2010 San Francisco Medicine

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SAN FRANCISCO MEDICINE April 2010 Volume 83, Number 3 Medicine and the Environment: Practice, Prevention, and Policy

12FEATURE A Climate ARTICLES Change for the Better 4MONTHLY Membership COLUMNS Matters

13 FromLinda OutBirnbaum, in the WorldPhD, and to JohnUnder Balbus, the Skin MD, MPH 5 Classified Ad

7 Executive Memo 15 TedScientific Schettler, Support MD, MPH for Endocrine Disruption

9 President’sMary Lou Licwinko, Message JD, MHSA 17 LorettaCan Plastic Doan, Hurt PhD, You? and Linda C. Guidice, MD, PhD

Michael Rokeach, MD, and Steve 19 WilliamThe Weight H. Goodson of Evidence: III, MD, Chemicals and Shanaz and Dairkee, Obesity PhD 11 EditorialHeilig, MPH

20 J.P.Is Ignorance Myers, PhD Bliss? Measuring My Own Toxins Philip R. Lee, MD; Steve Heilig, MPH; 34 Hospitaland Michael News Lerner, PhD

22 MercuryLarry B. Silver, Update MD 2010 38 In Memoriam: Edgar Wayburn

23 ChemicalJane Hightower, Policy MD Reform: A Clinical Perspective William S. Andereck, MD

36OF INTERESTBook Review: 25 GinaThe NavigationM. Solomon, Guide: MD, MPH The Science Behind Practice Slow Death by Rubber Duck

Patrice Sutton, MPH; Jeanne Conry, MD, PhD; Pablo Rodriguez, MD; and 37 PublicSteve Heilig, Health MPH Report: 27 TraceyTaking Woodruff, Action to PhD, Prevent MPH Harm: County Medical Associations Antibiotics (Still) at Risk

28 VitaminRobert Gould, D and MD, Calcium and Cindy Russell, MD Steve Heilig, MPH Toxic Matters Brochure on Page 26 Toxic Matters 31 BiomonitoringWilliam B. Grant, Update PhD It is with great pleasure that we share with you , the UCSF Program on Reproductive Health and the Environment’s (PRHE) new print and online publication designed to help people avoid exposure to toxic substances that are present in our daily 32 CountingDavis Baltz, Roaches MS, and Sharyle Patton Toxic Matters lives. A pullout version of the brochure is located on page 26. is a nontechnical guide that provides evidence-based recommendations for preventing exposure to environmental substances with adverse reproductive Editorial Philip and Landrigan, Advertising MD, Offices: MSc and developmental health impacts. 1003 A O’Reilly Ave., San Francisco, CA 94129 The online version of this brochure, as well as further resources, is available on the Phone: (415) 561-0850 extension 261 Toxic Matters e-mail: [email protected] Web: www.sfms.org program’s website, www.prhe.ucsf.edu/prhe/tmlinks.html. If you would like more infor- Advertising information is available by request. mation on , including information on getting copies for groups, seminars, clinics, etc., please e-mail [email protected] or visit the website at www.prhe.ucsf.edu. www.sfms.org April 2010 San Francisco Medicine 3 Membership Matters

April 2010 Volume 83, Number 3 A Sampling of Activities and Actions of Interest to SFMS Members

Guest Editors Philip R. Lee Managing Editor Amanda Denz Join the Fight to Protect Medicine Copy Editor Mary VanClay CMA’s 36th Annual legislative Leadership Conference of the Department of Public Health. Dr. Chow has been president of the Commis- Editorial Board Tuesday, April 27, 2010 sion and will now serve as vice president. Obituarist Nancy Thomson CMA Legislative Day 2010 is sched- Commissioner Chow is an internist and Stephen Askin Shieva Khayam-Bashi uled for , at the the executive director of the Chinese Toni Brayer Arthur Lyons Sheraton Grand Hotel in Sacramento Community Health Care Association. Linda Hawes Clever Ricki Pollycove (please note the new date). The SFMS is again pleased and proud to Gordon Fung Stephen Walsh At the conference, you will hear have someone of Dr. Chow’s knowledge Erica Goode about the issues facing medicine in and distinction so intimately involved California from an impressive array of with health services in San Francisco.

SFMS Officers experts who live and breathe the politics He is currently the only physician on the President Michael Rokeach and policy on these issues. Armed with 2010Commission. SFMS Seminar Schedule President-Elect George A. Fouras this knowledge, you will then head to Secretary Peter J. Curran the Capitol to meet with legislators to Treasurer Keith E. Loring make sure the voice of doctors is heard In conjunction with Practice and Liability Immediate Past President Charles J. Wibbelsman in Sacramento. Will you join us? Consultants The 2010 Conference will feature the Contact Posi Lyon at plyon@sfms.

SFMS Executive Staff new Speaker of the Assembly, John Perez, org or (415) 561-0850 extension 260 for Executive Director Mary Lou Licwinko who will discuss the latest political hap- more information or to register. Advance Director of Public Health & Education Steve Heilig penings in the Capitol, and Robert Hertz- registration is required. Director of Administration Posi Lyon berg, Speaker Emeritus of the Assembly, Customer Service/Front Office Director of Membership Therese Porter who will give insight on proposed struc- TelephoneTuesday, May 11, Techniques/Difficult 2010 Director of Communications Amanda Denz tural reforms to our state government. Patients Skills Learn about the 2010 budget and its effect

Board of Directors on health care from key officials who put Term: Jan 2010-Dec 2012 Roger Eng the budget together. Get the latest from This half-day practice management Gary L. Chan Thomas H. Lee CMA’s Center for Government Relations seminar provides valuable training to Donald C. Kitt Richard A. Podolin on legislation and how it will affect physi- enable your staff to handle front desk Cynthia A. Point Rodman S. Rogers cians. Meet directly with your legislators tasks and patients both efficiently and Adam Rosenblatt or their staff on issues that affect your professionally. Physicians and managers Lily M. Tan Term: Jan 2008-Dec 2010 practice and your patients. You will be should not assume their staff members Shannon Udovic- Jennifer H. Do provided with talking points and other inherently have customer service/patient Constant Shieva C. Khayam-Bashi resourcesPlease to bring allow your for a whitesuccessful coat. visit. relations skills. This seminar gives them Joseph Woo William A. Miller the tools for positive patient relations that Jeffrey Newman enhance the practice. Term: Jan 2009-Dec 2011 Thomas J. Peitz 9:00 a.m.–12:00 p.m. (8:40 a.m. Contact Therese Porter in the Mem- registration/continental breakfast) Jeffrey Beane Daniel M. Raybin Andrew F. Calman Michael H. Siu bership Department to RSVP, at tporter@ $95 for SFMS/CMA members and their Lawrence Cheung sfms.org or (415) 561-0850 extension staff ($85 each for additional attendees 268 for information about appointments from the same office); $150 each for

CMA Trustee Robert J. Margolin sfms with our p legislators.ast-President edward Tellnonmembers. Us Why You Are a Member! AMA Representatives Chow reappointed to Health H. Hugh Vincent, Delegate Commission Robert J. Margolin, Alternate Delegate SFMS is launching a new member- driven promotional campaign and needs Edward A. Chow, MD, has been reap- your help. The campaign, entitled “Why pointed to an unprecedented sixth term I’m a Member,” will draw exclusively on the San Francisco Health Commission, upon quotes from members about their 4 San Francisco Medicine April 2010 the governing and policy-making body experiences with SFMS. www.sfms.org To help get this Membership Matters

The San Francisco Medical Society Advocating for Physicians and Patients campaign off the ground, we are asking you to share memorable moments, sto- As San Francisco Medical Society members know, since its inception in 1868 SFMS has ries, and anecdotes that exemplify why been an activist organization when it comes to the health of our community. Many projects you are a member of SFMS.Membership Please keep Direc all- and activities that have begun in San Francisco have gone on to have implications for the state torysubmissionsSan Francisco under 200 Medicine words. We will be and the nation. Here are some highlights from the current SFMS community health agenda. including these in the , in , and on the Agenda for 2010 website. E-mail submissions or questions to Jonathan Kyle, [email protected]. We thank you for your participation • Preserving the safety net and public health programs in times of severe budget cuts. andStay look Informed forward andto hearing Help from SFMS you Go • Testifying in support of antitobacco legislation and San Francisco’s law banning the Green! sale of tobacco in pharmacies. With the California Medical Association, submitting amicus brief opposing lawsuit to overturn the ban. • Working with Mayoral Task Force to develop and support the Healthy San Francisco Make sure SFMS has your e-mail program and participating in the lawsuit to preserve the program. address (SFMS does not share its mem- • Providing physicians for medical consultation for the San Francisco Unified School bers’ e-mail addresses). You can add this District. information to your membership profile • Participating in the Hep B Free program in San Francisco and educating physicians by going to the Member Log-in section of SFMSand patients Community on prevention Health and treatment Activities of hepatitis B. the website at www.sfms.org, by contact- ing the Membership Department at (415) UNIVERSAL ACCESS TO CARE: 561-0850 extension 268, or by e-mailing [email protected] Your Mailboxes! SFMS leaders have long advocated that every San Francis- can should have access to quality medical care, and our representatives served on the Mayoral Membership Task Force that designed the Healthy San Francisco program. SFMS joined in the lawsuits to Directory and Physician Desk Reference The 2010–2011 SFMS preserve that program as well. SFMS members advocated for, and even created, community clinics dating back to the original Haight-Ashbury Free Clinics in the 1960s. ANTI-TOBACCO ADVOCACY: will be going out in late May. This important resource is a benefit of membership SFMS advocates were in leadership roles in the banning and is free to active SFMS members. of tobacco smoking in San Francisco restaurants, ahead of the rest of the state and nation; we Dedication advocate for ever-stronger protections from secondhand smoke, for removal of tobacco products from pharmacy settings, for higher taxes on tobacco products, and more. SFMS signed San Francisco Medi- onto an amicus brief in support of upholding San Francisco’s law banning the sale of tobacco cine in pharmacies. This issue of HIV PREVENTION AND TREATMENT: , appropriately focused on environmental health issues, is dedicated The SFMS was at the center of medical advocacy to the memory and legacy of Edgar for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, appropriate tracking and reporting, optimal funding, and more. Wayburn, MD, former president of SCHOOLS AND TEEN HEALTH: the SFMS and Sierra Club as well as a SFMS helped establish and staff a citywide school health former editorSan of Francisco this journal. Chronicle He died in March at the age of 103 and leaves education and condom program, removed questionable drug education efforts from high what the schools, and worked on improving school nutritional standards; it provides ongoing medical rightly calls “a towering legacy.” See consultation to the SFUSD school health service. In addition, SFMS has authored a resolution allowing minors to receive vaccines to prevent STIs without parental consent. his full obituary on page 38. ENVIRONMENTAL HEALTH:

SFMS’s many environmental health efforts include estab- Space for Rent lishing a nationwide educational network on scientific approaches to environmental factors in human health and advocating for the reduction of mercury, lead, and air pollution exposures. REPRODUCTIVE HEALTH AND RIGHTS: ON-CAMPUS medical space at St. Mary’s (650) 282-4620 or SFMS has been a state and national leader [email protected]. in advocating for women’s reproductive health and choice, including access to all medical- 4 San Francisco Medicine April 2010 www.sfms.org www.sfms.org indicated services. April 2010 San Francisco Medicine 5 SAN FRANCISCO MEDICINE __04_01_10__ 8.5”wide x 11”high 0UBC8222PRV_PrivateBank_SFM

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49141_SFM.indd 1 3/10/10 3:47:18 PM Executive Memo

Mary Lou Licwinko, JD, MHSA

Reform: The Medical View

n March 21, the United States Congress passed a historic health care reform bill. The SFMS and CMA worked O diligently to help craft the legislation to best serve immediately to eliminate the Medicare SGR formula, update the the interests of physicians and their patients. There were several payment localities (GPCI), overturn the Independent Medicare important provisions added or deleted from the bill because of Board, and improve the quality reporting programs in follow-up SFMS/CMA efforts, but there is still work to be done. The day legislation this year. following the bill’s passage, CMA President Brennan Cassidy, MD, We will continue that fight as we shift to the implementation sent the following letter to all members of the CMA, summing up phase of health care reform. There is much to be done before the current position of CMA on the bill: this bill goes into effect. The success of health care reform will ultimately be measured by the actions of the federal regulators tasked with interpreting and implementing the legislation. The Yesterday a historic Congressional vote was taken. Regard- legislative and regulatory implementation of this bill will be a less of your political persuasion or whether you supported or lengthy and difficult process. CMA will continue to be involved opposed the health care reform legislation just enacted by Con- in every aspect. gress, we should all acknowledge the significance of this moment Once again, I urge all of us to set aside our personal political for our patients. Health care will go through major changes as a views. If we dwell on the past or shake our heads in disappoint- result of this legislation and we have a significant obligation to ment that the bill failed to do everything we wanted, we will be vigilant and ensure that its implementation really works for fail to take advantage of this moment. We will have failed our our patients. As your president, I can assure you that my fellow patients and our fellow physicians who need us to assure them officers and I, and your CMA trustees, have set aside our personal that we will keep advocating on their behalf. We cannot allow politics to advocate for you and your patients. ourselves to be overwhelmed by the uncertainty of change, but CMA fought for and gained some significant improvements rather we must lead because it is our responsibility as physi- in the final health care reform bill but obviously fell short on cians. some of our policy goals. We expanded coverage for more than Thank you all for your leadership, your advocacy with your 5 million Californians, ended some insurance company abuses, Congressional Representatives, and your continued commit- and provided substantial increases for primary care and rural ment to CMA. surgeons in Medicare and Medicaid. We will be relentless in our Sincerely, J. Brennan Cassidy, MD fight to complete our unfinished business. Congress must act President, California Medical Association Welcome New Members!

Michael Burns, MD Referred by Gerald Gellin, MD The San Francisco Medical Society would like to welcome the following new members: anessa Kenyon, MD Referred by Aditi Mandpe, MD , Michiko Shibata, MD Referred by Eric Tabas, MD V , Dennis Song, MD , Jeanne Tyan, MD , University of California Davis, 2004 Thomas Haddad, MD Referred by Gary Chan , The Permanente Medical Group David Petruska, MD , Stephanie Po, MD , The Permanente Medical Group Transferred from the Alameda-Contra Costa Medical Association , The Permanente Medical Group

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SF_1251.indd 1 2/22/10 4:23 PM President’s Message

Michael Rokeach, MD, and Steve Heilig, MPH

A “Historic Step Forward”?

