Exploring Social, Economic and Environmental Determinants of Health
The Break the Cycle Program focuses on raising awareness of children's environmental health disparities
and on cultivating future leaders.
Past conference monographs and presentations are available here.
The Southeast PEHSU and Break the Cycle of Health Disparities, Inc. invites university students from a variety of disciplines to participate in our 16th Annual Break the Cycle of Children’s Environmental Health Disparities training program.
Theme for Break the Cycle 16 Symposium:
COVID 19 AND CHILDREN'S HEALTH DISPARITIES
COVID 19 has infected over 123 million people and killed nearly 3 million worldwide and in the USA over 30 million people have been infected and over 500,000 have died. Examination of those who have been infected and have died clearly points to a disproportionate impact on vulnerable populations such people living in low-income communities and from minority groups in the USA and around the world.
This symposium will explore the patterns of illness among different populations and use the knowledge gained to develop strategies to reduce health disparities and promote health equity for all children.
See the World Meter website for updates on COVID 19 statistics around the world.
Download the programs for Day 1 and Day 2
DAY 1 CONFERENCE PROGRAM:
TRAINEE PRESENTATIONS & KEYNOTE
DAY 2 PROGRAM:
INTERNATIONAL SYMPOSIUM ON
COVID-19 AND CHILDREN'S HEALTH DISPARITIES
Na’Taki Osborne Jelks,
Dr. Na’Taki Osborne Jelks is an Assistant Professor in the Environmental and Health Sciences Program at Spelman College in Atlanta, GA. Dr. Jelks investigates urban environmental health disparities; the role that place, race, and social factors play in influencing health; cumulative risk assessment; the impact of climate change on vulnerable populations, and the connection between urban watersheds, pollution, the built environment, and health.
She also develops, implements, and evaluates community-based initiatives that set conditions to enable low-income and communities of color to empower themselves to reduce exposure to environmental health hazards and improve health and quality of life. Jelks is particularly interested in approaches that engage environmentally overburdened communities in monitoring local environmental conditions, generating actionable data for community change, and developing effective community-based interventions that revitalize toxic, degraded spaces into healthy places.
Dr. Jelks co-founded the West Atlanta Watershed Alliance (WAWA), a community-based environmental justice organization that works to grow a cleaner, greener, healthier, more sustainable West Atlanta through authentic community engagement, organizing, education, community science, and participatory research. Since 2018 she has served on the National Environmental Justice Advisory Council (NEJAC), a federal advisory committee that works to integrate environmental justice into the Environmental Protection Agency’s programs, policies and activities as well as to improve the environment or public health in communities disproportionately burdened by environmental harms and risks.
Jelks studied Chemistry and Civil and Environmental Engineering at Spelman College and the Georgia Institute of Technology respectively before earning a Master of Environmental and Occupational Health degree at Emory University and a Ph.D. in Public Health at Georgia State University.
Linda Hansen, MD, MPH
Dr. Linda Hansen received her medical degree from Loyola University Chicago Stritch School of Medicine and completed her fellowship in Endocrinology, Metabolism and Molecular Medicine at Northwestern University Feinberg School of Medicine. She worked as a clinical endocrinologist in academia and large multi-specialty organizations for nearly 25 years.
Due to her growing concerns about adverse health effects from exposure to environmental endocrine disruptors, Dr. Hansen completed a Master of Public Health with concentrations in Environmental Health and Epidemiology at the University of Florida College of Public Health and Health Professions. Her children’s environmental health assessment for the DuPage County Health Department in Wheaton, Illinois launched the county’s Children’s Environmental Health Initiative. Her work on the initiative included educating primary care providers on associations of environmental exposures and adverse childhood health outcomes.
Dr. Hansen joined the Agency for Toxic Substances and Disease Registry (ATSDR) in Atlanta in September 2020 as Team Lead in the Environmental Medicine and Health Systems Intervention Section (EMHSIS) in the Office of Capacity Development and Applied Prevention Science (OCDAPS). She now serves as Chief (Acting) for the Section and as the ATSDR programmatic lead for the Pediatric Environmental Health Specialty Units (PEHSUs).
Martha Berger, MPA
Martha Berger started working at the Environmental Protection Agency as a Presidential Management Intern in 1984. Martha has a BA in Urban Studies from Vanderbilt University and a Masters in Public Administration from the University of New Orleans School of Urban and Regional Studies.
