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2 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org January / February 2006, Vol. 79, No. 1
Environmental Health and Medicine
Feature Articles MEMBER SERVICES 4 On Your Behalf 11 The Mainstreaming of Environmental Medicine and Health Philip R. Lee, MD and Steve Heilig, MPH 43 In Memoriam 43 Calendar of Events 12 Toward an Ecological View: Complex Systems, Health and Disease Ted Schettler, MD, MPH MONTHLY COLUMNS 16 Air Pollution and Heart Disease: Recent Developments Michael Lipsett, MD 7 President’s Message Gordon L. Fung, MD 18 Environmental Contaminants and Human Fertility 9 Editorial Linda C. Giudice, MD, PhD, Alison Carlson and Mary Wade Mike Denney, MD, PhD 20 Standing Up to the Lead Industry: 40 Hospital News An Interview with Herbert Needleman, MD
23 Chemical Exposure and Parkinson’s Disease: A Plethora of Suspects Editorial and Advertising Offices Jackie Hunt Christensen and Deborah Cory-Slechta, PhD 1003 A O’Reilly San Francisco, CA 94129 25 The Real Rx: Slow Food, Lively Places, Real Vitality Phone 415/561-0850, ext. 261 Richard J. Jackson, MD, MPH, Megha Doshi and Monica Rai Fax 415/561-0833 Email: [email protected] 27 Choosing Sustainability: Paths to Green Chemistry in California web: http://www.sfms.org Michael Wilson, PhD, MPH San Francisco Medicine reserves the right to 32 Our Stolen Future: A Decade Later edit all reader contributions for brevity, John Peterson Myers, PhD, Dianne Dumanoski and Theo Colborn, PhD clarity and length as well as to reject any material submitted. All expressions of 34 Biomonitoring: Measuring Environmental Contaminants in the Body opinions and statements of supposed facts Davis Baltz, MS are published on the authority of the author over whose signature they appear and 36 Toxicants and Disease Database Update cannot be regarded as expressing the view Sarah Jannsen, MD, PhD, MPH of the SFMS, unless previously adopted by the society. Acceptance of advertising 37 Green Guidelines for Health Care in this publication in no way constitutes Charlotte Brody, RN approval or endorsement of products or services by the SFMS. 38 Methylmercury in Fish: An Update Jane M. Hightower, MD Subscriptions: $45 per year; $5 per issue. Advertising rates and information Of Interest sent upon request. Printing: 39 2005 SFMS Election Results Sundance Press P.O. Box 26605 Tucson, AZ 85726-6605
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 3 January/February 2006, Volume 79, Number 1 N OUR EHALF Editor O Y B Mike Denney, MD A sample of legislation and advocacy activities SFMS/CMA provide for you Managing Editor Edare K. Carroll Copy Editor Cynthia Rubin RETURNABLE FLU VACCINE December. In the meantime, physicians Cover Artist AVAILABLE; IT’S NOT TOO LATE should submit to Medicare claims for Alex Rothwell TO VACCINATE billed charges, rather than billing at 2005 The Centers for Disease Control & or 2006 fee schedule rates. Physicians will Editorial Board Prevention (CDC) have authorized be paid by NHIC, California’s Medicare Mike Denney, Chairman Nancy Thomson, Obituarist Sanofi Pasteur to begin on Friday, January carrier, at the reduced 2006 rates until Stephen Askin Wade Aubry Toni Brayer Corey Maas 6, selling its stockpile of flu vaccine to Congress returns and passes legislation Jaqueline Dolev Jerome Fishgold physicians and others. To encourage reimplementing the higher 2005 payment Alan Greenwald Erica Goode Gretchen Gooding Samuel Kao continued vaccination efforts, and to levels. Thomas Lee Arthur Lyons Rita Melkonian Kenneth Maybury minimize financial risk to physicians, the NHIC will then make appropriate Judith Mates Ricki Pollycove Jordan Shlain Leonard Shlain vaccine is being sold with a return policy. payment adjustments, including possible David Smith Kathleen Unger Physicians will be able to return unused positive retroactive payments if authorized Leo van der Reis Stephen Walsh Shieva Khayam-Bashi vaccine within 30 days for a credit. Flu by the legislation. (It is