T he United States has often been said to have the best health to all Americans and improving our nation’s health system. Every care system in the world. That may be true for many people, day physicians see the devastating effect being uninsured has on such as those who have health insurance, access to state- the health of patients. Physicians dedicate their lives to helping of-the-art clinicians, and other services. But, of course, too many patients, and we have an historic opportunity now to do just that. have not had such access. Thus our nation’s prolonged struggle “While the House-passed bill isn’t perfect, we cannot let the to increase access to care and to improve the various health in- perfect be the enemy of the good when it comes to something as dicators, some of which lag far behind other developed nations. important as the health of Americans.” After more than a year of partisan political warfare and rheto- The California Medical Association has provided a more de- ric ranging from high-minded to hateful, Speaker Nancy Pelosi tailed summary of the legislation. For patients who are concerned, and colleagues sentNew President York Times Obama the Patient Protection and CMA notes, “If you like your insurance, you can keep it; grandfa- Affordable Care Act, which had been “resurrected like Lazarus” (in thers in all existing coverage, including health savings accounts.” the words of the ) from what seemed inevitable The “Insurance Industry Reforms” bear printing here almost legal euthanasia just a short time before. And, surprising nobody, in full: requires health plans to spend 85 percent of revenue on President Obama signed it into law. Thus ended round one of the direct patient care versus profit and overhead; requires adequate latest season of “health care reform.” provider networks; requires plans to publicly disclose information While it might surprise some to see this as only round one, on claims payment policies, enrollment, denials, rating practices, the numerous legal, procedural, and practical challenges already out of network cost-sharing, and enrollee rights; prohibits plans underway force us to continue to advise that we must not hold from denying coverage for pre-existing conditions; prohibits plans our collective breath when it comes to seeing real results soon. from rescinding coverage when a patient becomes ill; prohibits But some significant changes are likely to survive the challenges, plans from setting annual or life-time limits on benefits. and most of these might be quite positive. There is much more detail, of course, which cannot be cov- This is why mainstream or even “conservative” groups like ered here. the AMA, Consumers Union, and AARP endorsed this legislative The total costs of the new package are still unclear and will package. depend on many future factors. But the evidence-based impetus The primary intent of the law is to provide for coverage to for all this effort is that access to care is a powerful factor in qual- more than 30 million uninsured Americans by 2019, using both ity and length of life. Also, most everyone agrees that the health private and public insurance. In the lengthy political process, a insurance industry has long been in need of corrective regulation. much-debated “public option” was an early casualty. Hospitals, Beyond that, controversy will continue, and how it all plays out the pharmaceutical industry, and—to a lesser extent—health still remains to be seen. But as no “death panels” are in sight, and insurers all gained concessions to make the legislation more no real government takeover or “socialism” seems discernable in palatable to their bottom lines. Testy topics such as coverage for the legislation, it is doubly shameful how nasty the public debate illegal immigrants and abortion funding saw compromises that became, over proposals that even polls showed most Americans will satisfy few—and might yet be “corrected.” For physicians, favored. But such is democracy, the worst political system other numerous improvements were also achieved, including admin- than all the alternatives. istrative simplification for “Physician Billing in Private Sector” All of us should at least be hopeful that the benefits of these requirements, encouraging MICRA-type tort reform, financial reforms will outweigh the costs—to the whole system but espe- incentives for primary care, and more. cially for patients, which really means all of us. If so, our nation The AMA, which gave the legislation “qualified support,” might actually move closer to truly having the best health care issued this statement from AMA President J. James Rohack, MD: system in the world, one with more Americans having full access “Historic passage of health system reform by the U.S. House of to care within it. Representativeswww.sfms.org is an important step toward providing coverage April 2010 San Francisco Medicine 9 Independent But Not Alone.

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SF Med Society (Dr. Yoss).indd 1 2/3/10 9:22:40 AM Editorial

Philip R. Lee, MD; Steve Heilig, MPH; and Michael Lerner, PhD

Better Living through Chemistry?

R eform is in the air, whether we are talking about health of the health impacts of both newly developed and industrial San Franciscocare, banking, Medicine or the American political system itself. For chemicals now in use.” The AMA also will “encourage the training Medicine and the Environment, the theme of this issue of medical students, physicians, and other health professionals of , this is true as well. Change can be on the human health effects of toxic chemical exposures.” frightening, but it is change that can give us hope—even though, In this realm, Europe is leading the U.S. There, scientists and as with health care in general, “reform” can mean many things government have worked together to develop new safety and and can take many years. regulatory approaches to chemicals, where applications for use In 2002, the SFMS hosted a landmark conference focused of new chemicals would be evaluated to see if additional test- on the emerging science of industrial chemicals and their im- ing or restrictions are needed. The new European approach— pacts on human health. At that meeting, an international net- termed REACH (Registration, Evaluation, and Authorization of work of scientists, clinicians, patients, environmental advocates, Chemicals)—seems reasonable. This is not a fringe or radical and others was formed. In the eight years since, the Collaborative movement. Europe’s leading medical associations called for on Health and the Environment (CHE) has presented interna- stricter testing and regulation of chemicals. Such mainstream tional conferences, conference calls featuring leading figures in support from the medical profession reflects the ever-growing the field, and much more. conviction that improvement is warranted. We should note that When we take or prescribe most any medication, we as- this AMA policy originated in part here at the SFMS. sume it has been tested, not only for effectiveness but also for It took more than four decades to get from the United States safety. That is one of the primary roles of the U.S. Food and Drug Surgeon General’s first major report on tobacco in 1964 until Administration, and it reflects both medical ethics—the Hip- FDA regulation was achieved in 2009. As with tobacco, simi- pocratic dictum “First, do no harm”—and what most educated lar scenarios of delay and obstruction have hindered healthy modern people would see as common sense, as in the more changes in policy regarding proven toxins such as lead, mercury, parochial slogan, “Better safe than sorry.” PCBs, and alcohol. But experience shows what with concerted, In another important arena, however, the reverse has sustained attention to scientific evidence, and with action based been the common approach. With more than 85,000 industrial upon that research, progress is possible. chemicals registered for use in modern life and thousands more The modern industrial age has brought incalculable benefits added yearly, very few have been tested before use to make sure to humans. It has also brought some harms. We can no longer they are not hazardous to our health. afford, nor should we tolerate, “business as usual” in this regard. Our understanding of links between individual toxicants With a rational chemicalSan policy Francisco in place, Medicine we may yet see, without and diseases varies widely. The well-known examples of lead, qualification, an era of “better living through chemistry.” mercury, some pesticides, and environmental tobacco smoke, In this edition of , we offer perspec- for example, are proven. Recent research on bisphenol A (BPA), tivesPhilip and information R. Lee is chancellor from some and professor leading figures of medicine in the (emeritus), environ- a widely used chemical in plastics, has reached the point where Universitymental health of California, field. San Francisco; professor emeritus, Stanford mainstream medical organizations now urge its removal from University; former United States Assistant Secretary of Health and our environment and bodies. At any point along our lifespan, Human Services; and chairman of CHE. Steve Heilig is on the staff of “from womb to tomb,” chemical exposure, even at extremely the San Francisco Medical Society and the Collaborative on Health low levels in some cases, can result in health problems—sooner and the Environment and is coeditor of the or later. . Michael Lerner is president of Commonweal and In 2008, the American Medical Association called upon the vice chair of the Collaborative on Health andCambridge the Environment. Quarterly For of federal government “to implement a comprehensive chemicals moreHealthcare on CHE, Ethics see www.healthandenvironment.org. policy that is in line with current scientific knowledge on human andwww.sfms.org environmental health, and that requires a full evaluation April 2010 San Francisco Medicine 11 Medicine and the Environment

A Climate Change for the Better

Federal Initiatives on Climate Change and Health

Linda Birnbaum, PhD, and John Balbus, MD, MPH

4 W ith Washington, D.C., buried that the news on climate change is not nent greenhouse gas, carbon dioxide. under more than two feet of necessarily all bad, and that reducing Reducing black carbon emissions by pro- snow and Congress seemingly greenhouse gases has the potential to viding the developing world with cleaner paralyzed by the discussion of health care provide significant benefits to human cookstoves or installing diesel particulate and economic reforms this winter, one health, saving both lives and dollars in filters would provide the double benefit might have been tempted to believe that the process. Last November, scientists of improving health while immediately the human health impacts of climate and government officials from the United reducing the warming potential of the change have been lost in the blizzard of States and Great Britain came together in atmosphere. One caveat, however, is that other federal public health concerns. But Thean “across Lancet the pond” teleconference event where there is black carbon, there is often instead we can write today about the new to mark the release of a special issue of sulfur. Because sulfate aerosols have a and renewed federal efforts to address 2 that contained a series of stud- cooling effect on the atmosphere, diesel these broad impacts—efforts taking ies conducted in London and Delhi dem- particulate filters that require low-sulfur the form of research and interagency onstrating that significant health benefits diesel fuel may provide mixed benefits initiatives, which are emerging like the could result if measures were taken to for climate, since they would reduce crocuses under the leafless trees. As reduce greenhouse gases from household both warming and cooling air pollutants. spring arrives and these initiatives begin energy use, electrical generation, urban Because of the high stakes for both publicThe to bloom, physicians should be among land transport, and agriculture. healthLancet and as the complex considerations those taking notice. The key message from the series, of public policy in the climate arena, The public health community is be- which was cosponsored by the National authors recommend that policy ginning to fully realize that climate change Institute of Environmental Health Sci- makers consider all of the health implica- presents many long-term challenges to ences, the Wellcome Trust, and the tions in short-lived greenhouse pollutant human health. The American Medical London School of Hygiene and Tropical reduction measures. Association’s 2008 resolution on global Health Medicine, was that “[i]f properly Because physicians are at the front climate change and human health recog- chosen, action to combat climate change lines of treating diseases and reducing nized that immediate effects may include can, of 3itself, lead to improvements in mortality that may be associated with those related to heat, extreme weather health.” For example, interactions be- a changing climate, it is vital that you events such as flooding or drought, tween human health, climate change, and contribute your perspectives to these con- increased air pollution, and infectious short-lived greenhouse pollutants (those siderations. In addition to revealing new and vector-borne diseases. It also noted that last only Thea fewLancet weeks at most in the bricks in the path toward understanding longer-term impacts on food and water environment) were the topic of one of climate change impacts on health, this re- supplies that could1 result in malnutrition the papers in series, which il- search offers a road map to move not just and dehydration. The resolution also lustrated both the opportunities and the healthThe butLancet also energy, transportation, included a number of recommendations complexities of this science. Black carbon and agricultural policy forward on this aimed at encouraging the medical com- aerosols that result from incomplete fos- issue. authors noted, however, munity to become educated about the sil fuel combustion in household cooking that awareness of the potential for health impacts and threats from climate change, and diesel engines have been shown benefits to offset at least some of the costs particularly on vulnerable populations in numerous studies to contribute to of reducing greenhouse gases was gener- such as the elderly, children, and the poor; cardiovascular mortality, asthma, COPD, ally low. Physicians clearly have a role to to help such patients and communities and pneumonia. Other studies have sug- play in increasing such awareness. respond; and to become involved in policy gested that black carbon aerosols may Other federalContinued commitments on page to 16 re . . -. efforts to mitigate climate effects. contribute as much as 60 percent of the search on health impacts of climate 12 SaExcitingn Francisco new research Medicine is Aprilrevealing 2010 total climate forcing as the most promi- www.sfms.org Medicine and the Environment

From Out in the World to Under the Skin

Expressions of Socioeconomic Status

Ted Schettler, MD, MPH

S ocioeconomic status (SES) shapes was associated with a large increase in the related environmental conditions. fundamental biologic, psychologic, risk of asthma among participants with low The term “allostasis” refers to process- and physical realities. It is among SES but not in high SES subjects. es by which organisms respond to events the strongest determinants of health and Another prospective study found that and change in order to maintain homeosta- health disparities in the U.S. (Adler et al prenatal exposure to secondhand tobacco sis. A model using the concept of “allostatic 2010). Lower SES brings together, in various smoke had a greater adverse impact on load” is an attempt to integrate various combinations, increased exposures to many the neurodevelopment of infants when stressors associated with SES and link them kinds of environmental hazards, increased combined with postpartum maternal hard- to biologic changes, including alterations susceptibility, decreased capacity to cope, ships, such as shortages of food, clothing, in set points for neural, cardiovascular, au- and reduced capacity to recover. These or shelter (Perera 2005). Several studies tonomic, immune, and metabolic systems inescapable truths are relevant daily to found that increasing cumulative lifetime (McEwen 1998, 2008). Over time, excessive clinicians, public health officials, community community exposures to lead are associ- allostatic load can lead to feelings of help- planners, and other policy makers. ated with accelerated cognitive decline in lessness and hopelessness and to behav- Lower SES increases the risk of leading aging (Weisskopf 2007, Bandeen-Roche ioral changes, including excessive drinking causes of morbidity and mortality in the 2009, Weuve 2009). That connection ap- and smoking and changes in sleep patterns. U.S., including heart disease, hypertension, pears to be strengthened in neighborhoods These add to an already-substantive bur- diabetes, obesity, dementia, asthma, many that generate psychosocial stressors such as den and accelerate its impacts. Persistent kinds of cancer, premature birth, and low hypervigilance, alarm, or perceived threat and progressive changes in dysregulated birth weight infants. These are not only (Glass et al 2009). In both humans and biologic pathways can ultimately lead to more common but also often more rapidly laboratory animals, the adverse impacts of acute and chronic disease. Stressed regula- progressive in people whose lives include lead on neurodevelopment are significantly tory systems beginning in utero or during combinations of reduced income and increased in the setting of an impoverished, childhood may influence disease risks much education, inadequate employment, and stressful environment (Weiss et al 2006). later in life through epigenetic and other other measures of lower SES. The relation- Weiss and Bellinger argue that the social mechanisms currently being investigated ship between SES and health status exists ecology of developing children strongly (Gillman et al 2007). Of course, chronic across the entire socioeconomic spectrum influences their responses to exposures to disease can also interfere with education and does not apply only to people living in developmental neurotoxicants and should and employment opportunities, increasing poverty, although the gradient is not neces- not be treated as a collection of confounders the risk of lower SES. sarily linear for all measures. toM odels,be controlled Mediators, for in data and analysis. Pathways Levels of glucocorticoids and sympa- People of lower SES often live in thetic activity increase with allostatic load. neighborhoods with more environmen- Parasympathetic activity declines (McEwen tal stressors. Access to healthy food and Many studies investigate these links 1998, Adler et al 2010). Levels of proin- recreational facilities is frequently limited. and their underlying mechanisms. Study flammatory markers are higher in people In a self-reinforcing feedback loop, lower design is challenging. Income, education, with lower SES. For example, in a study of SES can worsen the impacts of various occupation, and race/ethnicity are com- children with asthma, lower family income environmental stressors. For example, a monly used alone or in combination as and higher levels of home stress were as- prospective study found that the risk of measures of SES. Each contributes, but to sociated with higher baseline (all children developing asthma in children exposed to varying degrees in differing circumstances were asymptomatic when tested) levels similar amounts of traffic-related air pollu- (Adler et al 2010). A study that controls for of IL-5, IL-13, and eosinophils (Chen et al tion was greater in children with lower SES one or two of these may miss independent 2006).Continued These findings on the suggest following that page lower . . . (Shankardass 2009). This study also found effects of the others. And it is often difficult SES situates children with asthma closer thatwww.sfms.org maternal smoking during pregnancy to separate the effects of SES from those of April 2010 San Francisco Medicine 13 Continued from the previous page . . .

