1. health and fitness

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COURSE BLUEPRINT: SPPH DL2
DRAFT – Subject to change
Course Title: SPPH 522 DL2
Course Credits and Duration: 3 credits
Course Type: Blended
Calendar Description:
This course is a survey of approaches to understanding and
assessing environmental health topics and an introduction to
specific issues of importance to the public health practitioner.
Environment is approached as one of the determinants of health for
individuals and human populations. Methods for evaluation of
environmental health including exposure assessment, toxicology,
epidemiology, risk assessment and standards are introduced.
Exposures to chemical, biological and physical hazards in air,
water, food and solid waste are considered while global climate
change, sustainability and urban/ecosystem health are included as
overarching issues. The course emphasizes prevention rather than
treatment of human illness with specific emphasis on measures and
programs currently in place in Canada to address risks from
environmental hazards.
Prepared by: Michael Brauer
Department: School of Population and Public Health
Date: November 4, 2013
1. Student/audience description:
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This course is designed for graduate students or upper-year undergraduate students.
2. Course objectives/outcomes
At the completion of the course, students are expected to be able to:
 Discuss environmental determinants of health within the population health
paradigm.
 Explain the main scientific and legal approaches used to assess potential
environmental health hazards. Discuss the benefits and limitations of these
approaches with reference to specific hazards. Describe the major
agencies/organizations involved in environmental health protection in Canada and
internationally and explain their basic responsibilities.
 Explain how risks are perceived by the public and how risk perception can be
incorporated into the management of environmental health risks
 Describe fundamental principles by which contamination of specific media (air,
water, soil, food) may impact human health. Support this description with specific
examples.
 Discuss examples of the effectiveness of interventions to mitigate impacts of
environmental contamination on human health.
 Discuss major human health impacts associated with global environmental
change, including an understanding of important uncertainties.
 Explain the linkages between public and ecosystem health and apply the
ecosystem approach to health to the management of an emerging environmental
health hazard.
 Analyze at least one current environmental health issue of concern to assess its
potential health significance and the scientific, social and legal/political
approaches to its management.
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3. Course Structure
Module 1: Introduction to environmental health and available tools
Topics:
1.1 Introduction and history of environmental health.
Learning Objectives: At the end of this session students should be able to
 Describe the general role and magnitude of environmental influences on health in
Canada and globally.
 List and define common metrics used to assess disease burden
 List and describe key determinants of health
1.2 Tools
1.2.1.
Exposure assessment, GIS
1.2.2.
Epidemiology
1.2.3.
Toxicology
Learning Objectives: At the end of this session students should be able to
 Demonstrate the application of exposure assessment, toxicology and
epidemiology to the assessment of environmental health hazards.
1.3 Risk assessment, perception, communication, and management
Learning Objectives: At the end of this session students should be able to
 Describe the basic components of the risk assessment/risk management paradigm
used by many government agencies.
 List some common uses of risk assessment
 Perform a simple risk assessment for an environmental hazard
 List key factors influencing public perception of risk and use these to explain how
a given risk source is likely to be perceived
1.4 Environmental Health in Canada: federally and locally
Learning objectives: At the end of this session students should be able to
 Differentiate and describe the roles of major Canadian agencies/organizations
involved in the protection of environmental health.
 List and describe the services provided through Health Protection programs in
Regional Health Authorities
 Discuss how Health Protection services provided by Regional Health Authorities
align with services provided and regulations enforced by other levels of
government and departments other than Health.
Module 2: Media-specific environmental contamination
Topics:
2.1 Food contamination and food security
Learning objectives: At the end of this session, learners should be able to
 Describe the major sources of foodborne illness in Canada
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 List the major regulatory and other programs designed to protect food safety in
Canada and describe their respective roles.
 Provide examples of linkages between the food production system and health and
discuss how changes in this these systems related to health risks.
2.2 Water
Learning objectives: At the end of this session, learners should be able to
 List the major drinking water contaminants of concern in the context of a source
to tap approach to drinking water quality
 Describe and provide an example of the multiple-barrier approach to protection of
drinking water
 Provide examples of health impacts in BC, Canada and globally related to
drinking water contamination
2.3 Waste Management and Soil
Learning objectives: At the end of this session, learners should be able to
 Classify the various types of waste and describe the environmental health
concerns associated with each.
