LUNG CANCER IN NEPAL: THE ROLE OF TRADITIONAL TOBACCO PRODUCTS AND COMBUSTION RELATED HOUSEHOLD AIR POLLUTION

The burden of chronic diseases such as cancer is increasing in low and middle income countries around the globe. Nepal, one of the world’s poorest countries, is no exception to this trend, with lung cancer as the leading causes of cancer deaths. Despite this, limited data is available on the environmental and behavioral risk factors that contribute to the lung cancer etiology in Nepal. The objectives of this dissertation are to: 1) investigate the ethnic differences in consumption of local tobacco products and their role in lung cancer risk in Nepal; 2) evaluate urinary metabolite of 1,3-butadiene as a biomarker of exposure to combustion related household air pollution (CRHAP); 3) investigate the association between CRHAP exposure and lung cancer risk using urinary metabolite of 1,3-butadiene as a biomarker of exposure; 4) investigate the association between CRHAP exposure and lung cancer risk using questionnaire based measure of exposure. Lung cancer cases (n=606) and frequency matched controls (N=606) were recruited from B.P. Koirala Memorial Cancer Hospital. We obtained biological samples and information on lifestyles including cooking habits and type of fuels used. We used liquid chromatograph tandem mass spectrometer (LC-MS/MS) to quantify urinary metabolites of 1,3-butadiene in urine samples. We employed a combination of logistic and linear regression models to detect any exposure-disease associations while controlling for known confounding variables. Overall, we found that ethnic groups in Nepal use different tobacco products that have different differing cancer potency -we observed the highest odds ratios for the traditional tobacco products. The biomarker analysis showed strong evidence that monohydroxybutyl mercapturic acid is associated with biomass fuel use among participants. However, we did not find significant association between urinary MHMBA and lung cancer risk. When we used questionnaire based measure of exposure to household air pollution, we observed significant, dose-response associations between CRHAP exposure and lung cancer risk, particularly among never-smokers. Our results show that important role of local tobacco products in lung cancer risk in Nepal. Furthermore, we demonstrate that CRHAP exposure is a risk factor for lung cancer risk, independent of tobacco smoking.

Integrating Environmental Justice and Social-Ecological Resilience for Successful Adaptation to Climate Change: Lessons from African American Communities on the Eastern Shore of the Chesapeake Bay

This research concerns the conceptual and empirical relationship between environmental justice and social-ecological resilience as it relates to climate change vulnerability and adaptation. Two primary questions guided this work. First, what is the level of resilience and adaptive capacity for social-ecological systems that are characterized by environmental injustice in the face of climate change? And second, what is the role of an environmental justice approach in developing adaptation policies that will promote social-ecological resilience? These questions were investigated in three African American communities that are particularly vulnerable to flooding from sea-level rise on the Eastern Shore of the Chesapeake Bay. Using qualitative and quantitative methods, I found that in all three communities, religious faith and the church, rootedness in the landscape, and race relations were highly salient to community experience. The degree to which these common aspects of the communities have imparted adaptive capacity has changed over time. Importantly, a given social-ecological factor does not have the same effect on vulnerability in all communities; however, in all communities political isolation decreases adaptive capacity and increases vulnerability. This political isolation is at least partly due to procedural injustice, which occurs for a number of interrelated reasons. This research further revealed that while all stakeholders (policymakers, environmentalists, and African American community members) generally agree that justice needs to be increased on the Eastern Shore, stakeholder groups disagree about what a justice approach to adaptation would look like. When brought together at a workshop, however, these stakeholders were able to identify numerous challenges and opportunities for increasing justice. Resilience was assessed by the presence of four resilience factors: living with uncertainty, nurturing diversity, combining different types of knowledge, and creating opportunities for self-organization. Overall, these communities seem to have low resilience; however, there is potential for resilience to increase. Finally, I argue that the use of resilience theory for environmental justice communities is limited by the great breadth and depth of knowledge required to evaluate the state of the social-ecological system, the complexities of simultaneously promoting resilience at both the regional and local scale, and the lack of attention to issues of justice.