yet to be vaccine is also available from some determined how these retroactive SFMS Officers Gordon L. Fung, President vaccine distributors, including FFF payments would be disbursed.) Only Stephen E. Follansbee, President-Elect Enterprise (nonreturnable) and McKesson physicians who submit claims for billed Charles J. Wibbelsman, Secretary Stephen H. Fugaro, Treasurer Corporation (returnable). Some charges will be eligible for these Mike Denney, Editor Alan G. Greenwald, Immediate Past President physicians who have extra vaccine for sale retroactive payments. Physicians who bill have also contacted CMA. Contact at the lower 2006 fee schedule will not
SFMS Executive Staff Robin Flagg (415)882-5110 or receive retroactive payment increases if Mary Lou Licwinko, JD, MHSA, Executive Director [email protected] for more information. indeed Congress returns physician Steve L. Heilig, MPH, Director of Public Health & Education Edare Carroll, Director of Communications/Managing Editor payments to the higher 2005 levels. Posi Lyon, Director of Administration Therese Porter, Director of Membership CONGRESS FAILS TO PASS Although the 2006 Medicare MEDICARE PAYMENT FREEZE BY participation enrollment period is over,
Board of Directors JAN. 1; PHYSICIANS URGED TO CMS has also indicated that it will allow Term: Jan 2006-Dec 2008 SUBMIT CLAIMS FOR BILLED physicians to change their participation Mei-Ling E. Fong, MD Thomas H. Lee, MD CHARGES UNTIL CONGRESS status once Congress has taken action on Carolyn D. Mar, MD STOPS THE CUT the physician payment issue. Rodman S. Rogers, MD John B. Sikorski, MD In mid-December, the U.S. House of Contact: Elizabeth McNeil (415) Peter W. Sullivan, MD John I. Umekubo, MD Representatives passed a federal budget 882-3376, [email protected], for more
Term: Jan 2005-Dec 2007 package that would have stopped the 4.4 information. Gary L. Chan, MD percent Medicare cut and frozen physician George A. Fouras, MD Jeffrey Newman, MD payments at 2005 rates. However, the CLARIFICATION ON Thomas J. Peitz, MD John W. Pierce, MD Senate passed an amended budget package PHLEBOTOMY CERTIFICATION Daniel M. Raybin, MD FOR MEDICAL ASSISTANTS Michael H. Siu, MD that had to go back to the House for final approval. Unfortunately, by that time Effective April 9, all persons Term: Jan 2004-Dec 2006 Richard L. Caplin, MD almost all members of the House had left performing phlebotomy in California Lucy S. Crain, MD Jane M. Hightower, MD Washington for the holidays and House must be either licensed or certified in Brian J. Lewis, MD Republican leaders declined to take action order to draw blood for laboratory testing. Michael Rokeach, MD Jordan Shlain, MD on the Medicare physician payment issue. The law does, however, provide an Alan M. Teitelbaum, MD Because Congress did not complete its exception for medical assistants working CMA Trustee Robert J. Margolin work, the Centers for Medicare and in physician offices under the supervision AMA Representatives Medicaid Services (CMS) were obligated of a physician, registered nurse or other H. Hugh Vincent—Delegate by law to implement the scheduled 4.4 licensed healthcare provider. Judith L. Mates—Alternate Delegate Judith L. Mates—AMA’s Women Physicians Congress percent rate cut on January 1. If a medical assistant wants to perform Governing Committee CMA and AMA are working phlebotomy outside a physician office or vigorously to get Congress to pass the clinic, he or she must be a Certified payment freeze that was agreed to in Continued on page 5