benefit as much as those with higher SES attributes that affect individuals and make to the threshold of clinical symptoms than (Govil et al 2009). The participants in this them a part of a vulnerable group. It is es- their better-off counterparts. study generally had at least a high school sential that recommendations from this Studies in adults typically find individ- education, and it is unclear whether these committee are incorporated in risk assess- ual SES, as measured by income and educa- findings are more broadly generalizable. ments performed by regulatory agencies tion, inversely related to levels of IL-6 and A previous study showed that a lifestyle and others charged with protecting public C-reactive protein (CRP) (Adler et al 2010). intervention program was less beneficial health,Ted including Schettler people MD, MPH, who isare science most A study of 851 adult men and women also for people who were less educated and had directorvulnerable. of the Science and Environmen- found community SES inversely associated lower health literacy and lower self-esteem tal Health Network, the Collaborative on with IL-6 and CRP (Petersen et al 2008). A (Winkleby et al 1994). Health and Environment, and is a science cross-sectional and prospective study also Clinicians can also become advocates advisor to the Health Care Without Harm found higher levels of markers of oxidative for improved access to healthy food, campaign. stress and lower levels of antioxidants as- adequate housing, recreation facilities, re- sociated with lower SES, as measured by duced exposures to hazardous chemicals References education, occupation, and income (Janicki- and environmental pollutants, and safer Deverts et al 2009). This association per- neighborhoods. These interventions will sisted after correcting for smoking, alcohol benefit everyone, particularly those people A full list of references is consumption, and depressive symptoms, who are more susceptible to acute and available online at www.sfms.org/ but it is unclear whether the effect size is chronic illness because of their SES. For environmentalhealth2010.Pollution-Related Illness Led to clinically relevant. example, in Dane County, Wisconsin, the $193M in CA Hospital Spending It is worth noting how commonly black-white difference in infant mortality elevated markers of inflammation and has nearly disappeared over the past ten oxidative stress are present in many com- years without any significant changes in Asthma, pneumonia, and other pollu- mon chronic diseases or disorders that obstetrical services available to low-income tion-related health problems contributed to $193 million in California hospital spend- disproportionately impact people of lower women (CDC 2009). This trend has not Sacramento Bee SES (Stein et al 2010). These are likely to be been observed in other Wisconsin coming between 2005 and 2007, according to among the mechanisms by which lower munities where health insurance coverage, a recent Rand study, the SES becomes entangled in causal disease targeted public health programs, and WIC reported on March 2, 2010. For the study, Mpathways.ultilevel Implications (Women, Infants, and Children) nutrition researchers analyzed treatment at more programs are also available. Many observ- than 400 California hospitals for conditions ers attribute the changes in Dane County to linked to air pollution. Researchers found The strong inverse relationship be- improved neighborhood safety and support that three-quarters of the health problems tween SES and chronic disease risk has and advocacy for low-income black women analyzed were the result of high levels of significant implications for individuals, and families, along with improved economic fine particulate pollution, in which small communities, clinical medicine, public status and social inclusion. One theory gain- quantities of soot get trapped in the lungs. health, and public policy decision making. ing increasing support holds that we must One-quarter of the analyzed conditions At a societal level, efforts to diminish the SES take a life-course perspective on factors that were triggered by breathing ozone. The gradient are among the ways to reduce its influence pregnancy outcomes rather than study found that pollution-related condi- impacts. Improved access to high-quality focusing on specific variables only during tions led to 29,808 emergency department education, making certain that households pregnancy (Lu et al 2003). visits and hospital admissions over the have adequate income, and improving Finally, since lower SES causes in- three-year period. It noted that more than employment opportunities will help, but of creased vulnerability to additional envi- 12,000 ED visits were related to asthma course these require resources and political ronmental stressors, it is incumbent upon for children younger than age seventeen. will. Minimizing the consequences of lower policy makers, regulators, and public health Researchers noted that hospital admis- SES by lowering the allostatic load in fami- officials to account for this when evaluating sions for acute bronchitis, pneumonia, and lies and individuals is another approach. risks. Recently, a committee of the National chronic obstructive pulmonary disease Clinicians can encourage lifestyle changes Research Council recommended that the were the most costly pollution-related in individuals in order to lower their risk framework for risk assessment of chemicals conditions, accounting for nearly one-third profiles through multiple mechanisms. If be modified to account for uncertainty and of the total health care spending. The study available, lifestyle intervention programs variability in the response to exposures also found that Medicare and Medi-Cal are are worth considering. One study of an (NRC 2009). In particular, the committee covering two-thirds of the health costs insurance-sponsored program for people recommended accounting for variability in related to poor air quality. A link to the full with coronary heart disease showed that responses attributable to age, ethnic group, study is available on our website, www. 14people San withFrancisco lower MSESedicine participate April and2010 and socioeconomic status, as well as other sfms.org/environmentalhealth2010. www.sfms.org Medicine and the Environment

Scientific Support for Endocrine Disruption

The Endocrine Society Makes the Case

Loretta Doan, PhD, and Linda C. Guidice, MD, PhD

E ndocrine-disrupting chemicals ies—and concludes that the evidence House of Delegates (HOD) passed a (EDCs) are substances in our en- indicates that EDCs are a significant resolution introduced by the Endocrine vironment, food, and consumer public health concern. EDCs function Society on the regulation of endocrine- products that interfere with hormone through a number of mechanisms, most disrupting chemicals. The resolution was biosynthesis, metabolism, or action of which involve pathways that are highly cosponsored by the American Association resulting in a deviation from normal ho- conserved across species. Mechanisms of Clinical Endocrinologists and the Amer- meostatic control or reproduction. Due include actions through nuclear and neu- ican Society for Reproductive Medicine, to the increasing body of scientific evi- rotransmitter receptors, steroidogenic with support from the American College dence indicating possible health threats enzymes, and many other pathways that of Obstetricians and Gynecologists; the posed by EDCs, the Endocrine Society can be modeled in the laboratory using in Society for Occupational and Environ- has undertaken a number of initiatives vitro and in vivo models. A broad array of mental Health; the California Medical to increase awareness of the science molecules have EDC functions, including Association; and from the Endocrine, of EDCs and to ensure that endocrine organochlorinated pesticides and indus- Subspecialty, and Young Physician Section research is considered in policy-making trial chemicals, plastics and plasticizers, Councils of the HOD. Upon passing the decisions and in regulatory processes. fuels, and many other chemicals that resolution,The AMA the HODwill work established with the new federal AMA The Society’s activities in the area of are in widespread use in manufacturing governmentpolicy on EDC to pursueregulation, the following which states: tenets: EDCs include scientific programming at and industrial applications, are present Regulatory oversight of endocrine-disrupt- its annual meeting, ENDO; an in-depth in the environment, or can be found in ing chemicals should be centralized so that scientific statement reviewing the state humans. The Endocrine Society makes a regulations pass through a single office to of the science of EDCs and making recom- number of recommendations to increase ensure coordination among agencies, with mendations for improvement of scientific understanding of EDCs’ effects and to the exception of pharmaceutical agents knowledge and regulatory processes; and ensure that policy decisions are informed that are regulated by the Food and Drug a position statement that outlines the So- by the entirety of the scientific evidence. Administration and are used for medicinal ciety’s views on the policy and regulation Specific recommendations include en- purposes; policy should be based on com- of EDCs. The Society continues to gain hancing increased basic and clinical prehensive data covering both low-level support for its efforts from the broader research, using precaution in the face of and high-level exposures; and policy should scientific and medical communities and uncertainty during policy and regulatory be developed and revised under the direc- is workingEndocrine-Disrupting actively in the realm Chemicals: of federal An decision making, and advocating involve- tion of a collaborative group comprising EndocrineEDC legislation Society and Scientificregulation. Statement ment of individual and scientific society endocrinologists, toxicologists, occupa- stakeholders in communicating and tional/environmental medicine specialists, implementing changes in public policy epidemiologists, and policy makers. presents the evidence that endocrine andMedical awareness. community supports disruptors have effects on multiple endo- EDC Policy Goals crine systems, including male and female The adoption of these principles by reproduction, breast development and the HOD represents a broad consensus cancer, prostate cancer, neuroendocri- In order to further a number of the among the entire medical community nology, thyroid, metabolism and obesity, policy goals outlined in the scientific that more needs to be done to protect and cardiovascular endocrinology. The statement and position statement, the the public from potential health risks of statement represents a comprehensive Endocrine Society is building support in exposure to EDCs. As AMA policy, these review of the scientific literature on the medical community and with policy tenets Continuedenjoy the full on supportthe following of the page House . . . EDCs—including animal studies, clinical makers. At the 2009 Interim Meeting, the of Medicine. 14 San Francisco Medicine April 2010 www.sfms.org observations,www.sfms.org and epidemiological stud- American Medical Association (AMA) April 2010 San Francisco Medicine 15 Continued from the previous page . . . necology, and Reproductive Sciences at the University of California, San Francisco. As EDC Regulation Gains Traction on a reproductive endocrinologist and trans- human health to be cochaired by the Capitol Hill lational scientist, she has a major interest OSTP, NIEHS, and EPA. The group will in environmental reproductive health coordinate federal research efforts on and particularly in endocrine-disrupting human health aspects of climate change Policy makers have shown interest chemicals. She was a co-organizer of the and work with the White House Climate in the effects of EDCs, introducing legisla- Vallambrosa Workshop on fertility and Change Adaptation Task Force to catalyze tion to ban bisphenol A, to strengthen the reproductive health and founder of the creation of an integrated response to EDC research program at the National UCSF Program on Reproductive Health climate change and health throughout Institute of Environmental Health Sci- and the Environment. To learn more, visit the different levels of government, from ences (NIEHS), and to reform the Toxic www.endo-society.org. federal to tribal, state, and local. The Substance Control Act (TSCA). Through crosscutting dimension of the group will its scientific statement, the Society has extend beyond government agencies to come to be recognized by lawmakers as A Climate Change for the Better engagement with various stakeholders a primary source of scientific expertise Continued from page 12. . . and partners, including the overlapping on EDCs. In support of its policy goals, the medical and public health communities Society endorsed the Endocrine Disrup- who will form an integral part of the U.S. tion Prevention Act of 2009 (HR 4190/S change are also showing new life. The NIH response to climate change. The Lancet 2828), introduced by Representative Jim has dedicated more than $3.5 million in Such engagement is supported by the Moran (D-VA) and Senator John Kerry American Reinvestment and Recovery Act AMA resolution, as well as by (D-MA) on December 3, 2009. Entirely in funds to support five studies of health im- authors who issued a call to health profes- line with the Society’s positions, the bill pacts of climate change, including model- sionals to “reach beyond conventional pro- will advance EDC science and improve ing health impacts of wildfires and assess- fessional boundaries to collaborate with the regulatory process by ensuring it is ing vulnerability to heat stress. Over the policy makers and scientists concerned informed by the best science. Specifically, past two years, EPA’s STAR grant program with the study, development, and imple-

the bill addresses the need for more re- has invested $17 million in studies of how mentation of policies and 1technologies to search on EDCs and coordinated output climate change effects on air quality and mitigate climate change.” The NIEHS is of research results, proposing to develop water quality can in turn affect health, thrilled to see the public health and medi- a research program under the auspices as well as in modeling health cobenefits cal communities warming to the idea that of NIEHS. of greenhouse gas reduction actions. we all have a role to play in preventing ad- To advance the Society’s goal of And a soon-to-be released white paper ditional illness and suffering as a result of strengthening regulation of EDCs, the authored by a team of federal scientists climateLinda change. S. Birnbaum, That’s a change PhD, DABT, in climate ATS, Society has discussed the findings of the (led by the National Institute of Environ- iswe director should ofall thewelcome. National Institute of En- scientific statement with staff of the com- mental Health Sciences) summarizes the vironmental Health Sciences (NIEHS) of mittees that have jurisdiction over this state of the science on health effects and the National Institutes of Health and the issue, including the House Energy and identifies research needs to help guide National Toxicology Program. The author Commerce Committee and the Senate future investments. One outcome of this of more than six hundred peer-reviewed Environment and Public Works Commit- exercise is that the input and engagement publications, book chapters, abstracts, tee, and with the staff of Representatives of physicians and other public health and reports, she has been president of the Moran, Slaughter (D-NY), Rush (D-IL), professionals in all forms and phases of International Union of Toxicology and and Markey (D-MA). The Society also this research will be critical to its success. of the Society of Toxicology, the largest provided comments on draft language to In addition to research, the federal professional organization of toxicologists overhaul the Toxic Substances Control Act government is taking a more active role in the world. John M. Balbus, MD, MPH, and continues to offer its support to this in building public health capacity for serves as senior public health advisor to ongoing process. responding to climate change. The CDC the NIEHS director and leads NIEHS ef- The Endocrine Society will continue recently announced a $1.8 million pro- forts on climate change and human health. to work to further its policy goals and gram to support state and local health He was formerly chief health scientist for to strengthen the case for science in the departments in a variety of public health Environmental Defense Fund. regulation of EDCs. The Society is encour- activities pertaining to climate change agedLoretta by the Doan, invaluable PhD, is supportassociate of direc the- health impacts, including surveillance References tor,medical Science community Policy, the in Endocrine these efforts. Society. and monitoring, response planning, and Linda C. Giudice, MD, PhD, is professor and program evaluation. The White House chair of the Department of Obstetrics, Gy- Office of Science and Technology Policy A full list of references is (OSTP) recently chartered a new inter- available online at www.sfms.org/ 16 San Francisco Medicine April 2010 agency group on climate change and environmentalhealth2010. www.sfms.org Medicine and the Environment

Can Plastic Hurt You?

The Case of BPA

William H. Goodson III, MD, and Shanaz Dairkee, PhD

T wo issues arise when considering a possible role of xenoestrogens in breast that tobacco smoke was safe because it possible role of synthetic estrogen- cancer has been brought to light, mark- was all around us. like chemicals or xenoestrogens, ing a likely end to this debate. A recent Bisphenol A was first synthesized such as bisphenol A, in the risk of breast National Cancer Institute study looking more than 100 years ago. During the ex- cancer. First, is there an increase in breast at breast cancer in men in the same SEER plosion of information about hormones in cancer that is not explained by other fac- data reports that male breast cancer has the 1930s, Dodds and Lawson in England tors? Second, does bisphenol A (often increased at the rate of 0.86 percent per reported that the phenanthrene ring called BPA) have carcinogenic effects? year during the same three decades that system structure that is typical of steroid There has been a steady rise in female female breast cancer has risen. Clearly, hormones is not actually necessary for breast cancer, at a rate of 1.39 percent per the increasing incidence of male breast estrogenic effects. One of the chemicals year, since collection of SEER (Surveil- cancer cannot be attributed to prescribed tested a few years earlier by Easson and lance Epidemiology and End Results) hormones, reproductive patterns, or in- colleagues was 4:4’-dihydroxy diphenyl data began in 1973. After publication fant nursing practices. As the authors of methane—bisphenol A for short. The of the Women’s Health Initiative study, this study have concluded, there are likely story goes that diethylstilbestrol was which showed increased breast cancer common “environmental exposures” tested at the same time, and it was devel- in women taking combined estrogen and shared by men and women that increase oped for clinical use because it was even progestin hormone replacement therapy the risk of breast cancer in both groups. more potent. (HRT), a slight drop in breast cancer rates As an aside, some studies of xenoes- During World War II, BPA found a was reported. Intuitively associated with trogens in malignant and nonmalignant major role in the war effort in aircraft the discontinuation of HRT use, the drop breast tissue have failed to observe any windshields and other materials. Cur- actually started about two years before effects. These studies are reminiscent of rently we encounter BPA in many prod- the report was published. More impor- the public discourse 100 years ago about ucts ranging from eyeglasses to safety tantly, over the last thirty years there the safety of lead service pipes for home masks to Blackberries. We also ingest has been a steady increase in hormone plumbing. The skeptics argued that four BPA in our foodstuffs. BPA leaches from responsive (ER-positive) breast cancers people could drink water from the same the epoxy lining of food and beverage in women between the ages of thirty and pipe, but since only one got sick there cans into our daily diet. It is sobering to fifty years, a group not usually on HRT. must be another cause that affected just know that in 2003, the National Health Some have argued that this might that one person. At the time, the concept and Nutrition Examination Survey and be an effect of oral contraceptive use. of individual genetic variability was not the Centers for Disease Control found Although there is data suggesting that well understood. It turns out that, for BPA in urine from 90 percent of a random early high dose oral contraceptives might reasons not yet discerned, only about half sample of representative Americans. This increase premenopausal breast cancer, of persons who drink water with high is especially poignant since BPA ingested more recent studies have showed no lead content will actually develop high by volunteers clears from blood within effect with newer low-dose oral contra- lead blood levels. Of those with high lead 24 hours. ceptives. blood levels, only about half will actually There are few studies of BPA in se- Most recently, British epidemiolo- get severe lead poisoning. rum, but two available reports confirmed gists have concluded that the increasing ThisWall is theStreet state Journal of affairs with xen- exposure of vulnerable populations— incidence of ER-positive breast cancer oestrogens. Note the unsigned editorial unborn children. Both studies measured is due to delayed childbirth and the de- in the (January 31, BPA concentration in maternal and cord creased time of nursing that is common 2010), which stated that BPA is safe be- blood. ContinuedOne also measured on the following BPA in placenta page . . . in developed Western countries. cause it is already all around us. This is tissue. In these studies, one in the United 16 San Francisco Medicine April 2010 www.sfms.org www.sfms.org On the basis of these studies, the tantamount to arguing thirty years ago April 2010 San Francisco Medicine 17 Continued from the previous page . . . References