At EPA, Martha has experience working in budgeting, strategic planning and children’s environmental health issues. Currently at the EPA’s Office of Children’s Health Protection, Martha covers international issues for the Office of Children’s Health Protection and works with partners in health and in environment to promote understanding and research on the linkages between environment and health in the reproductive period and through childhood.
Martha ran the Children’s Health Protection Advisory Committee as the designated federal official for over ten years and is the EPA manager of the Pediatric Environmental Health Specialty Units. She is co-chair of the climate change subcommittee of the President’s Task Force on Environmental Health Risks and Safety Risks to children.
PhD, MPH, REHS, DAAS, CPO
Captain, U.S. Public Health Service
CDC National Center for Environmental Health
Captain (CAPT) Troy Ritter has served as a water quality subject matter expert with CDC’s National Center for Environmental Health since 2015. In this capacity, much of his time is spent investigating waterborne disease outbreaks, providing water-related technical assistance for state, local and tribal health authorities and responding to emergencies and disasters. He also manages an interagency agreement between CDC and the Indian Health Service’s Division of Sanitation Facilities Construction where he advises IHS leadership on tribal water quality issues. Prior to CDC, CAPT Ritter spent 16 years working for the Indian Health Service and the Alaska Native Tribal Health Consortium. Much of his career has been dedicated to addressing children’s health issues through improved access to water and better housing and air quality.
Catterina Ferreccio R.
Director MAUCO Cohort/Deputy Director Advanced Center of Chronic Diseases (ACCDiS).
Director PhD Program in Epidemiology
Department of Public Health/ School of Medicine
Pontificia Universidad Católica de Chile
I lead a research group, experienced in population-based epidemiological studies of health effects, in particular cancers, associated with chemical exposures (arsenic in drinking water, aflatoxins) and chronic microbiological infections (HPV, Helicobacter pylori, Salmonella typhi). Our field-epidemiology infrastructure includes strong ties with local universities, health systems and international collaborators. We actively participate in the public health implementation of our findings. We designed and conducted the first National Heath Survey 2003, and the first Chilean population-based large cohort and biobank of chronic diseases, the MAUCO cohort. We run a high impact master program in Epidemiology and we recently open the first Chilean PhD in Epidemiology program, which I direct. I am currently a member of the COVID19 advisory committee for the MoH and the President of Chile.
Publications: 177 peer-reviewed.
Funding: CONICYT, NIH.
MD MPH, MCM
Enrique Cifuentes is currently a Visiting Professor in the Department of International Health at the Mount Sinai School of Medicine.
From 2010 to 2019 he served the Harvard T.H. Chan School of Public Health. During his years at Harvard, he implemented exchange programs using innovative approaches to teaching and training that gave countless public health professionals from Latin American, the Caribbean, Canada, the US, and others an opportunity to learn in complex environments. He also developed teaching case studies for post-grad students from both Harvard’s Graduate School of Design and T.H. Chan School of Public Health.
Before joining the Harvard T.H. Chan School of Public Health, he conducted extensive research on water, sanitation and public health (including Dengue), particularly in Latin America and the US Mexico border. He also held academic appointments at the National Institute of Public Health (NIPH, 1995-2010) and the National Institute of Nutrition (1983-1994) in Mexico, as well as the Mount Sinai School of Medicine in New York (2008-2012). Between 1983-89 he directed a Primary Health Program in indigenous Nahuatl communities, Mexico.
Enrique Cifuentes holds an MD (National Autonomous University of Mexico, 1979); Masters in Community Medicine (1982) and a Ph.D., Epidemiology and Population Sciences, London School of Hygiene and Tropical Medicine, UK (1995).
Prof.K. Srinath Reddy
Prof.K. Srinath Reddy is the President, Public Health Foundation of India (PHFI) and
formerly headed the Department of Cardiology at All India Institute of Medical
Under his leadership, PHFI has established five Indian Institutes of Public Health (IIPHs) in different regions of India, to advance multi-disciplinary public health education, research, health technologies and implementation support for strengthening health systems.
He was appointed as the First Bernard Lown Visiting Professor of Cardiovascular Health at the Harvard School of Public Health in (2009-13) and presently serves as an Adjunct Professor of Epidemiology at Harvard (2014-2023).