4 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org Phlebotomy Technician under regulations CHANGE IN CIVIL RIGHTS LAW of the California Department of Health BARS DISCRIMINATION BASED Services. There are three levels of ON MARITAL STATUS certification for phlebotomists: Limited JUST ONE OF DOZENS OF LAWS All SFMS members Phlebotomy Technician (skin punctures), THAT WILL IMPACT PHYSICIANS are cordially invited Certified Phlebotomy Technician I California anti-discrimination law to the (venipunctures and skin punctures), and has been updated to outlaw discrimination Certified Phlebotomy Technician II (skin based on marital status. California’s Annual Dinner punctures, venipunctures, and arterial Business & Professions Code has for years punctures). prohibited discrimination on many Celebrating the Health care professionals—including grounds, including marital status, and installation of our physicians, registered nurses, licensed provided that all invidious discrimination 2006 President vocation nurses, and clinical laboratory could result in a finding of unprofessional scientists—do not need additional conduct. Gordon L. Fung, MD phlebotomy certification to perform skin, The state’s civil rights law, the Unruh vein, or arterial punctures, as they are Civil Rights Act, had previously barred and the 138th year of authorized to do so under their discrimination based on sex, race, color, the San Francisco professional licenses. More details are religion, ancestry, national origin, available in CMA ON-CALL document disability, sexual orientation, medical Medical Society #1605, “Medical Assistants.” condition and other grounds, but it did not specifically include marital status. In Thursday, SAVE THE DATE: EMR 2005, the Unruh Civil Rights Act was January 26, 2006 CONFERENCE IS MARCH 25 IN amended by the Legislature to bar SAN FRANCISCO discrimination based on marital status. Delancey Street Catering, CMA is cosponsoring the Healthcare The law requires physicians to treat Town Hall Information and Management Systems all “similarly situated” patients equally. So, 600 Embarcadero Society’s electronic medical records while a physician can choose not to conference, “Physicians Adopting perform a certain procedure at all, if that Cocktails: 6:30 pm. Computer Technology.” The one-day physician performs a procedure for married program is March 25 at the San Francisco patients, he or she cannot deny the Airport Marriott. Attendees will receive procedure to similarly situated patients Dinner and program: step-by-step guidance on selecting and who are unmarried. Physicians should 7:30 p.m. implementing electronic medical records ensure that they treat patients without (EMR). Presented by physicians who have regard to their sex, color, race, religion, been through the process, the conference ancestry, national origin, disability, Black Tie Optional will explore: choosing the best system for medical condition, marital status, or Parking Available your practice size, budget, and specialty; sexual orientation and that differences in converting successfully from paper to treatment are based on medically relevant Mail Your RSVP back by electronic records; avoiding common circumstances. mistakes; helping colleagues and staff who This law is just one of dozens of new January 16, 2006. aren’t computer savvy; ensuring the laws that will affect physicians in 2006 and system integrates well with hospitals, beyond. For more information on new Call Posi Lyon at pharmacies, and other practices and laws of interest to physicians, read CMA’s (415) 561-0850, ext. 260 avoiding legal problems and ensuring annual “New Laws” article. Contact with any questions. confidentiality. The conference also CMA’s legal information line for more includes product exhibits and information at (415) 882-5144 or demonstrations of today’s top EMR [email protected]. sfm Come join your products. colleagues and mentors Register by March 6 and receive $50 SFMS IS MOVING AT THE END for a night off the registration fee. CMA members OF JANUARY. OUR NEW ADDRESS pay $139, nonmembers $169. (After of history and fun. IN THE PRESIDIO WILL BE: March 6, members pay $189, nonmembers 1003 A O’REILLY $219.) SAN FRANICSCO, CA 94129
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 5 Physician Wanted
PSYCHIATRIST – SAN FRANCISCO STATE UNIVERSITY STUDENT HEALTH SERVICE JOB #300
Full-time during Spring and Fall Semester (8 mos), Half-time during Summer Semester and Winter Break (4 mos); Days & Times to be arranged.