gun” yet? Not quite, but we have much States and one in Germany, maternal supportive evidence. There has been an Anderson WF, Jatoi I, Tse J, Rosenberg BPA levels ranged from 0.2 to 22 pg/ml increase in hormone-driven breast can- PS. JMale Clinical breast Oncology. cancer: A population- and fetal or cord blood ranged from 0.2 cer. But males show the same increase, so based comparison to female breast can- to 11 pg/ml. the usual suspect of prescribed hormones cer. 2010; 28:232-239. It has been known for a long time that cannot explain this outcome. We know Calafat AM et al. ExposureEnvironmental of the U.S. exposure of mice to ingested BPA has de- for a fact that we are all exposed to BPA Healthpopulation Perspectives. to bisphenol A and 4-tertiary- velopmental consequences. At California all the time. We also know that at-risk octylphenol: 2003–2004. Pacific Medical Center Research Institute, populations are similarly exposed to BPA. 2008; 116: 39-44. we asked if similar levels of BPA alter hu- We can demonstrate that nonmalignant Dairkee, SH et al. Bisphenol A induces man cells. Instead of using immortalized human breast epithelial cells change Cancera profile Research. of tumor aggressiveness in high- cell lines, we designed our studies with when exposed to BPA at the concentra- risk cells from breast cancer patients. cells freshly removed from human tissue tions already known to persist in people. 2008; 68: 2076-80. and sustained in tissue culture for just a We know that such BPA-induced changes PadmanabhanJournal of V Perinatology. et al. Maternal bi- few generations (one to two months at are commonly harbored by aggressive sphenol A levels at delivery: A looming the most). breast tumors. problem? 2008; Since we wanted to test the effects of WilliamThere is H.cause Goodson for concern III, MD, isand a senior need 10:1-6. BPA on a more vulnerable, high-risk pop- clinicalfor a lot research more work scientist immediately. at the California Schonfelder G etEnvironmental al. Parent bisphenol Health ulation, in accordance with IRB approved Pacific Medical Center Research Institute. Perspectives.A accumulation in the human maternal- guidelines and patient consents, we col- He is also in active practice as a breast fetal-placental unit. lected cells by fine needle aspiration from surgeon at CPMC and is a past president 2002; 110:A703-A707. the opposite breast of women undergoing of the SFMS. Shanaz H. Dairkee, PhD, is Vom Saal FS, Hughes C. An exten- breast surgery. The total sample size was a senior scientist at the California Pacific sive new literature review concerning the equivalent of three drops of breast fat Medical Center Research Institute Environmentallow-dose effects Health of bisphenol Perspectives A shows and cells combined. These women were the need for a new risk assessment. known to be at increased risk because of . 2005; personal or family history of breast can- 113:926-933. cer, a biopsy that showed a premalignant change, or increased breast density on San Francisco Heart Health mammograms. We were uniquely successful in growing these cells, enabling comparisons between no treatment and BPA exposure at An innovative cardiovascular practice a concentration as low as that reported in pregnant moms at parturition. Working providing the means to achieve and with colleagues at the Stanford Genome Technology Center, we used gene array maintain optimal heart health with technology to scan the RNA isolated from less dependence on drugs or invasive the above-mentioned exposures for the expression of 44,000 gene sequences. Our surgery. results were sobering. Peter Curran, MD In cells exposed to BPA at a concen- Director tration found in human mothers, sets of genes that control cell differentiation Benefits: were suppressed or turned off, and those • Direct access to your cardiologist that regulate metabolism, protein synthe- • Unhurried appointments 909 Hyde Street, Suite 317 sis, cell cycle—metabolic activity—were San Francisco, CA 94109 • Individual electronic health profile turned on or overexpressed. When we (415) 310-5764 looked at breast cancers, in those cases • House calls [email protected] that harbored this same pattern of de- • Validated parking sanfranciscohearthealth.com creased differentiation and increased metabolism, the patients had a marked decrease in survival from cancer. 18 SaDon weFra havencisco the proverbialMedicine “smokingApril 2010 www.sfms.org Medicine and the Environment

The Weight of Evidence

Will Reducing Chemical Exposures Combat the Obesity Epidemic?

J.P. Myers, PhD

O besity has reached epidemic et al: disruption of weight regulation by early life is also a window of sensitivity proportions in many countries endocrine-disrupting chemicals (EDCs) in to chemical exposures, which can power- around the world. This is espe- the environment. Plausible mechanisms fully affect the course of development and cially evident in the United States, where, by have emerged from animal and cell re- cause chronic diseases later in the life of 2002, 30 percent of adults met the criteria search, and some epidemiological studies the animal. of “clinically obese” (Hedley et al 2004). have suggested associations between cer- Prior to 2005, the experimental litera- After two decades of sharp growth in the tain contaminants and obesity (Newbold ture is peppered with scattered examples final fifth of the twentieth century, one in et al 2007; Heindel and vom Saal 2009). in which animals in the experimental six U.S. adolescents is now obese (Ogden This is potentially very good news for group show weight gain compared to et al 2010). the fight against obesity. If EDCs are con- controls (Baille-Hamilton 2002), but these How serious is this trend? Enough to tributing to the epidemic, then measures experiments were never designed to test engage the White House, with First Lady taken to reduce exposures may offer a for weight gain per se. Indeed, viewed Michelle Obama launching a campaign in practical means to alleviate some portion through the lens of traditional toxicology, February 2010, to curb childhood obesity. of this disease burden. Several of the im- weight gain is good; it implies health. The Unfortunately, it appears that the focus of plicated contaminants are not persistent toxicologists were concerned more with that campaign may be missing some very and are eliminated relatively quickly from weight loss, which was seen as an adverse big opportunities. human fluids and tissue. Previous experi- outcome. Interventions to combat the obesity ence demonstrates clearly that policy In 2005, Newbold et al published epidemic, including the new White House interventions can lead to dramatic declines results of an experiment expressly de- effort, have targeted what are widely be- in U.S. contamination levels, even with signed to test the hypothesis that early lieved to be the two principal contributors highly persistent compounds (e.g., lead, life exposure to an EDC could cause adult to obesity: insufficient caloric expenditure DDDT,evelopmental hexachlorobenzene). Origins of Adult obesity (Newbold et al 2005). Newbold and excess caloric intake (“the big two,” Disease had noticed that experimental animals Keith et al 2006). Yet despite widespread (mice) used in her research on the synthetic and expensive efforts focused on “the big estrogen diethylstilbestrol (DES) often two” by public health agencies, private Concerns about the potential con- developed into morbidly obese adults fol- foundations, educators, and medical prac- tribution of EDCs to childhood obesity lowing exposure to DES right after birth. titioners, the high prevalence in youth has build from two considerations, one out of In the experiment, Newbold et al treated remained steady for the past ten years human biology and the other from animal the animals with approximately one part (Ogden et al 2010). experiments: per billion of the animal’s body weight per A recent review of “the big two” con- First, it is now well established that day (1µg/kg/day) for the first five days of cluded that undue attention was being events early in human life, particularly neonatal life. While the females did not devoted to reduced physical activity and in the womb, can have long-term conse- differ from controls during treatment, by excessive caloric intake “leading to neglect quences for health, including increased adulthood the DES-treated female mice of other plausible mechanisms and well- risks of heart disease, obesity, and type II were obese. intentioned but potentially ill-founded diabetes. Studies of people clearly show A series of studies now unequivo- proposals for reducing obesity rates” (Keith that fetal nutrition plays a vital role in set- cally demonstrate that obesity in adult et al 2006). ting risk to these chronic diseases (Gluck- animals can be caused by exposures to Since publication of that review, man et al 2007). specific chemicals in the womb (reviewed substantial evidence has emerged that Second, while research on “develop- in Newbold et alContinued 2009, Heindel on page and 21 vom . . . increases the plausibility of one of the al- mental origins” initially focused largely Saal 2009). They also shed light on the po- 18 San Francisco Medicine April 2010 www.sfms.org ternativewww.sfms.org mechanisms suggested by Keith on nutrition, animal research proves that April 2010 San Francisco Medicine 19 Medicine and the Environment

Is Ignorance Bliss?

Measuring My Own Toxins

Larry B. Silver, MD

It impacted me A s a child and adolescent psychia- ing many other areas of developmental and,ter, food, thus, and my air family impacts everyone, in every trist, my primary areas of clinical disabilities as well as major organizations place throughout the world. work and research have related concerned with significant health issues. . to the neurologically based disorders that Between the speakers and the informal Ignorance was bliss. Now, the infor- impact cognitive, language, and motor interactions of the participants, I quickly mation on environmental toxins took on functioning: learning disabilities, language became aware that there was extensive a personal meaning. What could I do for disabilities, sensory processing disorder, information on the negative impact of myself, my wife, my children, my grand- attention deficit hyperactivity disorder, environmental toxins. And these impacts Thechildren? Study and Its Findings and the intellectual disabilities. were not just on the developmental dis- Brain development occurs early in abilities I studied but on the increases in pregnancy through a complex process in- many forms of cancer as well as other The overall findings for the twelve volving genetic messaging and neuroendo- significant diseases. participants showed the presence of crines. This complex interaction between I read Rachel Carson’s books years sixty-one chemicals out of the eighty- the genetic code and the specific neuroen- ago. Now I began to read current and more nine tested for. All twelve participants docrines are critical to the development relevant books (see “Suggested Reading” tested positive for at least twenty-six of of the brain, including cell proliferation, on page 21). I became active with the the tested chemicals. Each had detectable cell migration, formation of connections Learning and Developmental Disabilities levels of bisphenol A (BPA), mercury, lead, between nerve cells, programmed cell Initiative and the Safer Chemicals, Healthy polybrominated diphenyl ethers (PBDEs), death, and myelination. Families coalition. perfluorinated compounds (PFCs), poly- At birth, the brain has every nerve As part of these activities, I was asked chlorinated diphenyl ethers (PCDEs), and cell it will ever have. Through a planned to participate in a biomonitoring project organic pesticides in their bodies. Eleven process of maturation combined with the called the Body Burden Study. I became of the twelve participants had detectable impact of stimulation versus lack of stimu- one of twelve individuals who agreed to levels of triclosan. lation of specific nerve cells, the infant have blood and urine samples taken to look I went back and read the literature. brain evolves into the child brain and then for the presence of a set of synthetic chemi- But now I was not looking up an alphabet the adolescent and adult brain. cals and heavy metals. The results changed tosoup me of terms. I was looking for what was Excellent research literature has pro- my thinking, magnified my concerns about inside of me. What did the findings mean vided increasing knowledge on the impact environmental toxins, and expanded my ? of environmental toxins in the air, water, interest in environmental toxins from a I was high in polychlorinated diphenyl and food on brain development in utero comfortable consumer of information to ethers (PCBs). These are fire retardants and during childhood and adolescence. I an active advocate for change. found in many items of clothing, furniture, have found this increasing body of knowl- Prior to receiving the results from bedding, and more. edge fascinating and a possible explana- this study, I used to think that problems I was high in triclosan. This as an tion for the increased incidence of each of with toxic chemicals only related to the antibacterial found in soaps, toothpastes, the disabilities I had a special interest in. poor who lived near industry, toxic waste and many other personal care products. In 2000, as president of the Learning dumps, or in housing with lead-based I was high in the organochlorine Disabilities Association of America, I was paint. These problems related to others, pesticides. DDT was gone but I had lived invited to a conference on environmen- not to me. But the Body Burden Study, during its time period. It is in clordane, tal toxins. I joined representatives from as well as the results of many other such lindane, hexachlorobenzene. It is in weed organizations representing each of the studies done in the U.S., Canada, and other killers. Thus, even if I try to forget all of the developmental disabilities I worked with, countries, opened my eyes. The impact of materials I put on my lawn, what about the 2021plus Sa thosen Fr afromncisco organizations Medicine represent April 2010- environmental toxic chemicals in our wa- foods I eat or the liquids Iwww.sfms.org drink? I was high in perfluorinated com- lectualLarry rather B. Silver,than personal. MD, is clinical profes- ubiquitous, and the exposure is at levels pounds (PFCs). These chemicals are sor ofOh, psychiatry well. It is at too Georgetown late now. University capable of causing obesogenic effects in everywhere. If they are on the surface of Medical Center. animals. For example, the U.S. Centers for something, they minimize anything stick- Disease Control reports that bisphenol A ing to the surface (Teflon). They act as Suggested Reading can be measured in more than 90 percent water repellents (Scotchgard). Generations at Risk: Reproductive of Americans, with higher levels in youth. My mercury level was higher than Health and the Environment Almost no human data are available to recommended by the Centers for Disease test the obesogen hypothesis in people. No Control and Prevention. I knew to limit the , by Ted Schet- epidemiological evidence exists, because amount of tuna I ate. Where else might I tler, InGina Harm’s Solomon, Way: Toxic Maria Threats Valenti, to Child and the hypothesis is so new. A few studies as- have been exposed? What is it doing in Development—AAnnette Huddle. MIT Report Press, by Boston, the Greater 2000. sociate chemical levels measured in adults my body? Boston Physicians for Social Responsibility with obesity (e.g., Stahlhut et al 2007), but My lead level was high as well. Maybe these are not relevant to a developmental as a child I lived in a house with lead-based , model. One in vitro experiment, however, paint. But such intakes would have cleared by Ted Shettler, Jill Stein, Fay Reich, Maria has demonstrated that exposure to obe- by now. Where did this come from? What Valenti, and David Wallinga. Published by sogens increases the rate of conversion of doesWhat it mean?Should/Could I Do? the Greater Boston Physicians for Social human stem cells to adipocytes (Kirchner Responsibility,Our Stolen Future11 Garden Street, Cam- et al 2010), confirming the validity of the bridge, MA 02138, 2000. basic mechanism and the relevance of the I read the literature on each of these , by Theo Colborn, Canimalonclusion studies to people. chemicals. Then I met with my personal Dianee Dumanoski, and John Peterson physician and showed him my test results. Myers.Slow Penguin Death byBooks, Rubber New Duck York, New He could not correlate the findings with York, 1996. Chronic diseases are rarely the result any medical problems I have had or have , by Rick of a single risk factor (Kirchner et al 2010). now. But we both agreed that we were less Smith and Bruce Lourie. Counterpoint Such is almost certainly the case for obesity. knowledgeable than we should be. Press, Berkeley, CA, 2009. Given the failures of current intervention There must be a way to avoid expo- The Weight of Evidence attempts that focus on “the big two” and sure to these toxins. How? I began to read Continued from page 19. . . the serious health and economic burden on this theme. I quickly concluded that that obesity is imposing on people around there was little I could do without major the world, the obesity epidemic challenges life changes, cost, and effort. Maybe I could tential molecular mechanisms underlying public health and medical professionals use a cast-iron pan for cooking rather than the effect: Many of these chemicals alter the to look widely at potential causes, includ- one that is Teflon-coated. Maybe I could behavior of specific genes that are involved ing those that at first might seem to be carefully study every item in my bathroom in determining the number of fat cells (adi- outside the box. These emerging studies, and look for products without these toxins. pocytes) an individual will have as an adult. summarized briefly above, indicate that a Maybe I could only buy organic foods, be- Animals exposed to contaminants that substantial—but as yet undetermined— ing careful to see how “organic” they were. increase the activity of these genes wind up portion of the obesity epidemic may be Maybe. . . . with more fat cells and thus are at greater caused by endocrine-disrupting chemicals. For now, I have given up on any but risk for obesity. Contaminants that have At the very least, this argues for urgent in- the easiest efforts. Even if I were convinced this effect have been termed “obesogens” vestment in additional research designed to do more, I doubt that I could get my (Grün et al 2006). Studies also suggest to test the obesogen hypothesis. It may family to go along. My body burden would other mechanisms, including interference also point toward interventions that are remain where it is. with neurochemical signals that provide far more practical and effective than those Maybe it is rationalization. Maybe it is information to the brain about hunger. indicated by a focus on “the big two.” That avoidance. Or, maybe it is reality. I shifted The list of contaminants implicated wouldJ.P. be Myers, a big PhD,win for is chief medicine scientist and of public Envi- my focus to taking more seriously the need by animal studies is substantial, includ- ronmentalhealth. Health Sciences in Charlottesville, to work with the organizations I belong to. ing several estrogenic EDCs such as DES, Virginia. I now have a personal awareness of the bisphenol A, soy phytoestrogens (particu- need to change the Toxic Substances Con- larly important given widespread use of References trol Act and to get the U.S. Environmental soy-based infant formula), certain phthal- Protection Agency to be more proactive. ates, and a family of compounds called Maybe I should not have volunteered organotins. A full list of references is to do the Body Burden Study. Then, all of It is particularly troubling that human available online at www.sfms.org/ 2021 San Francisco Medicine April 2010 www.sfms.org www.sfms.org my knowledge would continue to be intel- exposure to these is widespread, if not Aprilenvironmentalhealth2010. 2010 San Francisco Medicine 21 Medicine and the Environment