 List pathways by which solid waste and soil can impact human health
 Discuss the policy challenges associated with the management of contaminated
sites.
2.4 Outdoor Air
Learning objectives: At the end of this session, learners should be able to
 Describe the major air pollutants that contribute to population health impacts
 Discuss the types of evidence suggesting relationships between air pollution and
mortality
 Explain the general mechanisms by which particulate matter exposure affects
cardiovascular disease
2.5 Indoor Air
Learning objectives: At the end of this session, learners should be able to
 List the major air pollutants that contribute to population health impacts
 Discuss the utility of traditional hygiene approaches and exposure limits with
regard to typical indoor air quality issues
 Discuss management strategies for specific indoor air quality issues of concern
2.6 Physical Hazards
Learning Objectives: At the end of this session learners should be able to
 Describe the major source of exposure to ionizing and non-ionizing radiation
 Describe health risks associated with community noise exposure
 Discuss the application of the precautionary principle with respect to exposure to
physical hazards.
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Module 3: Sustainability and global issues
Topics:
3.1 Climate change and other global issues
Learning Objectives: At the end of this session learners should be able to:
 Provide examples of current and past global environmental health issues of
importance
 Describe the successes, failures and tradeoffs in addressing global environmental
health issues
 List the major health impacts associated with climate change – globally and in
Canada, including estimates of relative uncertainty of occurrence.
3.2 Disasters and Learning from mistakes
Learning Objectives: At the end of this session learners should be able to:
 Describe general trends in occurrence and impact of natural and technological
disasters
 Discuss common factors inherent in major technological disasters
 Describe what happened in significant technological disasters of the last 50 years,
including examples of lessons learned.
3.3 Sustainability and Ecosystem Health
Learning Objectives: At the end of this session learners should be able to:
 Provide a working definition of sustainability and apply it to global and local
contexts
 Describe the major barriers to global sustainability and their general trends over
time
 Discuss the ecosystem approach to health and compare it to traditional biomedical
approach
 Discuss trends in major indicators related to global environmental health
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4. Course materials and components
The course manual includes a list of required and optional readings. For most sessions
there is also a background text including links to highlight key points, short quizzes and
discussion points.
Textbook: The required text for this course is Environmental Health: From Global to
Local edited by Howard Frumkin (2nd Edition, 2010). The text, while still US-focused
has a more global perspective than most texts. Still, given that no Canadian
environmental health text book exists, this text is best used to describe general principles
and concepts and as a reference. We will post links to more specific and more Canadian
material on the course website and highlight Canadian issues and approaches during class
discussions. A limited number of copies of the text have been pre-ordered and are
available at the UBC Bookstore (in the SPPH section) at a cost of approximately $100.
Free (unlimited) online access to the text is available via the Vancouver Public Library
for anyone with a library card – the online version has no page numbers, so I have added
chapter/section headings to the syllabus so you can find the relevant sections.
Reading requirements for specific sessions are listed in the course schedule. In addition,
I have attached an extensive list of additional readings and will also post links to related
topical readings in the current scientific literature on the course website. These are
especially useful for student presentations and assignments and to provide more
detailed/current information on specific topics. Lastly, for each topic, recent news articles
are given to provide real-life examples of the topics covered in this courses.
Course website
The course CONNECT site will include all faculty presentations as well as student
presentations. Students are required to email their presentation to
michael.brauer@ubc.ca by 10 p.m. on the day before their in-class presentation. News
items of interest and related to course material (see above) will also be posted on the
website along with optional, but recommended, readings.
5. Assessment and Assignment
Assessment of student performance will be through participation in class discussions,
selected topic oral and written presentation and assignments.
Evaluation w ill includ e:
Participation d uring in class sessions (15%)
Participation d uring online d iscussions/ online posts w hich answ er the
d iscu ssion questions (15%)
Assignm ents (3 x 15% = 45%). 1 assignm ent p er m od ule
Ind ivid ual p roject / presentation (25%)
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Your participation mark will be based upon your active contribution to online and faceto-face class discussions. For a participation mark of 75% you are expected to speak at
least once (a comment or a question) in every face-to-face session and provide at least
one comment for each online discussion. Higher participation marks require sustained
contributions to class discussions and/or bringing insight from your own reading or
experiences to discussions.
