: a scoping review. *Ann Glob Health*. (2020) 86:42. doi: 10.5334/aogh.2745

12. Grobon A, Huang F, Simon-Rivé G, Benoit L, Koual M. Environmental health in medical schools in France: A call from medical students. *J Visc Surg*. (2023) 161:21–4. doi: 10.1016/j.jviscsurg.2023.10.004

13. Jowell A, Lachenauer A, Lu J, Maines B, Patel L, Nadeau K, et al. A model for comprehensive climate and medical education. *Lancet Planet Health*. (2023) e2–3. doi: 10.1016/S2542-5196(22)00215-7

14. Horton R, Beaglehole R, Bonita R, Raeburn J, McKee M, Wall S. From public to planetary health: a manifesto *Lancet*. (2014) 383:847. doi: 10.1016/S0140-6736(14)60409-8

15. Zschachlitz T, Kümpfel R, Niemann H, Straff W. The implications of the concepts One Health and Planetary Health for the environmental medicine of the 21st century. *Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz*. (2023) 66:669–76. doi: 10.1007/s00103-023-03711-6

16. Institute of Medicine (US) Committee on Curriculum Development in Environmental Medicine, Pope AM, Rall DP. *Environmental Medicine: Integrating a Missing Element into Medical Education*. Washington (DC): National Academies Press (1995). Available at: https://www.ncbi.nlm.nih.gov/books/NBK231987/
17. Barouki R, Gluckman PD, Grandjean P, Hanson M, Heindel JJ. Developmental origins of non-communicable disease: implications for research and public health. *Environ Health*. (2012) 11:42. doi: 10.1186/1476-069X-11-42

18. Vermeulen R, Schymanski EL, Barabási AL, Miller GW. The exposome and health: where chemistry meets biology. *Science*. (2020) 367:392–6. doi: 10.1126/science.aay3164

19. Terayama H, Sakabe K, Kiyoshima D, Qu N, Sato T, Suyama K, et al. Effect of neonicotinoid pesticides on japanese water systems: review with focus on reproductive toxicity. *Int J Mol Sci*. (2020) 23:11567. doi: 10.3390/ijms2319 11567

20. Etzel RA, Landrigan PJ. *Textbook of Children's Environmental Health*, 2nd Edition. New York: Oxford University Press. (2024).

21. Poore KR, Hanson MA, Faustman EM, Neira M. Avoidable early life environmental exposures. *Lancet Planet Health*. CABI (2017) 5:e172–3. doi: 10.1016/S2542-5196(17)30048-7

22. Kassotis CD, Vandenberg LN, Demeneix BA, Porta M, Slama R, Trasande L. Endocrine-disrupting chemicals: economic, regulatory, and policy implications. *Lancet Diabetes Endocrinol*. (2020) 8:719–30. doi: 10.1016/S2213-8587(20)30128-5

23. Laing G, Duffy E, Anderson N, Antoine-Moussiaux N, Beber CL, Berezowski J, et al. Advancing one health: updated core competencies. In: *CABI One Health*. (2023).

24. Bevan J, Roderick P. Infusing climate change and sustainability into the medical school curriculum. *BMJ Opinion*. (2021) 4:100065.