He holds advisory positions in several national and international bodies and recently published a book Make Health in India: Reaching A Billion Plus.
He is also an Adjunct Professor of the Rollins School of Public Health, Emory University and Honorary
Professor of Medicine at the University of Sydney.
He is the first Indian to be elected to the National Academy of Medicine, USA and was awarded several prestigious international and national doctorates and fellowships. He was President of the World Heart Federation (2013-15). He is a Padma Bhushan awardee. He is also an Advisor to the
Governments of Odisha, Punjab, Haryana and Andhra Pradesh on Public Health.
Tabia Henry Akintobi,
Tabia Henry Akintobi, PhD, MPH is Professor of Community Health and
Preventive Medicine, Associate Dean of Community Engagement, and
Principal Investigator and Director of the Prevention Research Center.
Germane to these efforts is her demonstrated excellence in community-based participatory research, community-engaged public health practice and experiential learning among trainees across the health professional career development pipeline. She received her Bachelor’s degree from the University of Miami and earned both a Master’s of Public Health and Doctorate of Philosophy in Public Health from the University of South Florida’s College of Public Health.
As Principal Investigator of the Centers for Disease Control and Prevention- funded Morehouse School of Medicine Prevention Research Center Dr. Henry Akintobi demonstrates leadership in local, national and global community-engaged clinical and translational evaluation and research collaborations and methodologies addressing health disparities, thereby contributing to related science and practice. She leads or collaborates in several federal (CDC, OMH, NIH) and privately- funded initiatives that model community-driven research, including but not limited to the Georgia Clinical and Translational Science Alliance (formerly Atlanta Clinical and Translational Institute’s Community Engagement and Research Program) and The Exploratory Center of Excellence on Health Disparities.
Her public health leadership is also evident through appointments to national task forces designed to shape the science and practice of effective community-based participatory- and translational-research and collaborations bridging the gaps between basic, clinical and community-based stakeholders to address disparities and advance health equity. Among them include the National Institutes for Health National Center for Advancing Translational Sciences Collaboration and Engagement Taskforce Lead Team, designed to advance team science towards becoming a major academic model in more equitable community-academic partnership -from research conceptualizing to dissemination.
Dr. Akintobi’s leadership is demonstrated through local, national and global clinical and translational research, training, and service initiatives addressing social and public health disparities and advancing health equity. Her repertoire of effective collaboration is evidenced by several federal grants where she serves as principal investigator or primary collaborator. She is also central to noteworthy research infrastructure grants, including the Atlanta Clinical and Translational Institute Community Engagement and Research Program and the Exploratory Center of Excellence on Health Disparities, where she leads community engagement key functions central to ensuring bi-directional research translation between communities and academic researchers.
She is a regularly invited speaker and lecturer and has received several awards for outstanding public health research leadership and teaching. Dr. Akintobi conducts these activities incorporating her expertise and dedication to effective community-engaged research, social marketing and participatory evaluation.
Dr Barbara Laughton
Dr Laughton is a developmental pediatrician with 20 years experience in neuro-developmental and behavioral assessments of infants and children, including 12 years in a formal research setting, in Cape Town South Africa.
She first started working with children with Cerebral Palsy and the neuro-developmental follow up of high risk graduates from the neonatal ICU. Based at the Family Centre for Research with Ubuntu, Tygerberg Hospital, Cape Town, South Africa, she is co-principal investigator responsible for the longitudinal neuro-cognitive and the neuro-imaging study on the Cape Town participants of the CHER (Children with HIV Early AntiRetroviral treatment) trial. She has set up a neurodevelopmental assessment team that is respected by local and international pediatric researchers (educational psychologist, research psychologist, pediatric neuroradiologist, developmental pediatrician, research assistants).
She is one of few developmental pediatricians with such an extensive experience in conducting assessments in children with HIV in South Africa, and the use of culturally appropriate assessment tools for a number of projects.