Completed assignments must be submitted to the course dropbox and must be received
by due date and time.
Without ad vance notification of class absence, no consid eration w ill be given for
late assignm ents or m issed class sessions (i.e. stud ents w ill be given a zero for
participation and any assignm ents that are d ue). No late assignments will be
accepted without approval in advance from the instructor.
Attendance during ALL face-to-face sessions is expected from all students. Poor
attendance and/or poor participation in class discussions (both online and face-to-face)
will be reflected in marks for participation. If you are unable to attend a face-to-face
session it is the student’s responsibility to notify the instructor in advance (whenever
possible). UBC accommodates students whose religious obligations conflict with
attendance, submitting assignments, or completing scheduled examinations. Please let
the instructor know in advance, preferably in the first week of class, if you will require
any accommodation on these grounds. As per UBC policy, those d isplaying flu
sym ptom s are being ad vised to self-isolate, w hich m eans staying hom e and
lim iting contact w ith others, includ ing not going to w ork/ school for at least 24
hours after the fever is gone. Stud ents w ho d isplay flu sym p tom s should contact
the instructor as soon as possible regard ing assignm ents and class attend ance.
Individual Project:
The individual project in this course consists of three components:
1) Prepare a 15 minute presentation based on your selected topic. Where applicable
the presentation should include a discussion of the tools used to address the
problem (i.e. exposure assessment techniques, major epidemiological/
toxicological studies relative to problem), the legal, political and social issues
affecting the problem and its management, and identification of the major
agencies (government and non-governmental) involved. According to the dates
and times given in the class presentation schedule posted on the class CONNECT
site, you are to give your presentation online during a synchronous session with
other students. The presentations will be recorded and posted on the class website,
so that they can be viewed by other students who are unable to attend the online
synchronous session.
2) Lead a class discussion (20 minutes) during one of the in-person class sessions.
This discussion should focus on the questions you introduced during your
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presentation, but you should also be ready to discuss other questions posed by
your fellow students.
3) Provide a written summary (3 pages, suggested; 5 pages absolute maximum –
including references; single spaced OK - 12 point font and minimal 1 inch
margins) of your presentation, including analysis, conclusions and
recommendations. Be sure to cite references.
Assessment of presentations will be based on:
 the quality and thoroughness of your research. You will need identify and
complete additional readings (review articles where available and/or some of the
primary literature) and understand the issue. Be prepared also to use sources
beyond PubMed (e.g. government reports, Web of Science, etc.).
 your analysis of the problem. You will need to think about the issue and analyze it
critically. We are especially interested in your critical analysis of the available
scientific and policy information and on your ability to apply it to the specific
topic. You will need to assimilate information from different sources and include
it in your analysis. Simply reporting summaries of information taken from other
sources is NOT critical analysis.
 the organization of your written and oral presentation. You will need to concisely
and convincingly present your analysis
 your ability to identify key points for discussion and on effective leadership of the
class discussion.
Written Assignments:
In this course, there are 3 assignments which must be submitted by email to
<michael.brauer@ubc.ca> and must be received by due date and time. Please request
that instructor confirms receipt of the assignment.
A portion of each written assignment will require the use of additional resources besides
the course text. Many relevant readings are already posted on the course website which
will continue to be updated throughout the course.
Answer each question using readings, lecture notes, your own thoughts AND any
additional references you wish to cite. Support your answers with evidence (including
references) wherever possible. Maximum 1 page for EACH numbered question (not
including references). Equal weight is given to all questions. Please be sure to read the
questions in their entirety!
Online Activities:
Online activities are to be completed on the online discussion forum, as described at the
end of the background section for some topics. These online activities should be
completed during the week which is dedicated to that topic, and without exception prior
to the corresponding face-to-face session.