Mercury Update 2010

Money, Politics, and Poison

Jane Hightower, MD

T en years ago, I began investigating as December 2008, issued a draft report of making that determination. The EPA cur- why I had so many health-conscious saying that the benefits of omega-3 fatty rently wants us to keep the mercury level patients who had similar symptoms acids far outweigh the risk of mercury and in our blood below 5.0 mcg/l. The current of fatigue, hair loss, headache, joint and that pregnant women should eat more fish literature supports the EPA’s advice, and muscle pain, gastrointestinal upset, and than the currently recommended twelve even questions whether this is protective the like. My investigation kept turning up ounces per week. That risk assessment did enough. A “safe” level for mercury has yet one thing in common: They were lovers not rely heavily on current literature, nor to be found. of fish, especially large predatory fish, and did it fully address the extent of mercury Current concerns about the health ef- they had blood and hair mercury levels effects on human health. fects of mercury include nonspecific symp- that surpassed what the Environmental In fact, the report stated that the FDA’s toms, cardiovascular disease, atherosclero- Protection Agency said was protective. risk assessment relied “heavily” on data sis, autoimmune disease, neuropsychiatric I was determined to find answers for from a massive poisoning that happened damage, and infertility. In-utero exposure my patients. I also wondered why so many in Iraq in 1971–1972. This poisoning that studies continue to identify lasting adverse physicians were ignorant of mercury’s occurred when the Ba’ath party (Sad- effects in children. effects, of how to interpret the laboratory dam Hussein being vice president) was The FDA is making itself obsolete. tests, and ofDiagnosis: what constituted Mercury—Money, mercury struggling for control of oil-rich lands It was originally established to protect Politicstoxicity. and My Poisonefforts led to the publication and majority rule. You would think that the public from charlatans and danger- of my book, by now, with all that we know about Iraqi ous whiskey distillers. It now struggles . history, the FDA officials would investigate in all areas to keep our food and drugs What started out as a concerned phy- for themselves whether such information safe. As physicians learn more about how sician inquiry ended up as an investigation provided accurate enough data to use in toxicants in our food and environmentBritish af- of a centuries-long medical debacle. Medi- constructingDiagnosis: a Mercuryreliable (and still current) Medicalfect our patients,Journal more people will come cal issues that pit industry versus govern- policy. forward, looking for answers. As a ment versus victim confuse what we do as is the first and only editorial in 1972 stated physicians even today. In mercury’s case, book to investigate how industry-funded in response to the Iraqi poisoning, “there everywhere it has been, there have been researchers, Saddam’s scientists, and the is a danger that hypothetical hazards will people adversely affected—and also a FDA decided for the people and for health attract study while little is done to prevent tremendous amount of money to be made care professionals how we should look at real hazards, for it is easier to form pious or lost. Syphilis pills, diuretics, skin creams, mercury exposure in our patients. To date, resolutions than to stop people doing and mirrors. Hats, mercurochrome, dental the FDA only gives warning for reproduc- dangerous things. But the manufacturers fillings, and vaccines. All have been cause tive women, infants, and children. The and distributors of substances known to for concern because of mercury content rest of us are on our own to look at the be dangerous can be identified and their and the resultant complaints of harm. literature. And because the current FDA activities controlled—though probably Even today, as the American public standard was decided upon in a court of only Janeby the Hightower, concerted MD, action specializes of medical in is being urged to eat more fish instead of law using industry-funded researchers, internalmen [and medicine women].” at California Pacific meat, the FDA has been poor at issuing we probably will not see a broadening of Medical Center in San Francisco and has guidelines about which types of fish are the mercury advisory any time soon. In the done extensive research on mercury expo- relatively low in mercury (sardines, ancho- court case that decided our fate, the thresh- sure from fish in adults. She is a member of vies, herring, sole, wild salmon) and which old for a minimal clinical effect level was the San Francisco Medical Society and has have high levels (swordfish, shark, sea bass, determined to be 400 mcg/l in the blood, served on the SFMS Board of Directors. tile fish, sail fish, large snapper, some large even though the type of epidemiological 22species San of Fr tuna).ancisco The FDA,Medicine even as April recently 2010 science conducted in Iraq was not capable www.sfms.org Medicine and the Environment

Chemical Policy Reform

A Clinical Perspective

Gina M. Solomon, MD, MPH

W hen I was a resident training tested for safety—manufacturers must is still the law of the land, chemicals are in Internal Medicine and Oc- submit whatever toxicity information they still not being tested for safety, the public cupational and Environmental have, but if they don’t test, they don’t have still has limited access to information, and Medicine, I saw a patient who changed the to tell; Broad Confidential Business Infor- the Environmental Protection Agency is course of my life. She was a young woman, mation (CBI) provisions allow chemical still paralyzed and unable to take action to pregnant with her first child, who had manufacturers and product formulators control dangerous chemicals. asked her obstetrician whether chemicals to keep most information about chemicals Not only is there a terrible personal in her workplace could harm her fetus. Her (even their names) secret; the government and emotional toll when someone is obstetrician referred her to the clinic where often does not have the authority to take sickened by toxic chemicals, but there is I then worked. action to protect the public from hazardous also a serious strain on our health care The patient had recently completed chemicals, since any chemical regulations system. Most practicing physicians are her master’s degree and had a good job in need to be demonstrated to be the “least acutely aware of the tremendous cost and the quality control laboratory of a specialty burdensome” for industry. burden of health care in the United States. chemicals manufacturing facility. She took The pervasive flaws of the 1976 TSCA But there’s one element of this burden tiny samples from each batch of chemicals law on toxic chemicals have conspired that many physicians don’t see. In the oc- made at the facility and dissolved them in to create a situation in which extremely cupational and environmental medicine a solvent before running them through a hazardous chemicals can be widely used clinic where I work at UCSF, we special- mass spectrometer to test them for purity. in workplaces and even in consumer prod- ize in seeing patients who have become

When she came to her appointment at the ucts, with minimal or no oversight. ill due to exposures to chemicals3 in their clinic, she brought with her a large stack There’s a real human cost to this workplace or environment. Sometimes of Material Safety Data Sheets (MSDS) flawed chemical safety system. In fact, al- the concerns are related to contaminants with some information about each of the though all of her treating physicians advised discovered in well water; sometimes it is a chemicals she handled. that the woman and her employer play it respiratory problem related to indoor air But when I started to go through the safe and avoid exposures during pregnancy, quality; sometimes chemicals in consumer stack, I noticed some real problems. Many the employer concluded there was no clear products are implicated in a child’s illness. of the chemical names weren’t listed. evidence that the chemicals were harm- One common theme is that these illnesses Instead, there were annotations of “confi- ful. No alternative job assignments were are preventable. dential business information.” Most of the available at the company. My patient had A recent report summarized peer-re- health information was blank or unknown. to decide between losing her job and risk- viewed scientific literature on environmen4 - I eventually threw the stack of papers on ing her baby. Her “Sophie’s choice” turned tally related disease and health. It conclud- the desk in disgust. What was I supposed out badly. ed that about 5 percent of childhood cancer; to tell my patient? During her third trimester, there was 10 percent of diabetes, Parkinson’s disease, It was my first introduction to the a chemical spill in the lab that soaked and neurodevelopmental deficiencies; flawed chemical safety system in the United her clothes and dissolved her gloves, she and 30 percent of childhood asthma are

States. I was shocked then to learn that: became ill,1 and shortly afterward she had likely to be attributable to environmental an estimated 60,000 chemicals that were a stillbirth. Since then, the science has be- exposures. Unquantifiable but significant already in use before 1976 were “grand- come clearer, and the solvent she handled fractions of reproductive problems and fathered in” under the Toxic Substances every day is now considered2 a known miscarriages are due to chemicals as well. Control Act (TSCA) and therefore were reproductive toxicant. The report concludes that even if chemical never tested for toxicity; the estimated I saw that patient in 1994, but unfor- policy Continuedreform only on reduces the following the prevalence page . . . 2,000 new chemicals that come on the tunately nothing has changed since then. of these diseases by one-tenth of one per- marketwww.sfms.org annually also do not need to be The flawed Toxic Substances Control Act April 2010 San Francisco Medicine 23 Continued from the previous page . . . Tracy Zweig Associates cent, the United States would save about $5 INC. billion dollars per year in health care costs. A REGISTRY & PLACEMENT FIRM But my motivation isn’t just the health care cost savings. I’m fighting for my patient. She shouldn’t have had to suffer because of Physicians a flawed chemical safety system. There is Nurse Practitioners ~ Physician Assistants a national effort underway to 5reform the Toxic Substances Control Act. If doctors have the data they need on chemical toxicity, theyGina can Solomon, advise MD,their MPH patients. is codirector Then we of thecan UCSFprevent Occupational what we cannot and Environmental cure. Medicine Residency and Fellowship Pro- gram. She is an associate clinical professor of medicine at UCSF and the associate director of the UCSF Pediatric Environmental Health Specialty Unit. Trained at Harvard and Locum Tenens ~ Permanent Placement Yale, she is a senior scientist at the Natural Resources Defense Council. Voice: 800-919-9141 or 805-641-9141 FAX: 805-641-9143 References [email protected] A full list of references is available www.tracyzweig.com online at www.sfms.org/environmental- health2010. Environmental Health Materials for Clinicians

Health & Environment From: http://healthandenvironmentonline.com/2010/02/18/environmental-health-materials-for-clinicians/ describes some work being done in the U.S. to make environmental health science relevant to clinical practice. Key concepts include trust and transparency, so that environmental health science is presented in such a way as to inspire clinicians’ confidence in its accuracy and relevance. However, the clinicians and public health practitioners trying to do this have a difficult impasse to break: Because of differences in the evidence streams between clinical medicine and environmental health, little environmental health makes its way into medical education. That lack of education itself feeds the perception that environmental health issues are not immediately relevant to health care, making it still more difficult to introduce that information into medical education and clinical guidance. One source of inspiration hasPediatric been the Environmental American Academy Health of Pediatrics (AAP), which is considered in many ways to be ahead of the game. More than fifty years ago, the AAP established itsSan committee Fran Med on environmental Mag health and in 1999 published its first practical text, , now in its third01-29-09 edition. The work by the AAP is being used as a platform for developing other environmental health tools in the U.S. Some of theEducational best of these, M andaterials other resourcesand Tool for Kits information, are listed below.

• PSR tool kit:

• USCDC ContinuingU.S. Physicians Medical Education:for Social Responsibility developed this tool kit for clinicians, which has been endorsed by the AAP. http://www.psr.org/resources/pediatric-toolkit.html • ARHP Clinical Proceedings: An accredited online learning module about environmental health issues, from the U.S. Centers for Disease Control and Prevention. http://www.atsdr.cdc.gov/emes/health_professionals/pediatrics.html A clinical guidance document by the U.S. Association of Reproductive Health Professionals, designed to explain some of the issues and to provide assurance on the merits of the science around environmental influ- 24 ences San F ronancisco reproductive Medicine health. April http://arhp.org/publications-and-resources/clinical-proceedings/rhe 2010 www.sfms.org Medicine and the Environment

The Navigation Guide

An Evidence-Based Tool to Bridge the Gap between Clinical Practice and Environmental Health Science

Patrice Sutton, MPH; Jeanne Conry, MD, PhD; Pablo Rodriguez, MD; and Tracey Woodruff, PhD, MPH

R apidly accumulating evidence indi- cals will have an adverse impact on their evidence—it will almost never be available. cates that ubiquitous exposure to pregnancies. Many more patients may be In the context of preventing adverse “everyday” levels of environmental unaware of the preventable harms they and exposure to environmental contaminants, chemicals can manifest in a wide range of their families face from toxic substances in clinicians need to take timely action based

adverse health outcomes across1,2 the human their homes, workplaces, and community primarily on scientific evidence from lifespan and generations. Approximately environments. Health care providers have animal (in vivo) and in vitro studies. This 87,000 chemical substances were regis- a professional and ethical responsibility can seem counterintuitive, because the tered for use in U.S. commerce as of 2006, to provide prevention-oriented guidance use of in vivo and in vitro studies are not with about 3,000 chemicals manufactured in all of these situations. By proactively routinely part of daily clinical practice and

or imported3 in excess of 1 million pounds intervening to protect patients from harm- are often misunderstood by clinicians as each, and 700 new industrial chemicals ful environmental exposures linked to a “weak” evidence. are introduced into commerce each year. myriad of chronic diseases and disabilities, However, in vivo and in vitro data Today, these chemicals are distributed health professionals can improve patient are integral to regulatory scrutiny of com- throughout patients’ homes, workplaces, health outcomes more broadly. pounds used every day in clinical practice. and communities, contaminating food, wa- In an effort to speed the translation Pharmaceuticals are tested for toxicity and ter, air, and consumer products. Everyone in of environmental health science into im- to ensure benefits outweigh harms before

the U.S. has measurable levels4 of multiple proved patient outcomes, the University a physician can decide whether or not to environmental contaminants. While many of California San Francisco’s Program on prescribe the drug (Figure, page 26). Before scientific questions remain, the strength of Reproductive Health andNavigation the Environment Guide a drug can even be tested in humans, the the evidence is sufficiently high that leading undertook an interdisciplinary collabora- company or sponsor is required to perform