Department of Paediatrics and Child Health
Faculty of Medicine and Health Sciences
Terri D. McFadden,
Dr. McFadden is a General Pediatrician and a Professor in the Department of Pediatrics at the Emory University School of Medicine. She is also the Director of primary care initiatives with PARTNERS for Equity in Child and Adolescent Health and an attending physician in the Primary Care Center at Children’s Healthcare of Atlanta, Hughes Spalding Campus. She is board certified by the American Board of Pediatrics and is a Fellow of the American Academy of Pediatrics where she recently served on the Executive Committee of the national Council on Early Childhood and currently serves as Immediate Past President of the Georgia Chapter. Her academic and professional interests include health equity, early childhood adversity, comprehensive care for the underserved, childhood injury prevention, early literacy/early brain development, and medical education. She is a graduate of Spelman College and the Johns Hopkins School of Medicine.
AGENDA: DAY 1
Zoom Program for April 19, 2021
8:30 AM - 3:30 PM
8:30 AM Welcome
Abby Mutic, PhD, CNM, Director SE PEHSU Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta GA
8:35 Message from ATSDR Linda Hansen, MD, MPH Chief (Acting), Environmental Medicine and Health Systems Intervention Section Office of Capacity Development and Applied Prevention Science (OCDAPS) Agency for Toxic Substances and Disease Registry (ATSDR) Centers for Disease Control and Prevention (CDC)
8:40 Message from US EPA Martha Berger, MPA Office of Children’s Health Protection US Environmental Protection Agency
8:45 Introduction to Break the Cycle Leslie Rubin, MD, Director, Break the Cycle Program Morehouse School of Medicine, Atlanta GA
Break the Cycle 16 Trainee Presentations
9:00 Exposure to Ambient Air Pollution and Fetal Growth Outcomes
Deniz Cataltepe, BA, MPhil
Mentor: Akhgar Ghassabian, MD, PhD
University of Massachusetts Medical School
9:20 Does Early Life Phthalate Exposure Mediate Racial Disparities in Children’s Cognitive Abilities?
Marisa Patti, MHS
Mentor: Joseph M Braun, RN, MSPH, PhD
Brown University School of Public Health, Department of Epidemiology
9:40 Health Break
Phthalate Exposure in Children: Assessing the Knowledge, Attitudes,
and Behaviors in Families with Low Socioeconomic Status
Rachana Charla, BS
Mentor: David Collier, MD, PhD
East Carolina University, College of Arts and Sciences, Department of Biology
10:10 Obesity Among Children from Low and Middle Income Families
Shannon C Conrey, MS
Mentor: Ardythe Morrow, PhD
University of Cincinnati College of Medicine, Department of Environmental and Public Health
10:30 6 Month Outcomes of Malnourished Children enrolled on the Nutritional Therapeutic Programme in a periurban informal settlement in Cape Town, South Africa
Suzanne Kerswill, MBChB
Mentor: Etienne Nel, FCPaed
University of Stellenbosch, Paediatrics
10:50 Health Break
COVID 19 Perspectives
11:00 Gender and Ethinicity’s Influence on Food Access Choices and Experiences
Jeffrey Hwang, BS
Mentor: Saskia Cornes, PhD / Catarina Martinez, PhD
Duke University, Trinity School of Arts and Sciences, Department of Environmental Science
11:20 Investigating Children’s Mental Health and Access to Green Space as a result of COVID-19
Sharmi Amin, BA
Mentors: Heather Stapleton, MS/PhD / Catherine Kastleman, MS / Kate Hoffman, PhD
Duke University, Trinity School of Arts & Sciences, Department of Environmental Science
COVID-19 on Children Attending Large Low-Income Urban Public
Nadav Sprague, MPH
Mentor: Andrew Rundle, DrPh, MPH
Columbia University, Mailman School of Public Health, Epidemiology
12:00 The Effects of COVID-19 on Incarcerated Youth
Mentors: Rebecca Fry,PhD and Elaine Cohen Hubal, PhD
University of North Carolina at Chapel Hill, College of Arts and Sciences, Department of Mathematics
12:20 PM Health Break
12:35 Virtual Poster Session and Lunch
1:50 Health Break
2:00 Keynote Address Environmental Justice: a Personal Perspective with Solutions Na’Taki Osborne Jelks PhD Spelman College
Improving Neighborhood Quality to Help End Health Disparities
Han Oo, BS
Mentor: Julie Herbstman, PhD
Columbia University, Mailman School of Public Health
Better Managing Waste from CAFOs can Break the Cycle of Emissions
Exposure for Local Residents, Particularly Young Children
Meera Chakrabarti BA
Mentors: Charlotte Clark, PhD / Tanja Vujic, J.D.