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Self-assessment short-answer and multiple choice questions (not marked)
Throughout the background reading material, short-answer questions and multiple choice
questions are provided. The short-answer questions are designed to make you think about
the topic in greater depth, and possibly devise an option about a challenging issue. The
multiple-choice questions are intended as a method of self-test. Neither the short-answer
or multiple choice questions will be marked. However, it is highly likely that the themes
covered in these questions will be discussed in class, and you will be expected to be
familiar with these topics and/or websites.
6. Instructor and Teaching Assistant:
Michael Brauer, ScD
Phone: 604 822-9585
e-mail michael.brauer@.ubc.ca
Office: 366A SPPH, 2206 East Mall
(office hours - scheduled online synchronous sessions TBA; contact by email and inperson office hours by appointment)
The role of the instructor is to facilitate learning during the course. This will be
accomplished by stimulating discussions during face-to-face sessions, delivering content
during face-to-face sessions and monitoring and contributing to online discussions. The
Instructor will have overall responsibility for course evaluation.
The teaching assistant will be responsible for maintenance of the course website,
monitoring online discussion, and be the one with primary responsibility for evaluation of
written assignments under the direction of the Instructor.
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7. How to proceed through the course
The course is grouped in three modules, which each contain several course topics. It is
strongly recommended that students work through one topic each week, according to the
class schedule provided. Without exception, students should work through all the
material in each module prior to the corresponding face-to-face session. This includes
completing all required readings and background text, participating in online discussions,
viewing (synchronous or asynchronous online video content), completing online quizzes
and required preparation for face-to-face sessions.
Each topic has
 a background section
 short-answer and/or multiple questions aimed at making the student consider a
topic in more depth, or as a method of self-test
 news articles providing recent real-world examples of the topics covered
 a list of required readings
 supplementary readings
 an online activity section (not all topics have one of these)
In addition to the work conducted independently or online, students are required to attend
all three face-to-face course sessions. During each face-to-face session students will
participate in discussions and group exercises based on their work completed for each
topic. As described above, there will also be one written assignment for each module and
all students will complete a project consisting of preparing background material on a
specific topic (to be assigned by Instructor), delivering this content to fellow students and
leading an in-class discussion or exercise on this topic during a face-to-face session.
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8. Sample of a lesson/topic and assignment
FOOD CONTAMINATION AND FOOD SECURITY
Learning objectives:
At the end of this session, learners should be able to
 Describe the major sources of foodborne illness in Canada
 List the major regulatory and other programs designed to protect food safety in
Canada and describe their respective roles.
 Provide examples of linkages between the food production system and health and
discuss how changes in this these systems related to health risks.
Background:
Food and health
Food can impact health in many ways:
 Disparities in food availability via overall excess or deficiency
 Nutrient excess and deficiency
 Contamination with microorganisms/toxins
 Chemical contamination (unintentional) through packaging, accidental
contamination, bioaccumulation
 Food additives: agricultural/processing, residues, (intentional)
Looking back on the article from Ezzati et al. 2002, which of these food-health
relationships is responsible for a greater burden of illness in Canada and globally?
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2802%29114036/fulltext
Foodborne illness in Canada
Major factors in foodborne illness
 Improper heating, cooking, refrigeration, storage
 Food handler hygiene
 Lag between preparation and serving
 Raw food / contaminated food without further cooking
 Cross-contamination
In Canada it has been estimated that there are 1.3 episodes/person annually of foodborne
illness1, with a large degree of under-reporting (Underreporting varies by
pathogen/symptoms) – 1 in 10 to 1 in 50 cases reported2 . Only a fraction (~10%) of
1
Majowicz et al, Magnitude and distribution of acute, self-reported gastrointestinal
illness in a Canadian community. Epi Infect. 2004;132:607-17.
2
Majowicz SE et al. Estimating the Under-reporting Rate for Infectious Gastrointestinal Illness in
Ontario. CJPH. 2005;96(3):178-181
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cases that are experienced actually result in a physician visit. Of these, roughly 50% have
stool samples taken for analysis and of the stool samples that are analyzed ~10% result in
a positive identification that are then reported to provincial public health authorities and
therefore officially recorded.
