The Environmental Justice League

Penn Nursing is committed to training the next generation of nurses on sustainability and the climate crisis, retooling its curriculum, transforming its physical footprint, and conducting research on how the environment affects vulnerable populations.

Sarah Hope Kagan, PhD, RN, FAAN, FGSA, AOCN, GCNS-BC has always focused her clinical practice and research on aging populations and the support systems they need to live healthy, fulfilling lives. A decade or so ago, she started integrating the climate crisis into this work.

“As nurses, if we don’t address what’s going wrong with planetary health and global heating, if we don’t look at the environment, air, soil, water, if we don’t think about sustainable health care, we’re all going to be in trouble,” says Kagan, the Lucy Walker Term Professor and a professor of gerontological nursing. “If we don’t act now, we’re going to miss our chance.”

“Environmental justice is all about looking at what’s been put upon vulnerable populations.”

Kagan isn’t alone in those feelings, and she’s one of a growing number of faculty, staff, and students at Penn Nursing who have incorporated climate and environmental justice into their research and syllabi, extracurriculars, and activism. The School itself has committed to this work at the highest level with support from Dean Antonia Villarruel, adding courses focused on the subject, creating a sustainability program, and more.

“Environmental justice is all about looking at what’s been put upon vulnerable populations,” says Assistant Dean Lucia DiNapoli, who co-chaired the school’s Green Team with Joseph Gomez, Director of Operations. “Nurses play a huge role in the mitigation of the impact on these populations. At Penn Nursing, we’re aiming to give students the ability to consider and have a clearer eye toward the inequities happening in health care spaces and in neighborhoods. It’s so important.”

The sustainability movement at Penn Nursing began subtly—with energy-saver reminder stickers on lights and sorting primers near recycling bins— championed by the school’s three Eco-Reps, which included Gomez. When he came on board in 2010, he joined DiNapoli and Jim Dorn from the finance department as the School’s delegates to the University-wide Penn Sustainability program, which focuses on greening offices and lab space.

“We leveraged every opportunity we could,” Gomez says. “When Penn Sustainability or, at the time, the Green Campus Partnership, offered pilots or initiatives, we’d raise our hand. All of those initiatives became conversation starters to get buy-in. That’s really where we started.”

Fortunately, Fagin Hall had just undergone a multi-year phased renovation. That meant a chance to think strategically about the environmental implications of the space and construction materials, to push for energy-efficient lighting and recycled carpeting, for instance, or a living landscape in the fourth-floor courtyard (still there today). For the Eco-Reps, the renovation offered a jumping off point to turn the school’s attention to the Green Office Program. “We wanted to create a culture of change around climate change,” Gomez says.

The appointment of Villarruel as Dean in 2014 gave the effort momentum; she challenged the School to become Penn’s first to achieve 100% Green Office certification, a goal it reached in 2017. A year later, she made the Green Team official—a standing committee of the School—with Gomez and DiNapoli at the helm.

Though the pandemic paused the efforts temporarily, the team is now full steam ahead again, regrouping and reenergizing to increase participant numbers on the committee itself, figuring out ways to communicate internally and share progress, and return to projects that had previously only partially materialized, like a full course on climate change and nursing and a sustainability-focused orientation program for incoming first years. They’ve also run two pilots in the simulation lab testing virtual and augmented reality as tools to not only teach students effectively but that could also limit waste in the process.

Kagan, in her role as Undergraduate Curriculum Committee Chair, is advancing how the School’s curriculum addresses environmental justice— and creates synergy with School efforts. “Where roads are placed, poor housing, poor attention to K through 12 education, lack of information for children and families to have agency for themselves— these all factor in,” DiNapoli says. “Student nurses are out in the environment in their clinical practice and their volunteerism, so everything and anything we can do to impact that knowledge base and that agency is crucial.”

17 partner institutions on 5 continents now participate in a virtual exchange program that launched in 2021.

Several courses in the School of Nursing already touch on this explicitly, like one Kagan teaches called “Comparing Health Care Systems in an Intercultural Context.” The class includes in-person clinical exchanges abroad at places like the University of Queensland in Australia. “When the pandemic broke, we had students there,” she says. Uncertain whether travel the following year would be feasible, Kagan and Peter Lewis, her counterpart at Queensland, started discussing ways to continue the exchange remotely.

With support from Penn Global and the help of Penn Nursing fourth-year doctoral student Nina Juntereal, BSN, RN and Advanced Senior Lecturer Maria White, MSN, RN, CCRN, the team launched its inaugural virtual exchange in spring 2021 focused on the effects of the pandemic. “At the end of that first year, we reflected on how it went and how we should move forward,” Kagan says. “I suggested we think about the climate crisis as a theme. We always thought this was going to be an exchange about global public health crises, and there is nothing bigger than the current climate crisis.”

From then on, the subject and the remote nature of the exchange became permanent. Emma Pascale Blakey, a nurse and recent chief sustainability officer clinical fellow for England’s National Health Service, joined as a content expert. Blakey, Juntereal, Kagan, and White now co-host the exchange and lead operations, including content delivery and course logistics for the dozens of people taking part in the exchange. “Human health is so intertwined with planetary health,” Juntereal says. “It’s a vital aspect to teach the next generation of nurses.”