health care professionals and scientists have5-7 tive effort to develop the , in vitro and in vivo laboratory tests to dis- called for timely action to prevent harm. a systematicNavigation and Guide transparent road map for cover how the drug works and whether it’s How have these calls to action rever- evaluating the relevant scientific evidence. likely to be safe and work well in humans. berated in the trenches of clinical practice? The is based onNavigation contem- Only after the substance has undergone The scientific evidence linking environ- Guideporary methods of evidence-based medi- toxicity testing can humans be exposed in mental contaminants and adverse human cine (EBM). The purpose of the RCTs. Finally, before a drug is approved for health impacts is voluminous and largely is to build a foundation that can be sale, an independent and unbiased review unfamiliar to practicing clinicians. There is used to provide the practicing clinician must establish that a drug’s health benefits no trusted, ready reference or compendium with an easy, transparent, and quick way to outweigh its known risks. Therefore, in to consult in order to provide patients with incorporate the state of the science, patient vivo, in vitro, and human experimental timely, evidence-based advice about their values and preferences, and other factors evidence—plusprior an analysis of risks and exposure to environmental contaminants into clinical care decisions. benefits—have all informed human expo- (unlike the situation with pharmaceuti- Perhaps the most unfamiliar aspect sure decisions to the substance’s entry cals). Hence providing evidence-based of environmental health for the practicing into the marketplace. Once a drug is on the anticipatory guidance about environmental physician is the need to advise patients market, postmarket RCTs are also possible exposures is far outside the comfort zone about their exposures in the absence of (such as testing the comparative efficacy of and time constraints of most clinicians. Yet human experimental data (i.e., randomized- two different drugs). patients armed with Internet printouts are controlled trials [RCTs]) linking the exposure In stark contrast, clinical practice clamoring for advice about topics as wide- to a health outcome. When it comes to decisions about patientprior exposure to ex- ranging as the potential for harm from the advising patients regarding their exposure ogenousContinued substances on the in followingthe environment page . . . chemicals in their babies’ bottles to whether to environmental contaminants, a clinician must typically be made to regulatory 24 San Francisco Medicine April 2010 www.sfms.org theirwww.sfms.org workplace exposure to toxic chemi- should not wait for human experimental April 2010 San Francisco Medicine 25 Continued from the previous page . . . Navigation Guide harm that keep (orNavigation should keep) Guide toxic drugs the U.S., isNavigation a key partner Guide in developing the scrutiny of a compound and in the absence with no patient or population benefits off . of risk-benefit analysis, because of our the market. The is a sys- The is currently current regulatory and legal structure for tematic way to compile, rate, and sort the in the final stages of development. We governing manufactured chemicals (Figure evidence Navigationstream to make Guide it easy and quick anticipate its publication in late 2010 in a below). Unlike the case with pharmaceuti- for clinicians to confidently do just that. peer-reviewed journal. We hope that by cals, the presence of a product on the shelf The is a systematic, 2011 it will begin to provide these and other at the local chain store does not mean the transparent EBM methodology that is a professional organizations with a currently product has been tested for toxicity and key step in moving the emerging science in missing tool in a much larger effort to ad- does not mean its benefits and harms have environmental health directly, rapidly, and dress the health impacts of widespread been compared. Advising patients about easily into the exam room—where it can patientPatrice exposure Sutton, to MPH, toxic issubstances a research inscien the- substances that lack regulatory oversight make a difference to the health of patients tistenvironment. in the Program on Reproductive Health presents a very different decision context and their families. The urgent need to ad- and the Environment at UCSF. Jeanne Conry, to the practicing clinician. Indeed, the dress the role of the environment on patient MD, PhD, is chair of the American College of vast majority of chemicals in commercial health is increasingly gaining traction in Obstetricians and Gynecologists, District IX, circulation have entered the marketplace state and national professional societies of assistant physician in chief of Obstetrics and without comprehensive and standardized physicians and other clinicalNavigation care providers Guide Gynecology at Kaiser Permanente North information on their8 reproductive or other (see related article by Gould and Russell in Valley. Pablo Rodriguez, MD, is associate chronic toxicities. this issue). Uptake of the chair of obstetrics and gynecology and clini- Ethical considerations also virtually by professional organizations will result cal associate professor in the Department of preclude experimental human data from in evidenceprofiles that provide uniform, Obstetrics and Gynecology at Brown Medical the evidence stream—one cannot experi- simple, and transparent practice guidelines. School and Women and Infants Hospital of ment by exposing some people to polluted To this end, the American College of Rhode Island. Tracey Woodruff, PhD, MPH, water and others to clean water and then Obstetricians and Gynecologists District is associate professor and director of the see what happens. Instead, human evi- IX, which represents moreNavigation than 5,000 Guide Program on Reproductive Health and the En- dence in environmental health sciences is California physicians, is actively engaged vironment at UCSF. Visit http://prhe.ucsf.edu. collected by observing how exposures are in the development of the differentially distributed in the real world to support the clinical practice of its state References and measuring health outcomes among and national fellows. Likewise, Planned populations more (often occupationally) Parenthood Federation of America, whose or less exposed. While of scientific import, affiliates serve more than three million A full list of references is available online at studies that link workplace and/or com- women and men per year throughout www.sfms.org/environmentalhealth2010. munity exposures to adverse health outcomes represent a failure of prevention. For example, animal data on the carcinogenicity of a variety of chemicals have preceded as well as predicted later epidemiological observations in humans, and strong evidence exists that experimental results can be extrapolated9 qualitatively to human subjects. Whereas an experimental animal carcinogenic study typically lasts two years,

it can take twenty years to get9 a result from a comparable human study. Moreover, the benefits of environmental chemicals are mostly not health related, exposures are unintentional, and they vary and may or may not be significant depending on the toxicity of the agent. For all of these reasons, to protect their patients from harm related to environmental contaminants, clinicians must take timely action based on the same “upstream” 26in vivo San and Fra inncisco vitro indicators Medicine of April potential 2010 www.sfms.org Medicine and the Environment

Taking Action to Prevent Harm

County Medical Associations and Environmental Health

Robert Gould, MD, and Cindy Russell, MD

M embers of SF-Bay Area county the dangers of pesticides. More recently, in As exemplars of “First, do no harm,” medical associations, largely response to alarming trends in obesity and all of these policies provide a basis for based in the San Francisco diabetes, CMA has adopted comprehensive physicians to help transform our institu- Medical Society (SFMS) and Santa Clara policies encouraging hospitals to take the tions by addressing the environmental County Medical Association (SCCMA), have lead in improving health of patients and contributors to our patients’ health. For increasingly recognized that providing for the population overall by implementing example, members of SCCMA breathe life the best care for our patients and families food purchasing practices and menus into these policies by working on hospital- involves addressing the environmental and that promote health and prevent disease. based “green teams” and engaging hos- public health issues that impact patient This includes eschewing non-sustainably- pitals through environmental audits and and community health. Commencing in produced food such as meat from Concen- Grand Rounds about addressing climate the late 1990s, physician delegates to the trated Animal Feeding Operations (CAFOs) change in the healthcare setting, based CMA House of Delegates (HOD) tackled and instead choosing free-range animals, on information provided through a joint the issues posed by the hospital industry’s food grown on small and medium-sized project of Practice Greenhealth, Health own contribution to environmental pol- local farms, and food grown according to Care Without Harm, and Physicians for lution. These efforts led to CMA adopting organic or other methods that emphasize Social Responsibility. policies that reduce and ultimately would renewable resources, ecological diversity, Allied with parallel efforts by physi- eliminate a wide variety of hospital-based and fair labor practices. In 2009, CMA cians in other states’ medical associa- pollution. For example, the elimination responded to the rapidly accumulating tions, all of the foregoing measures have of mercury and various PVC plastics in evidence linking the overuse of antibiot- had an enormous impact on shaping the hospital practice will prevent impacts ics to serious outbreaks of drug-resistant recent direction of American Medical ranging from neurodevelopmental defects infections by joining the rising voice of Association (AMA), which has adopted to cancer. Subsequently, CMA policy ad- physician opposition to the use of non- policies promoting the incorporation of en- dressed the dangers of flame retardants therapeutic antibiotics in livestock. vironmental health into medical education, and responded to the warnings in 2009 CMA’s current efforts to address its supporting reforms in chemical policy, and by the Endocrine Society about the health longstanding concern about the adverse addressing mercury exposure and other impacts of endocrine-disrupting chemicals impact of air pollution are linked to issues key environmental health issues. Most and the need for timely action to prevent of fossil fuel use and the unfolding global recently, AMA has made a major commit- harm. health threats posed by climate change. ment to participate in actions to address Recent CMA policies have moved CMA has called for hospitals to use the climate change and has adopted a policy beyond the targeting of specific toxic cleanest and most sustainable forms of to promote the engagement of clinicians agents of concern to call for the adoption energy and has encouraged physician and policy makers in creating a healthy of public-health protective chemical policy support for binding reductions in national and sustainable food system. to address the well-documented inadequa- and global greenhouse emissions. In 2009, As such, the work of CMA physicians cies of the existing regulatory framework, CMA adopted policy in support of “smart has been successful in bringing diverse under which there is lack of toxicity test- growth” strategies that protect health issues that had long been outside the ing for the vast majority of the more than and endorsed the education of health range of patient care to the forefront of the 80,000 chemicals in commerce. professionals with resources, such as the concerns of mainstream medical practice. Reflecting the adage that “we are what Eco-Health Footprint Guide distributed by Our charge now is to transform this new we eat,” CMA has passed many policies the Global Health and Safety Initiative, to awareness that permeates multiple levels aimed at protecting vulnerable popula- help mitigate the impacts of health care of the health careContinued system into on the page concrete 29 . . . tions, including schoolchildren, farm work- system contributions to climate change measures needed to transform our institu- 26 San Francisco Medicine April 2010 www.sfms.org ers,www.sfms.org and agricultural communities, from and toxic pollution. April 2010 San Francisco Medicine 27 Medicine and the Environment

Vitamin D and Calcium

Increasing Evidence for Optimal Health

William B. Grant, PhD

I nformation on the health benefits of been determined that serum 25(OH)D which prevented rickets; this amount has vitamin D and calcium for optimal levels should be at least 40–60 ng/mL no other health benefits. The Institute of health has been appearing at an for optimal health. The mean population Medicine of the National Academies has increasing tempo during the past few serum 25(OH)D levels in the United States formed a committee to review vitamin D years. The benefits include reduced risk are 16 ng/mL for African Americans, and calcium requirements and is due to of many chronic, infectious, and autoim- 21 ng/mL for Hispanic Americans, and make its recommendation in May 2010. mune diseases as well as adverse preg- 26 ng/mL for white Americans. African There are few adverse effects of nancy and birth outcomes. The chronic Americans have a 25 percent higher vitamin D. With whole-body UVB irradi- diseases include many types of cancer, mortality rate than white Americans, and ance, one can make at least 10,000 IU/ cardiovascular disease, congestive heart this difference can be explained in terms day in a short time. Adverse effects such failure, diabetes mellitus type 2, osteopo- of lower serum 25(OH)D levels. Solar as hypercalcemia have been found in rosis, falls, and fractures. The infectious ultraviolet-B (UVB) radiation is a good general only for 20,000–40,000 IU/day diseases include both bacteria infections source of vitamin D when the sun is high for very long periods. However, those (pneumonia, dental caries, periodontal enough that the atmosphere transmits with certain diseases, such as adenoma disease, tuberculosis, sepsis/septicemia) sufficient UVB. The way to take advantage of the parathyroid gland, granulomatous and viral infections (Epstein-Barr virus, of the sun as a source of vitamin D is to diseases, lymphoma, sarcoidosis, and influenza type A). The autoimmune expose as much of the body as possible tuberculosis, should limit their vitamin D diseases include asthma, type I diabetes without sunscreen for ten to thirty min- intake or production due to the fact that mellitus, multiple sclerosis, and perhaps utes, depending on skin pigmentation, the body’s innate immune system pro- rheumatoid arthritis. Adverse pregnancy being careful not to turn pink or red or duces too much 1,25-dihydroxyvitamin outcomes include primary Cesarean- burn. While there is a risk of skin cancer D in the serum, leading to hypercalcemia. section delivery, preeclampsia, and infant or melanoma from solar or artificial UV, Several studies have examined how health problems. the risk can be minimized by not burning, much mortality rates and economic The mechanisms whereby vitamin D not tanning excessively, and not wearing burdens of disease could be lowered if produces its benefits are reasonably well sunscreen when there is little danger of population mean serum 25(OH)D levels known. The classical benefit of vitamin burning. For those living south of about were increased to 40–45 ng/mL. These D relates to absorption and metabolism 37º, those who develop nonmelanoma studies were for Western Europe, Canada, of calcium; calcium intake increases the skin cancer have reduced risk of internal the Netherlands, and the United States. health benefits of vitamin D, not only cancers since it is warm enough that they The results generally showed that mor- for bones but also for cancer. For cancer, can produce enough vitamin D to greatly tality rates could be reduced by about vitamin D helps with cell differentiation reduce risk of internal cancers. 15 percent, corresponding to about two and destruction of rogue cells and also Supplements represent an efficient additional years of life, and that the eco- reduces angiogenesis around tumors and way to obtain sufficient vitamin D. Each nomic burden of disease could be reduced metastasis. For metabolic diseases, the 1,000 IU/day translates to about 10 ng/ by about 10 percent. mechanisms include increased insulin mL increase in serum 25(OH)D levels for During pregnancy and lactation, sensitivity and insulin production. For the average-sized person. Thus, African women should be taking about 6,000 IU/ infectious diseases, vitamin D induces Americans should consider taking 3,000 day. Bruce W. Hollis and Carol L. Wagner production of cathelicidin and defensins, IU/day while white Americans should of Medical University of South Carolina which have antimicrobial and antiendo- consider taking 2,000 IU/day. The cur- recently completed a randomized con- toxin activities. rent dietary guideline, approximately trolled trial vitamin D supplementation From reviews of disease outcomes 400 IU/day, was based on the amount of for pregnant and nursing women and 2829related SaSan toFFr aserumncisco 25(OH)D MMedicine levels, April it 2010has vitamin D in a spoonful of cod liver oil, found that 2,000 IU/day www.sfms.org was inadequate than 180 papers in peer-reviewed journals. County Medical Associations His bibliography can be found at http:// Continued from page 27. . . and that there wereVitamin no adverse D Scientists’ effects www.researcherid.com/rid/B-8311-2009. withCall 6,000to Action IU/day. For the text of References tions and practices to meet the challenges , please go to www. of our time. Armed with the policies and grassrootshealth.net. It is also possible evolving tools we have developed, Cali- to orderWilliam a home B. Grant test kit has for a serum Ph.D. in25(OH) phys- A full list of references is forniaDr. physicians Robert Gould can continueis associate to makepatholo an- icsD levels (U.C. Berkeley),for $51. a thirty-year career in available online at www.sfms.org/ gist,enormous Kaiser and San critical Jose; president impact. of the San atmospheric studies, and a fourteen-year Denvironmentalhealth2010.isclosure Francisco Bay Area Physicians for Social career in studying the risk modifying fac- Responsibility; and a CMA delegate from the tors for chronic and infectious diseases Santa Clara County Medical Association. Dr. with an emphasis on diet, ultraviolet ir- Dr. Grant receives funding from the Cindy Russell is a plastic and reconstructive radiance, and vitamin D, starting with UV Foundation (McLean, Virginia), the surgeon and cochair of the Environmental the first paper on diet as a risk factor for Sunlight Research Forum (Veldhoven), Health Committee of the SCCMA and also a Alzheimer’s disease. He has published more and Bio-Tech-Pharmacal (Fayetteville, Ar- delegate to the CMA. kansas) and has previously received funding from the Vitamin D Society (Canada). America Pushes to Overhaul Chemical Safety Law The President’s Congress Considers Stronger Regulation Cancer Panel Diagnosing shortcomings, Brendan Borrell Prescribing Precaution Nature 463, 599 (2010)