Food regulation in Canada is governed both federally by the Canadian Food Inspection
Agency (http://www.inspection.gc.ca/eng/1297964599443/1297965645317) as well as
provincially by the Ministry of Health, the BC Centre for Disease Control and the BC
health authorities (http://www.health.gov.bc.ca/protect/ehp_foodprotection.html).
Furthermore, Canada must also reach international food standards put forth by the World
Health Organization and the Food and Agriculture Organization of the United Nations
(FAO) (http://www.codexalimentarius.net/web/index_en.jsp)
Vancouver Coastal Health provides the public with information regarding inspections of
restaurants, food facilities, and stores. Visit this site and review at least three detailed
reports and closure lists.
http://www.vch.ca/your_environment/food_safety/
In 2010, a report comparing food safety performances ranked Canada 4th out of 17
countries considered. Although Canada was ranked highly with respect for Consumer
Affairs and Recalls, it was ranked as 15th out of 17 for traceability and management.
(Table 2 in the report)
Hazard Analysis and Critical Control Points (HACCP)
The Hazard Analysis and Critical Control Points (HACCP) is a systematic preventative
approach to food safety. HACCP can be used at any point in the food chain – from
production up to consumption. Many of you will certainly be familiar with this process if
you have worked in the food industry. Traditionally, HACCP has specific governing
principles which aim to identify hazards in the food chain which can lead to an unsafe
final product, implement corrective action, and maintain accurate records of procedures.
A thorough discussion of HACCP and these principles is provided in your text (Chapter
18).
Maple Leaf Foods Outbreak
The most recent serious foodborne illness outbreak in Canada occurred in August 2008,
with two cases of listeriosis (Listeria monocytogenes) reported at a Toronto area nursing
home. Over the next 2 weeks a food safety investigation linked these cases to ready-toeat meats produced at a Toronto Maple Leaf Foods plant. During the investigation, maple
Leaf food voluntarily recalled two products which was then expanded to other products
from the same line. In total, 192 products were recalled. Production resumed in
September 2008 with a "hold and test protocol.” 57 confirmed and two probable cases of
illness: 21 deaths in which listeriosis was linked to products from plant. machines
identified as likely source (now disassembly protocol; enhanced testing. Despite the
seriousness of the outbreak, the response from the company has been cited as a model of
effective risk communication. Do you agree?
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Following the Maple Leaf Foods outbreak (see video 1 and video 2), Canadian food
safety practices have been questioned (Holley et al, CMAJ). For example, critics contend
that: 1)the Canadian food safety system is reactive, and has not kept pace with new
knowledge. 2)The Food-borne illness surveillance is passive patchwork of regional
systems feeding poor quality data on illness outbreaks into database on notifiable
infectious diseases. At present, food operations are now inspected at three government
levels to different standards.3)Surveillance ignores large sporadic illness component,
which is more useful in discovering the major sources of illness and developing policy to
manage them. 4)The food protection system must address changes in pathogens (identity
or antimicrobial resistance) and foods as they evolve. Holley et al suggest a)Smarter, not
more, inspection b) More efforts directed towards campylobacter (poultry, beef) c) More
irradiation and freezing of foods Further, given that most cases of food-borne illness are
acquired in restaurants and residential homes; education and training in food handling
and preparation must continue to be a high priority
Chemical contamination
Chemical contamination of food can occur via “naturally” occurring contaminants (e.g.
contamination of shellfish), agricultural additives (pesticides, fertilizers, antibiotics) or
unintentional introductions of contaminants into the food supply (e.g. Hg, PCBs, PBDEs
in fish, melamine).