Seventeen partner institutions on five continents now participate, and once a week for 11 weeks students learn from leaders around the globe on topics like clinical operations in green hospitals, environmental activism, and more. “We spend time walking them through the foundational knowledge—this is what the climate crisis looks like in health care— then we take it topic by topic, from reproductive health to mental health,” Kagan explains.

“As a profession, we’ve been trying to play catch-up for some time,” she adds. “That’s not a position that nurses or any other health professionals, for that matter, can maintain given what the science has shown us. Penn Nursing is part of a much larger movement saying we understand the interconnections between human health and environmental health.”

A new community-based course from Jennifer Pinto-Martin PhD, MPH, the Viola MacInnes/ Independence Professor of Nursing, and Monique Dowd, MA, RD, LDN, CDE, CSG, a lecturer in the Department of Biobehavioral Health Sciences, speaks directly to that. Partnering with the Penn Food and Wellness Collaborative and using Penn Park Farm as a learning laboratory, Pinto-Martin and Dowd plan to focus the class on how climate change affects food insecurity, as well as physical and mental health.

In addition, two other courses in the Penn Nursing undergraduate curriculum—“Health, Sustainability, Built Environment Design,” and “Environmental Health Issues and Global Implications,” a separate global engagement seminar that Jianghong Liu, PhD, RN, FAAN, taught in 2017 and 2018—put climate center stage. Liu, the Marjorie O. Rendell Endowed Professor in Healthy Transitions and faculty director of Penn Nursing’s Global Health minor, brought students to China to study the global implications of environmental health, capping a course that integrated environmental justice throughout. For the past two decades, Liu has also studied environmental exposure on health outcomes there.“

“Regardless of your race, background, or income, you should have the same environmental protections. But that’s not always the case.”

Liu has a background in maternal and child health, and she helped get off the ground two projects looking at lead exposure in early childhood, one in China in 2004 funded by the National Institute of Environmental Health Sciences and another in Philadelphia called the Health Brain Behavior Study in 2008. “I wanted to understand what happens to cognition and behavior when there’s consistent exposure,” she says. “What is the mechanism at play?”

In Jintan, a city in Jiangsu province on the eastern coast of China, industrial waste and air pollution put children in frequent contact with lead. There, Liu and colleagues recruited 1,600 preschool age children, participants they followed through late adolescence. In Philadelphia, the researchers, which included colleagues from Penn’s Perelman School of Medicine and the School of Arts & Sciences, recruited 450 11- and 12-year-olds.

Parsing the data collected—which, over the years, has included EEGs and brain imaging, as well as variables around environment toxicology, neurocognition, nutrition, demographic risk, and more—Liu has learned a significant amount about how lead affects young bodies and minds. “We determined that lead exposure was related to a drop in IQ and to behavior problems. We also reported that it affects sleep and nutrition,” she says.

A recently published study, done with Pinto-Martin and others, focused on heart rate and more specifically, the link between lead and the body’s physiological response to stress. They found that even limited contact with lead affected the heart’s ability to regulate. “Lead exposure is a risk factor for many different outcomes, but it doesn’t have to be someone’s destiny since there are many protective factors like good nutrition,” Liu says. To that end, she and Pinto-Martin are part of Penn’s Center of Excellence in Environmental Toxicology (CEET), the aim of which is to “identify environmental health questions of concern,” then mobilize experts to answer them.

The same could be said of work from Karen Glanz, PhD, MPH, the George A. Weiss University Professor of Epidemiology and Nursing and founding director of the Center for Health Behavior Research. Glanz focuses her attention on the intersection of psychology, public health, and epidemiology.

For the past 30 years, she’s worked on skin cancer prevention, and in 2021, was appointed to a National Academy of Sciences committee asked to assess the connection between sunscreen and impacts on aquatic environments, including damage to coral reefs. (The group found the current science inconclusive.) She’s also collaborated with CEET colleagues to analyze the effect of air pollution in low-income areas. “For many of these issues, environmental health and environmental science go head-to-head with human health,” Glanz says. “We need to find a balance between the two.”

Striking that balance between caring for patients and caring for the planet can be a challenge in health care, something the pandemic made abundantly clear as disposable PPE and other single-use resources became the greatest protection against a new and unknown virus. COVID-19 is still around, and it likely won’t be the last such disruption. “How can we move forward taking that into account, but also thinking about sustainability, environmental justice, and healthy living?” says PhD student Juntereal.

It’s a notion Kagan contemplates a lot. “For a long time, nursing writ large has imagined that health and well-being must come first, and we rarely made the connection between what we’re doing in health care, what we’re doing outside of health care—in our personal lives, communities, and the world—and how that all fits together,” she says. “In a strange way, a lot of what we do to help people maintain and recover their health and well-being can paradoxically harm it and the environment.”

This holds true for some communities more than others, another notion COVID-19 reinforced. “Regardless of your race, background, or income, you should have the same environmental protections, but that’s not always the case,” Liu says. Understanding and challenging those environmental inequities motivates Liu in her research, Kagan in her teaching, Gomez and DiNapoli in the work they do with the Sustainability Committee. And it’s what undergirds Penn Nursing’s momentum in this area.

“Nurses have always been social justice champions. They’ve always had an eye toward the environment. They live and work in these spaces and with populations in need,” DiNapoli says. “The question now is, where do we take the conversation from here? How do we dig even deeper to continue to integrate community, diversity, and justice? How do we bring it all together as opposed to keeping them separate? Environmental justice is right in the middle of all of that.”

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