In 2009, the overseeing panel of the When it comes to commercial chemi- were submitted with any health and safety National Cancer program held hearings cals, the presumption of innocence may be data, and the EPA has been able to require on the environment and cancer, with the coming to an end. The Toxic Substances testing for only about 200 chemicals. About intent of producing a report on current Control Act (TSCA) allows the U.S. Envi- 95 percent of notices of new chemicals science and policy. The report is due soon, ronmental Protection Agency (EPA) to test include confidential information, ostensi- but the panel’s chair, LaSalle Leffall, Jr., chemicals that pose a health risk—but only bly to protect company trade secrets; this MD, has provided introductory remarks when it has evidence of harm. effectively prevents scientists outside the in Reviews on Environmental Health that Since the law was passed in 1976, the EPA from challenging the chemicals’ safety. includes papers from the Panel meetings. agency has restricted just five chemicals, out With the TSCA essentially tooth- An excerpt: “The percentage of of tens of thousands on the market. “It’s a less, state officials have emerged as key cancers that develop as a result of en- deeply flawed bill that needs to be rewrit- watchdogs, banning chemicals in toys and vironmental exposures is not known. ten,” says Terry Davies, an environmental elsewhere and supporting research into Furthermore, it is believed that existing policy expert who worked on the act and is nontoxic alternatives. But in December, estimates are based on outdated science now at Resources for the Future, a nonprofit Lisa Jackson, the head of the EPA, told Con- and significantly underestimate the research organization in Washington, D.C. gress that the TSCA needed to be “updated actual influence of the environment on Congress is likely to take up a bill this and strengthened.” U.S. regulators should cancer…infants, children, and adolescents spring that would shift the burden of proof benefit from comprehensive chemical are especially vulnerable to environmen- to manufacturers. Advocates for reform are testing being conducted under Europe’s tal contaminants. Prevention efforts in pushing for potential legislation to include Registration, Evaluation, Authorization, and environmental cancer are impeded by scientific advances in recent decades, such Restriction of Chemicals (REACH) legisla- insufficient research and ineffective as how chemicals affect people at different tion, which came into force in June 2007. regulations. The current regulatory ap- ages and how multiple chemicals interact Davies will be watching the reform proach in the U.S. is reactionary rather in the body. efforts closely. “I’m quite optimistic that than precautionary and is impaired by The TSCA gave the EPA the authority to something will happen,” he says. “How inadequate funding and staffing, weak regulate chemicals and chemical mixtures good it will be or how far it will go, I’m not laws, decentralized and uneven enforce- not covered under laws for food, drugs, so sure.” ment, complex requirements, and indus- cosmetics, and pesticides. But the 62,000 try influence.” chemicals that were already on the market Proceedings of the meetings can in 1976 were exempted. Of 21,000 chemi- be found at http://deainfo.nci.nih.gov/ cals registered since 1976, only 15 percent advisory/pcp/pcp.htm 2829 SaSan FFrancisco MMedicine April 2010 www.sfms.org www.sfms.org April 2010 San Francisco Medicine 29 When’s the last time your insurance company paid you?

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Biomonitoring Updates

Measuring Chemical Exposures

Davis Baltz, MS, and Sharyle Patton

CDC’s Fourth National Report on Human Exposure to Environmental Chemicals the first report in 2001 to 116 chemicals Addressing this gap, nongovernmental in 2003 to 148 chemicals in 2005. organizations have stepped forward to Although the number of tested chemi- raise awareness about the significance of cals is increasing, critics say that the federal personal chemical body burdens by testing I n DecemberFourth National 2009, the Report Centers on Humanfor Dis- effort could be improved. John Stephenson, small groups of individuals who then often Exposureease Control to Environmental and Prevention Chemicals published GAO director for Natural Resources and publicly speak about the toxic substances its Environment, recently testified before measured in their bodies and the impact . Congress and called for a coordinated these substance can have on human and (www.cdc.gov/exposurereport/index. research strategy among government ecosystem health. html) Biomonitoring, or biological moni- agencies to ensure that biomonitoring col- One recent example of public inter- toring, is the measurement of chemicals lection and analyses are better coordinated est biomonitoring is the Mind, Disrupted and their breakdown products or metabo- with research needs. project by the Learning and Develop- lites in human tissues and fluids. Commenting about the fourth report, mental Disabilities Initiative (LDDI), an Some portions of the CDC report have Senator Frank Lautenberg (D-NJ) noted international partnership of organizations been published earlier but, taken together, that the CDC’s findings highlight the need concerned with environmental threats to the fourth edition is the most comprehen- to reform the Toxic Substances Control neurological health. Twelve LDDI lead- sive assessment so far of U.S. residents’ Act (TSCA), the only U.S. law regulating ers and advocates were found to carry in exposure to chemicals in the environment. industrial chemicals, which dates to 1976. their bodies bisphenol A, PBDEs, PFCs, Two hundred and twelve chemicals were “Far too little is known about the and other chemicals associated in animal measured in the blood and urine of some hundreds of chemicals that end up in or human studies with neurological dys- 2,400 Americans. our bodies, and the EPA has far too little function. One of the provocative findings was authority to deal with the chemicalsGreenwire that The study participants are troubled the discovery that perchlorate was found science has already proven dangerous,” by the number of children and adults in in the urine of all study participants. Lautenberg was quoted in a the United States currently diagnosed with Although perchlorate is a naturally oc- article published Dec. 11, 2009. Lauten- learning and developmental disabilities. curring salt, most exposure occurs from bergDavis is expected Baltz, MS, to isintroduce special projects legislation advi- While increased awareness and improved anthropogenic sources such as rocket sorto reform for the TSCACollaborative in 2010. on Health and the diagnostic criteria play a role in the current fuel, fireworks, and road flares. It has Environment. figures, studies controlling for those factors contaminated water supplies across the imply that other culprits, such as chemi- U.S. High levels of perchlorate adversely Mind, disrupted: How Toxic cal contaminants and gene-environment affect thyroid function, while effects from Chemicals may change How interactions, also likely play a role in the lower exposure are being studied. How- We Think and Who We Are rising incidence of these diseases. ever, as with other chemicals, low levels Participants also expressed concerns of exposure during critical periods of fetal about inadequate federal policies govern- gestation can be particularly harmful to ing environmental chemicals, calling for the developing neurological and other T he CDC biomonitoring survey sup- better neurotoxicity testing of chemicals, organ systems, and the timing of exposure plies valuable information about protection for those most vulnerable from can be a critical variable in understandingNational Ex- chemical exposures in United States exposures to neurotoxicants, and readily posurehealth effects.Reports populations, but it does not convey indi- understandable information about path- Since the CDC began its vidual results, nor are its analytical pro- ways ofContinued exposure. on the following page . . . , the number of chemicals tocols designed to explore associations Executive Director of the Learning haswww.sfms.org risen from twenty-seven chemicals in between exposures and health outcomes. April 2010 San Francisco Medicine 31 Medicine and the Environment

Counting Roaches

Reducing Pesticide Exposures via Integrated Pest Management

Philip Landrigan, MD, MSc

K nowing all that we know about the home to teach the mom and the fam- costs were equal, and in future years we pesticides, what are the strategies ily about how to clean up food residues. anticipate that IPM homes would have that we as a society can adopt to The handyperson also spent a couple of lower costs than conventionally treated reduce exposures? I tend to think that hours closing cracks and crevices in the homes. control of a toxic exposure such as pes- apartment, the portals through which So IPM works. It’s doable. It’s some- ticides ought to proceed on three levels. cockroaches typically enter apartments. thing that I commend to you and wish you There are steps that need to be taken at We evaluated levels of pesticides in well with. In fact, the City of New York was the national level having to do with pes- the homes that participated in the IPM so impressed with this approach and with ticide registration and standard setting; program and compared them to levels the cost savings that resulted from it that there are steps that need to be taken at the of pesticides in the homes that received it hasPhilip made Landrigan, IPM the standard MD, MSc, of is practicedirector state or the city level; and there are steps conventional pesticide spraying. We also ofin Newthe Children’s York City publicEnvironmental housing. Health that people can take in their own homes, engaged in the interesting exercise of Center and professor of pediatrics and pursuing the maxim that a parent is the conducting roach censuses, which we chair of the Department of Preventive Med- CEO in his or her own home. did by taking a sticky pad about the size icine at Mount Sinai School of Medicine. With regard to control of pesticides of a piece of computer paper and placing in the home, I’d like to tell you about it under the kitchen sink once a month something we did a few years ago in East for twenty-four hours, then doing a body Harlem, New York City. We undertook a count to see how many roaches actually Biomonitoring Updates rigorous evaluation in the East Harlem accumulated. Continued from page 31. . . community to see if integrated pest We found three things. First, the management (IPM) could be successful homes that swore off chemical pesticides in a mostly poor, 90 percent minor- and went to integrated pest management Disabilities Association of New York State ity community. We partnered with two decreased their indoor contamination and project participant Stephen Boese neighborhood health centers in East Har- with chemical pesticides by 90 percent. said, “As a father of four boys, one of whom lem that are about ten blocks apart. We Second, in homes that went to IPM there lived a short life of overwhelming disabil- introduced IPM to the parents who were was a 50 percent reduction in the num- ity, I am keenly aware that prevention of attending one clinic, and we taught a vig- bers of roaches actually counted as com- learning and developmental disabilities orous fire-safety and accident-prevention pared to the homes that used traditional is both an individual and a community program to parents in the other. Parents pest control, which had no reduction in responsibility. The enormous rise in the in the second group continued to receive roach counts. This confirms that tradi- incidence of these disabilities is coupled conventional pest control, in which the tional pesticides simply chase the roaches with a huge increase and proliferation of exterminator visited each month and from one apartment to another, like the chemicals in everyday consumer prod- sprayed the apartment. Over a year, we coming and going of the tide. ucts. These chemicals are largely untested followed the two groups of families to see Finally, by year’s end there was for humanMind, safety Disrupted and largely unknown to whether IPM could make a difference. At virtually no cost difference between the the public.” the end of the year, to achieve equity, we two. There was a one-time, up-front cost The report was introduced everything to everyone. per unit in the IPM homes to bring the releasedSharyle February Patton directs 4, 2010: the Common www.- The way the IPM worked was that handyperson in to do the repairs, and wealminddisrupted.org Biomonitoring. Resource Center in when a mom who was pregnant came then after that the monthly costs in the Bolinas, California. in to the clinic for her prenatal care, we IPM homes were much less because there offered to provide her IPM at no cost. If was no need to purchase expensive pes- 32she Sa agreed,n Fra nciscowe sent aM handypersonedicine April out 2010 to ticides. Thus, by the end of one year, the www.sfms.org Dr. David Young, MD reconstructive plastic surgeon

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CPMC Kaiser UCSF Michael Rokeach, MD Robert Mithun, MD Elena Gates, MD

CPMC is proud to announce the opening The San Francisco Asthma Task Force Health is influenced by myriad envi- of the DROP-IN Fine Needle Aspiration Biopsy formed in 2001 when community activists, ronments, including clinical settings, family, (FNA) Service, supported by the Department many from Bayview Hunters Point, joined and society. In this issue, you’ll find several of Pathology. Under the directorship of Dr. forces with the Board of Supervisors to create examples including an evidence-based tool Ian Jaffee and with the support of Dr. Richard a citywide response to an asthma epidemic. called the Navigation Guide to bridge the gap Garcia-Kennedy and Dr. Shine Yun, all board- Kaiser Permanente San Francisco has been an between clinical practice and environmental certified experts in cytopathology, the FNA active partner since the beginning, support- health science, and an online resource called Service provides same-day availability on the ing projects that prevent and control asthma, Toxic Matters (see page 26). Recently launched California Campus (3700 California St., fourth such as reducing exposure to environmental by UCSF, Toxic Matters was created to facilitate floor), from 9:00 a.m. to 4:00 p.m., Monday triggers and promoting medical management. smarter decisions about substances that can through Friday. The FNA Service provides Our environmental advocacy work includes harm general and reproductive health. UCSF diagnostic aspiration of superficial, palpable improving outdoor and indoor air quality in is constructing a medical center at Mission masses of all body sites. For coordinating both homes, schools, and child care settings, as well Bay, incorporating evidence-based design dis- schedules and same-day drop-in requests, as coordinating efforts with local agency and coveries that demonstrate that buildings can please contact Client Services at (215) 600- community partners. These projects include affect healing, safety, and well-being. Targeting 2200. a new Renters’ Rights Clinic, offering free legal LEED gold certification, the new hospitals The Forbes Norris MDA/ALS Research advice to tenants in the Bayview Hunters Point incorporate green design and soothing visu- and Treatment Center has won the Program district as well as the promotion of consumer als. Therapeutic roof gardens will comprise of the Year award from the California Speech- access to green cleaning products that do not part of the largest green space planned for an Language-Hearing Association. The CSHA is contain known asthmagens. Additionally, plans urban U.S. hospital. Patient rooms will include a nonprofit organization dedicated to helping are underway for training at a Housing Author- materials undergoing an unprecedented children and adults with communication chal- ity family development in Visitacion Valley to assessment to eliminate most known toxic lenges. The award is one of the highest that reduce pesticide use and cockroach infestations. elements, and the percentage of workstations CSHA gives out and is a fitting tribute to the The Asthma Task Force also supported a project with daylight will rank among the highest in extraordinary work that the staff at Forbes to improve the capacity of Housing Authority U.S. hospitals. Norris do every single day. staff to investigate mold and water infiltration in For the past few years, UCSF pediatri- CPMC physician Dr. Nadine Burke, housing units by using thermographic (infrared) cians and researchers Robert Lustig, MD, and medical director of the Bayview Child Health cameras. Work in schools continues with the Michele Mietus-Snyder, MD, have focused on Center in Bayview Hunters Point, was recently San Francisco Unified School District (SFUSD) the “toxic” environment surrounding children San Francisco Chronicle profiled in an article in the Style section of the to improve indoor air quality by transitioning that encourages unhealthy food choices and . The article featured a to green classroom and custodial cleaning prod- sedentary lifestyles. Their 2008 published day in the practice of Dr. Burke and highlighted ucts and by implementing the USEPA Tools for article describes neuroendocrine survival many of CPMC’s successes. Dr. Burke was also Schools Program, including recommendations mechanisms in the brain designed to prevent one of three doctors recently honored at the to reduce the use of bleach and to provide ac- starvation (hypothalamus), heighten reward Medical Center’s annual Wishes for Wellness cess to registered disinfectants that are safer for (nucleus accumbens), and attenuate stress fund-raising gala for their contributions to those with asthma. Ongoing participation in the (amygdala). This “limbic triangle” makes health. Dr. Burke is a U.C. Berkeley-trained Bay Area Environmental Health Collaborative weight gain in modern times almost inevi- physician with a master’s degree in public advocating for Air District regulatory strate- table, and interventions based on cognitive health from Harvard. To review the complete gies to reduce cumulative air pollution impacts education alone likely to fail. “An integrated article, you may log onto www.sfgate.com/ on disproportionately burdened communi- approach that alters the family environment cgi bin/article.cgi?f=/c/a/2010/02/19/LVG- ties will improve overall outdoor air quality. and a societal commitment to alter the food O1BVMCV.DTL . For more information, visit www.sfgov.org/ and built environments will both be necessary 3435 San Francisco Medicine April 2010 asthma. to combat obesity,” said Lustig. www.sfms.org Hospital News