Pesticides: Registration (PMRA) – conducts risk assessment and benefits and efficacy
assessment using manufacturer-supplied input data. Maximum Residue Limits are set by
Health Canada. Residue testing/screening on foods conducted by CFIA. Random
sampling to verify compliance with MRLs (>250 compounds; >200,000 tests/yr). In
addition to pesticides screening includes veterinary drugs, agricultural chemicals,
industrial/environmental pollutants, natural toxins. Surveillance testing conducted to
confirm presumptive positive samples and identify suspected contamination. Samples
from 5 separate shipments are tested – 1 violation leads to compliance phase. Compliance
phase: involves ban on importation and notification to country of origin
[http://www.inspection.gc.ca/english/fssa/frefra/safsal/cmlmce.shtml] and removal from
market until 5 shipments tested (at expense of grower/importer) and meet MRL
Food security - Global food consumption and production trends
While there has been increased average consumption globally due to increased
production and extensive international trade, there are few opportunities for increased
agricultural land and most importantly, limited water available for irrigation. Further, the
increases in food yields have coincided with increasing reliance on monocultures which
may lead to ecological damage and decrease food security (loss of indigenous crops, loss
of diversity) in the long term. Further, increased yields have typically required increased
energy and resource use as well as increased irrigation. Thus, the sustainability of
“modern” agriculture has been questioned. Further, the increasing globalization of food,
while reducing some disparities in food availability has led to increasingly global food
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contamination/foodborne illness events (e.g. BSE) and may discourage regional/local
food production/food security. The FAO released a report in 2011 highlighting the
impacts of the world food crisis of 2006-2008, demonstrated the particular vulnerability
of the world’s poorest countries. A provocative article in Science suggests a blueprint for
future global food security:
Comment on the assertions in the article. If the suggested approaches are followed, what
are the implications for Canada/BC?
Genetically Modified Foods:
Most experts include GM foods as necessary for future global food security.
 Risks
◦ “gene escape” to wild plants
◦ development of resistant pests
◦ allergen introduction (or elimination)
▪ labeling
 Potential Benefits
◦ Increase agricultural productivity
▪ Reduced pesticide/fertilizer use
▪ Reduced land use
◦ Increased food production
▪ likely to make LDCs more dependent
Organic Foods
No pesticides, synthetic fertilizers, antibiotics released into environment. Potential health
issues related to use of of biosolids (sewage sludge) – although not allowed for most
“certified organic” foods. Yields may be lower than conventional (non-organic)
agriculture. However, despite the recent boom in this industry, the health benefits of
organic foods compared to conventional foods remain unclear. A recent review of the
evidence concludes that there is a lack of strong evidence that organix foods are
significantly more nutritious than convention foods, although consumpton of the former
may reduce exposure to pesticide residues and antibiotic-resistant bacteria3
Multiple Choice / True or False
1. Over half of food-borne illnesses are reported to health agencies (True/False)
2. Internationally, Canada is ranked highly for its food safety performance
(True/False)
3
Smith-Spangler et al. Are Organic Foods Safer or Healthier than conventional alternatives?: A
systematic review. Ann Intern Med. 2012;157(5)348-366.
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3. The HACCP approach usually also suggests an inspection of the finished product
(True/False)
4. Which of the following is not believed to be a potential risk associated with the
use of genetically modified foods
1. “gene escape” to wild plants
2. development of resistant pests
3. increased cost of food
4. allergen introduction (or elimination)
What's in the news:
 Germany Says Bean Sprouts Likely E.Coli Source – NYTimes (2012)
 Feeding the World_How Much is Enough _ The Economist (2011)
 What's on your plate? Canada lags in tracing food for safety and profit
Required Readings:
 Ch 18: 635-667, 674-682 (Food Safety- full chapter except Food Safety Agencies
and Institutions)
 Ch 17: 609-618 (Pesticides; Patterns of Pesticide Use; Pesticide Toxicity)
 Ch 11: 346-350 (Agriculture; Food Security)
 Michael Pollan. The Vegetable-Industrial Complex. October 15, 2006, The New
York Times Magazine
Additional Resources:
 Holley RA.Smarter inspection will improve food safety in Canada.CMAJ. 2010
Mar 23;182(5):471-3.
 Godfray HC, Beddington JR, Crute IR, Haddad L, Lawrence D, Muir JF, Pretty J,
Robinson S, Thomas SM, Toulmin C. Food security: the challenge of feeding 9
billion people. Science. 2010 Feb 12;327(5967):812-8. Review.)
 Achievements in Public Health, 1900-1999: Safer and Healthier Foods MMWR
October 15, 1999 /48(40);905-913 http://www.cdc.gov/mmwr/preview/mmwrh
 Video: http://www.ted.com/talks/carolyn_steel_how_food_shapes_our_cities.html