Duke University, Trinity School of Arts and Sciences, Department of Environmental Science
3:10 Summary Remarks Leslie Rubin, MD
3:20 Awards Presentation
3.30 Day 1 Conclude
AGENDA: DAY 2
Zoom Program for April 20, 2021
8:30 AM - 12:30 PM
INTERNATIONAL SYMPOSIUM ON COVID-19 AND CHILDREN'S HEALTH DISPARITIES
8:30 am Welcome and Introduction
Leslie Rubin MD Morehouse School of Medicine
COVID 19 and Children’s Health Disparities: Global Perspectives
8:50 am Troy Ritter PhD, MPH, REHS, DAAS
Centers for Disease Control and Prevention (CDC)
Water and Sanitation Disparities among Alaska Native and American Indian Populations and COVID 19
9:05 am Barbara Laughton MBChB DCH(SA) FCPaed(SA) MSc PhD
Stellenbosch University, Cape Town, South Africa
COVID 19: Challenges Experienced in South Africa.
9:20 am Catterina Ferreccio, MD MPH
Pontificia Universidad Católica de Chile
COVID 19 Disparities in Chile.
9:35 am Enrique Cifuentes MD MPH MCM
Mount Sinai School of Medicine
Social Determinants of Health in Megacities: Are we Prepared for the Next Pandemic?
9:50 -10:30 am Panel Q&A
10:30 am Break
COVID 19 and Children’s Health Disparities: Reaction and Action
Srinath Reddy MD DM
Public Health Foundation of India (PHFI)
Impacts of COVID 19 on CEHD in India
11:00 am Tabia Henry Akintobi PhD, MPH
Morehouse School of Medicine
COVID 19 and African Americans: Child Health Equity and the Path Forward.
11:15 am Terri D McFadden MD, FAAP
Emory University School of Medicine
Helping our Children to Recover after COVID 19
11:30 – 12:10 am Panel Q&A
12:10 pm Concluding Remarks
12:30 pm Adjourn
Environmental Health Disparities
Children who grow up in circumstances of social and economic disadvantage are at greater risk for exposure to adverse environmental factors and are more likely to suffer adverse health and developmental consequences. Break the Cycle supports an interdisciplinary set of student-driven research projects that explore the environmental, economic and social factors that adversely affect children’s health and creatively develop strategies to promote the health of children and, thereby, Break the Cycle of Children’s Environmental Health Disparities.
About the Program
Students are required to work with academic mentors from their respective university programs to submit a proposal on how they would develop a project to Break the Cycle. All proposals will be reviewed, and a limited number will be selected based on relevance to the cycle of environmental health disparities, creativity, feasibility, and strength of the project plan. Those selected will have the opportunity to work with the Break the Cycle faculty and other students from around the country and internationally, to see the project to completion and present their research results and findings at an annual conference in Atlanta scheduled for the spring of 2021. There will be monthly conference calls to review projects and provide perspectives and guidance on the projects. During these conference calls, faculty and students will have the opportunity to communicate and collaborate with their counterparts in other disciplines at other universities. Students will also be required to write a scientific paper on their project which will be published in an international peer-review journal as well as a chapter in a book
Who Can Apply
Students from all disciplines and training levels are encouraged to apply. This includes undergraduates, graduate students, medical residents, and fellows.
A History of Success
Since the inception of the Break the Cycle program in 2004-2005, have we partnered with over 40 different university departments in 11 States in the USA as well as internationally, and have supported research for over 120 students.
We have had 11 monographs published in international journals and 11 books.
In 2012 we conducted a survey of past students who rated their experience with Break the Cycle valuable, and many continued to pursue careers related to their Break the Cycle projects.
If you have any further questions, feel free to contact firstname.lastname@example.org or our Project Coordinator, Nathan Mutic at email@example.com and we will be happy to discuss potential projects with you.
Best wishes for success.