St. Mary’s Veterans Richard Podolin, MD Diana Nicoll, MD, living, compared to 23 percent of the nonde- PhD, MPA pressed participants. The link between depression and increased risk of later disability remained significant even after the researchers adjusted for age, gender, physical condition, health status, socioeconomic status, and other factors. Lead author Kenneth E. Covinsky, MD, MPH, a geriatrician at SFVAMC, says that the study was not designed to examine the reasons Nearly ten years ago, St. Mary’s Medical People with symptoms of depression in for the link. It is not clear, he says, whether Center established an Environmental Action middle age have a significantly greater risk in treating middle-aged depression with an- Committee (EAC), and the group has been old age of being physically disabled or unable tidepressive medications will help prevent meeting ever since. The EAC is comprised of to carry out tasks of daily living, according to later disability. “It might make just as much employees from numerous departments, from a study led by researchers at the San Francisco sense to think about mechanisms by which purchasing to engineering to our food service, V.A. Medical Center and the University of Cali- depressed people might become physically who are committed to making ecologically fornia, San Francisco. disabled,” he says. “For example, we know that informed decisions that will both support our The study followed 7,207 adults who people with depression are socially isolated, medical center and protect our environment. enrolled in the Health and Retirement Study which in turn compromises their ability to For example, the EAC tries to purchase supplies in 1992, when they were aged 50 to 61. The live independently. They are also less physi- that are made from recyclable content or that research is an ongoing national prospective cally active, which has a direct effect on health. can be recycled after use. It is also the EAC’s study of health, income, and wealth. The So we might want to include interventions mission to raise awareness about recycling and authors found that by 2006, 45 percent of the that improve social functioning and level of Journal of the other environmental issues within our hospital 877 participants who reported significant physical activity.” The study appears in the American Geriatrics Society community. St. Mary’s now recycles medical depressive symptoms in 1992 had persistent online Early View section of the supplies with Ascent Healthcare Solutions, a difficulty with mobility or activities of daily . company that reprocesses and remanufactures medical supplies originally designed for single Peter J. Panagotacos, MD use. We recycle office supplies, electronic equip- Board Certified Dermatologist ment, and waste containers. Our food service/ Specializing in nutrition department serves food in paper and biodegradable materials only, and it purchases Hair Restoration fair-trade coffee. In our meetings, water is for men and women for over 35 years at served in pitchers, not plastic bottles, and we 2001 Union Street are planning to start a composting program San Francisco, CA 94123 soon. The marketing department has taken on the challenge of reducing waste by distributing (415) 922-3344 reusable bags (made of 100-percent recyclable Award-winning educational website material) at patient and marketing events. www.HairDoc.com All these environmental efforts are paying off. In 2009, 25 percent of all waste at St. Mary’s Author of the guide to hair loss causes and was recycled. We cut down water use by more medical and surgical treatment options. than 3 million gallons in a single year. We are Hair Loss Answers proud of these accomplishments, but we are 2nd edition also committed to expanding our efforts. St. Mary’s has applied to the San Francisco Depart- ment of the Environment for a grant to assist • Member of SFMS and CMA for over 30 years in the purchase of a used, 40-yard, recyclable • AMA Lifetime Member • Fellow of the American Academy of Dermatology material compactor. All new construction and • Member of Advisory Council of American Society of Hair Restoration • Member of International Society of Hair Restoration Surgery renovations will feature low-flow flushometer • Member of International Society of Dermatologic Surgery toilets and energy-efficient lighting. We see these efforts as the logical extension of our role 3435 San Francisco Medicine April 2010 www.sfms.org aswww.sfms.org stewards of the health of our community. April 2010 San Francisco Medicine 35 Book Review

Steve Heilig, MPH

Slow Death by Rubber Duck

Slow Death by Rubber Duck The Secret Danger of Everyday Things

By Rick Smith and Bruce Lourie (Counterpoint, 336 pages, $25) The Simpsons

P oor Marge Simpson. In a recent episode of , the terms our ongoing “slow poisoning,” since “we’re all marinating in iconic but insecure cartoon housewife made the mistake of chemicals every day.” using nonstick cookware and offering plastic cups with the The political dynamic is equally if not more difficult. The wrong number stamped on them. The other mothers at her party large and powerful chemical industry maintains what the authors grabbed their children and ran as if a bomb had gone off. Another term a “don’t worry, be happy” argument, similar to that taken by party ruined. tobacco spokespeople for decades. Every step of the way, lobbyists Were the parental panic and Marge’s ostracism justified? Does and their front groupsSlow Poisoning tend to fight by Rubber any restrictions Duck on the use of the threatening appearance of chemicals such as PFCs (in nonstick their products, or any negative press supporting such restrictions. pans) and BPA (in plastics) on America’s most renowned television The bulk of is seven case stud- series mean concern about toxics has finallySlow gone Death mainstream? by Rubber ies regarding phthalates, PCBs, mercury, antibacterial products, DuckPanic, no; but concern and action, yes, argue Canadian environ- pesticides, and, yes, Teflon on pans and BPA in plastics. Most of mentalists Rick Smith and Bruce Lourie in these stories have been told in detail before, but the summaries , for “there is no separation between environmental issues and here are clear and compelling. health issues.” Marge’s guests got it right that “children are most at In a nice twist, the authors conducted mini “toxic experiments” risk to the many serious ailments linked to toxic chemicals,” they on themselves. Smith did all he could to first avoid and then expose argue, including “asthma, autism, attention deficit hyperactivity himself to “normal” phthalate-containing products for twenty-four disorder (ADHD), obesity, and reproductive disorders, among oth- hours each, and he had his urine monitored for the chemicals in ers.” Add in serious diseases arising later in life, such as Parkinson’s question. “I was actually shocked at the results,” he notes. “My little and Alzheimer’s plus some cancers, and it’s a frightening scenario. experiment showed how amazingly easy it is to dramatically crank So, what to do? up levels of MEP (one problematic phthalate) after a simple change Self-education is an essential first step, and this book is a in toiletries for two days. Who knew that conditioning your hair good resource for that. Chemicals increasingly linked to health could be hazardous to your health?” problems are found in “toys, baby bottles, kid’s pajamas, popcorn San Francisco started a legislative restriction on phthalates bags, mattresses, and thousands of other products we assume to that moved to the state and then national levels, as told by the be safe.” What might that mean? Smith and Lourie trace concerns authors. New chemical regulations in Europe are driving even about health-threatening chemicals in consumer products to the American-based chemical companies to clean up their products. use of radium in luminescent pocket watches made for soldiers in So, at least in some arenas, healthy progress is underway—but World War I. When women painting the radium onto the watch much more is needed. faces started to get ill, they sued, and people threw the watches Smith and Lourie provide advice to consumers on how to away—but the five woman plaintiffs all died of radiation-induced reduce exposure to each of the troubling chemicals they explore. cancer. Phosphorus in matches, mercury in hats—the resulting “I am not a chemophobe,” avers Smith. “I love chemicals. Most of dementia resulted in the term “mad as a hatter”—toxic lead in paint, the chemicals in my life . . . are just dandy. . . . What I object to are and other examples resulted in new safety laws and agencies. But the chemicals like triclosan that aren’t necessary, are possibly dan- most chemicals have escaped serious study and regulation. gerous, and are foisted on us every day without our knowledge or Thus, to date most industrial chemicals have been assumed consent.” Steve Anybody Heilig, MPH, who is reads director this of book public will health likely and come education to object for innocent until proven guilty. While research has taken long strides theto that San as Francisco well. Medical Society. A previous version of this review in showing how many of the roughly 80,000 industrial chemical in appeared in the . use can impact animals and humans, showing definitive proof is a 3637long, Sa complexn Francisco scientific M process.edicine And April thus 2010 what one advocate herein San Francisco Chronicle www.sfms.org Public Health Report

Steve Heilig, MPH

Antibiotics (Still) at Risk

“How You Gonna Keep ‘Em Down on the Farm?”

B acteria are the likely the best creatures known for teaching stronger. The most intensively studied country, Denmark, saw a 50 and demonstrating evolution in action. They reproduce percent decrease in total antibiotic use without negative impacts so fast and are so responsive to environmental selection on farmers or consumers but a large public health benefit. But pressures that one can alter a colony’s genetics in very little time. what about in the USA? It’s literally a textbook case of Darwinian survival of the fittest. In 2002, the SFMS convened a conference on this issue, co- Of course, that’s not always a good thing for other species. chaired by two living legends of medicine and public health, Philip And with bacteria and antibiotics, it’s been war from the start. Lee, MD, and Lester Breslow, MD. One result of that meeting was a Drug-resistant strains and colonies began to arise as soon as anti- policy resolution urging the phaseout of routine use of antibiotics biotics came online; the race to keep ahead of them is constant and in agriculture; this policy was adopted by the CMA and AMA. But, escalating. In fact, Alexander Fleming, who discovered penicillin, to be frank, not much has changed in practice. warned about just this threat in his 1945 Nobel Prize address. The latest federal legislation introduced to stop the use of hu- Antibiotic-resistant infections kill tens of thousandsRising Plague of man medicine-important antibiotics is called PAMTA, the Preser- Americans each year and have been estimated to cost the U.S. up vation of Antibiotics for Medical Treatment Act (HR 1549/S.619). to $34 billion annually. Brad Spellberg, MD, author of , Hundreds of health, medical, and consumer and environmental warns, “We are seeing infections . . . that are literally resistant groups have endorsed it. to every antibiotic that is FDA approved. These are untreatable And what do farmers think? Many smaller producers, es- infections. This is the first time since 1936, the year sulfa hit the pecially in the “organic”-type sector, already forego antibiotics market in the U.S., that we have had this problem.” unless absolutely necessary. But “big agriculture” lobbyists fight Experts have long warned that we use too many antibiotics any restrictions. They have argued that restrictions in Europe in agriculture, as growth promoters and prophylaxis in meat pro- have led to outbreaks and higher costs, although authorities there duction. The concern was that this reservoir might spill over into say that this is a “creative” and untrue rumor. And now even the human infections. According to the Union of Concerned Scientists, USDA holds that the cost savings of using antibiotics are a mirage 70 percent of antibiotics used in this country are fed to healthy in most cases. livestock; another 14 percent treat sick livestock. The remaining The sad precedent of the tobacco wars is conjured: Evidence 16 percent go to people and pets. In recent years, some resistant of a severe health threat is strong; corrective measure are pro- strains of human pathogens have found their way from feedlots posed and endorsed; political lobbying gridlocks the remedy. and farms into hospitals and humans. AsClinical an old Infectious song asked, Diseases “How The risk keeps growing, and people suffer and die. PAMTA, at a you gonna keep ’em down on the farm?” minimum, needs to be enacted. Even more is likely warranted. Apparently, we cannot. A 2002 Will our leaders listen before uncontrollable disaster strikes? meta-analysis of more than 500 studies found that “many lines of Martin Blaser, MD, a past president of the Infectious Diseases evidence link antibiotic-resistant human infections to food-borne Society of America, warns of “lethal pandemics” if antibiotic re- pathogens of animal origin.” The Institute of Medicine concluded sistance is not brought under control. In fact, some longtime in 2003, “Clearly, a decrease in the inappropriate use of antimicro- observers of this threat fear that, rather than a nuclear or other bials in human medicine alone is not enough. Substantial efforts threat, it might well be our smallest, longtime, invisible enemies must be made to decrease inappropriate overuse in animals and that prove For more the information,end of humanity, see www.keepantibioticsworking.com. bringing about our demise, as T. agriculture as well.” S. Eliot warned, “not with a bang but a whimper.” That’s a brief summary of expert opinion and evidence. In light of this, the European Union has banned the use of antibiotics 3637 San Francisco Medicine April 2010 www.sfms.org inwww.sfms.org livestock except to treat illness—and the evidence has grown April 2010 San Francisco Medicine 37 In Memoriam

William S. Andereck, MD

Edgar Wayburn, MD

Dr. Edgar Wayburn ended his long and distinguished career RA, had already been on March 5th, in his home in San Francisco. He was 103. The done. Still, he was only Sierra Club referred to him as the “twentieth-century John Muir.” 73 at the time, and he The San Francisco Chronicle called him a “quiet hero.” His con- was needed in Alaska. I servation efforts led him and his wife Peggy to develop the Red- watched in awe as each woods National Park and to lead the Sierra Club in its successful June for the next ten campaign to protect the Alaskan wilderness. Dr. Wayburn, along years, he would pack with colleagues Amy Meyer and Phil Burton, was instrumental his family up and take in preserving the most significant wild space in the Bay Area, the off to tour the wilds of Golden Gate National Recreation Area (GGNRA). the forty-ninth state. I knew Ed as a colleague and physician for more than thirty Patient, persistent, and years. It’s not as well recognized that, in addition to his remarkable focused, he developed accomplishments in the environmental world, Dr. Wayburn had an and guided the strategy illustrious career as an internist in San Francisco. During fifty-two that was to result in the years of private practice, he was on the staff of both Stanford and Alaska Lands Act. All UCSF, ending his career at California Pacific in 1985. He served the the while, he continued San Francisco medical community as Medical Society president in to see his patients each 1965 and for many years represented SFMS at the CMA’s House afternoon after spending the morning with Sierra Club staffers. of Delegates. He also served as a member of the board of trustees Ed received many awards in his distinguished career, includ- of California Pacific Medical Center in the early 1980s. ing the Albert Schweitzer Prize for Humanitarianism, presented Ed was born in Macon, Georgia. He completed his under- by President Clinton in 1995. One he held dearly was his fifty-year graduate work at the University of Georgia and headed to Harvard member pin from the San Francisco Medical Society. I was with for medical school, graduating in 1929. He was not a typical child him in 1983 when he received his award with full pomp and cir- of the South. His mother was from San Francisco and, from what cumstance. Subsequently, he realized that he had not joined the we can tell from the Macon newspapers, was quite a radical for Medical Society until 1934, one year after starting practice. So Ed, her times. His father died when he was two years old. Trips to in his proper, patient, and methodical way, convinced the Society the Bay Area with his mother may explain why, after completing to issue him a second fifty-year pin at its awards ceremony the a residency in Germany, he moved to San Francisco in 1933. Dr. following year. He was quite proud of the fact that he had earned Wayburn began his medical practice with his uncle, Dr. Ernest two fifty-year pins! Voorsanger, a tuberculosis and early pulmonary specialist. Dur- Vision is not a quality you can appreciate in a man until you ing World War II, he was stationed in England with the Army Air have known him for a long time. A story he once told me exem- Corps. At the close of the war, he oversaw one of largest chest X-ray plifies that vision. After President Carter signed the Golden Gate screening programs ever attempted, imaging every GI returning National Recreation Area into law, Ed was sitting in a suite in the from the European theater. Fairmont with the bill’s main sponsor, Phil Burton. This was in Returning to San Francisco after the war, he met Peggy 1972, at the end of the Vietnam era and the height of the Cold Elliot, the Manhattan copywriter who would become his wife War. Phil, who, according to Ed, was already on his fifth or sixth and partner for the next fifty-five years. He arrived for their first Stoli by then, raised his glass: “To that provision you stuck in the date dressed for a day in the woods. Then they went for a hike in bill,” he exclaimed, ”that if the Army should ever, for any reason, Marin. At the time, she would tell me years later, she didn’t have decide to decommission the Presidio, it would revert automati- anything but her fancy Madison Avenue shoes, but she got some cally to the GGNRA!” Ed remembers thinking he would never live good hiking boots the next day, because they went hiking the to see that day. second weekend as well. Ed Wayburn not only lived to see the Presidio become a Na- I joined Ed in the practice of medicine in 1979. Georgia boy tional Park but to see the rest of his work celebrated throughout to Tennessee boy, we formed an immediate bond. Our relation- the world. I have lost a mentor. The environment has lost a friend. ship was founded on mutual respect and trust, cemented by a The medical community of San Francisco has been blessed to have handshake, nurtured with frequent lunches and hikes in Bolinas. had a true hero in its midst. He had already served three terms as president of the Sierra Club, Ed and Peggy had a son, William; three daughters, Cynthia, 38and Sa hisn work Francisco on the Redwoods Medicine National April 2010 Park, and even the GGN- Laurie, and Diana; and three grandchildren. www.sfms.org

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