A Grief Group for Today’s Teens: Using Human-Centered Design to Develop an Evidence-Based Intervention for Teens Who Have Lost a Parent
Presenters: Julia Chavez BA, University of Chicago Pritzker School of Medicine
Amelie Liu, University of Chicago Laboratory School
Mentor: Alexis Barnes MIPH, University of Chicago School of Social Work
City of Atlanta Parks and Recreation Equity Dashboard: A Data-driven Tool for Prioritizing Investments in Under-resourced Neighborhoods
Presenter: Diamond Spratling, MPH, Emory University, Atlanta Georgia
Mentor: Giselle Sebag, MPH, LEED ND, Global Cities Consultant at Bloomberg Associates: Advancing Healthy, Sustainable & Inclusive Cities for All,
New York, New York
Multigenerational ACEs and Youth Health Outcomes
Presenters: Sarah Allen Ray, M.Ed. and Austin Yoders
Mentor: Dr. David Wood MD MPH
Department of Pediatrics, Quillen College of Medicine, East Tennessee State University
Johnson City, Tennessee
Examining Protective Parenting Practices in the Association between Prenatal
Stress and Infant Cognitive Functioning
Presenter: Elaine Johnson
Advisor: Patricia Brennan, PhD, Department of Psychology, Emory University,
An Exploration of Food Pantries and Food Insecurity among Families with
Children during the COVID-19 Pandemic
Presenters: Kailey Clinton, Martha Rayner, BS
Mentor: David Buys, PhD, MSPH, CPH, FGSA, State Health Specialist, Mississippi
Description of CPACS/Cosmo Interventions to Bridge the Gap of Children’s
Health Disparities Caused by Covid-19 Pandemic.
Presenter: Alexis Nkusi, MBBS MPH,
Emory University Rollins School of Public Health, CPACS Cosmo Health Center,
Mentor: Amitha Sampath, MD, MPH, FAAP. Compliance Officer and COVID-19
Testing & Vaccine Team Lead, CPACS Cosmo Health Center, FQHC,
Interrupting the Cycle of Pollution and Poverty in Glynn County, Georgia,
through Youth Education
Presenter: Aaron Bell
Mentors: James B. Deemy Ph. D., College of Coastal Georgia and
Rachael Thompson, Director, Glynn Environmental Coalition
Enabling the Transition to Young Adulthood in Individuals with Cerebral Palsy
Presenter: Deirdre Flanagan, Yale University, New Haven, Connecticut
Mentor: Michael E. Msall MD, JP Kennedy Research Center on Intellectual and
Neurodevelopmental Disabilities, and Emma Lynch MPH, Come Children’s Hospital
Section of Developmental and Behavioral Pediatrics, University of Chicago,
Evaluating the Birth Outcomes of Pregnant Women Living with HIV Attending an Antenatal Clinic in Cape Town, South Africa, Compared to Those Who are not Living with HIV.
Name: Lindie Rossouw MB,ChB, DCH, DipHIVman
Mentor: Barbara Laughton, MBChB, DCH, FCPaed, MSc, PhD
Family Research Centre with Ubuntu
Stellenbosch University, Cape Town, South Africa.
Neighborhood Safety and Sleep During Childhood
Presenters: Lauren Gullett, B.S. and Nyree Riley, B.S.
Primary Mentor: Dr. Chandra L. Jackson, Ph.D., M.S.,
Secondary Mentor: Dr. Symielle A. Gaston, Ph.D., M.P.H.
Epidemiology Branch, National Institute of Environmental Health Sciences,
An analysis of the impact COVID-19 has had on Food Insecurity in Relation to
Children’s Health Outcomes
Presenter: Piper Alexander
Mentor: Nicole Coffey Kellett, PhD. Department of Anthropology, University of Maine at
Breaking the Cycle of Disproportionate Access in Healthcare: Being Black and
Brown in the United States During COVID-19
Presenters: Paige L. Moore, MSW, James Y. Kim, MPA
Mentor: RaJade M. Berry-James, PhD, School of Public and International Affairs, North
Carolina State University,
Raleigh, North Carolina
Black Women’s Environmental Wellness Project, Increasing Environmental
Health Literacy to Protect Kids Health
Presenters: Morgan Barns, Sahdeja Serieux, Eunheh Koh
Mentors: April Reid, Abby Mutic, Jemea Dorsey
Center for Black Women’s Wellness
Nell Hodgeson Woodruff School of Nursing, Emory University,
Please email firstname.lastname@example.org if you have any questions
Break the Cycle of children’s Environmental Health Disparities is a program featuring students from universities around the country who will present their projects on strategies to improve the quality of life for children who grow up under adverse social, economic and environmental circumstances.