Providing outpatient psychiatric care for diverse community of 30,000 students.
MINIMUM QUALIFICATIONS: Completion of a psychiatry residency, valid California medical license, DEA Cert, CPR cert. Board certification in Psychiatry or ability to obtain within two years of hire.
Strong background/current knowledge of psychopharmacologic agents and psychological methodologies; experience with adolescents and young adults care.
For further information please visit http:// www.sfsu.edu/%7Ehrwww/jobsearch/112105.htm for the week of Nov. 21 & send res. w/ SS# & Job #300 to HR Dept, 1600 Holloway Ave, Room 252, SF, CA 94132-4252. Open until filled. EEO/ ADA.
ATTENTION SAN FRANCISCO PHYSICIANS: Your journal currently seeks your CREATIVITY. We want poetry, short anecdotal stories, photography, photographs of paintings, drawings, sculptures, or other original works of art for publication in San Francisco Medicine. Don’t be shy. Submit your work and encourage other physicians to participate. We’d like to begin including original artwork in each issue. We are also looking for future cover art. Send to Edare Carroll, managing editor, at [email protected] or mail to San Francisco Medicine, c/o 1409 Sutter Street, San Francisco, CA 94109.
6 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org Gordon L. Fung, MD President
President’s Message
What Is the Mission of the San Francisco Medical Society?
s I prepare for the year 2006 as your elected president, the needs of all San Francisco physicians and advances the health I am deeply indebted to Alan Greenwald, MD, your of our patients and community.” Aimmediate past president, for arranging a retreat for I believe this is a very action-oriented statement that more the leadership of the SFMS. The timeliness of the retreat was key closely reflects the activities and proceedings of our organization. as we, your leaders, have embarked on a course that will focus our Numerous physicians volunteer their time and expertise at SFMS energies on the mission of this medical society. to address the needs of members and offer solutions to the Over the last year, we have accomplished many things, challenges of working in the beautiful but expensive city of San including a very successful delegation to CMA’s House of Delegates, Francisco. The liability insurance crisis that exists in other states where numerous resolutions were developed by SFMS delegates is not such a problem in California due to our previous efforts with and brought to fruition at the House. We welcomed the biannual MICRA and the continued watchful surveillance of the CMA visit by the Hiroshima delegation from Japan as they performed and the delegates as well as SFMS members on CMA’s Council of their biannual evaluations on the survivors of the Hiroshima Legislation and Board of Trustees. The SFMS delegation met with bombing. And I am pleased to report, albeit with mixed feelings, Assemblyman Leland Yee and our state legislators to defeat several that we also sold the mansion at 1409 Sutter Street, the current issues and bills that would restrict in-office imaging to a single location of the SFMS. As part of the sale, we disbanded our rentals specialty group of physicians, impose onerous responsibilities on and catering enterprise, which although successful at the outset us to have on-site interpretation in every medical office, and require was a victim of the 9/11 cutbacks and never really recovered to its physicians to have required CME on use of antidepressants, cardiac initial glory. As we prepare to move to a new location in a few risk factor management and warning signs of a myocardial weeks, the retreat has been a wonderful opportunity to review the infarction and stroke. purpose of the SFMS and redirect our energies. We also developed specific plans to address four major areas: The retreat process can sometimes be mundane and tedious. membership, information technology, fellowship and wellness, and But this one energized us and gave us a sense of purpose. It helped political advocacy. to focus the SFMS leadership and staff and gave us all a working As your president, I welcome your input and energy. I look blueprint for the next year—my year as president. forward to serving you in any way I can. It is coincidental but During the morning hours of the retreat, we learned something highly fortuitous that 2006 is the Chinese Year of the Dog. The interesting—very few of us knew what the mission of the San dog is a giving and compassionate personality; offers kind words, Francisco Medical Society was. Thus, we spent a fair amount of support and advice to friends and family; and is a listener, always time discussing the strengths and weaknesses of the organization; available to lend an ear or a shoulder to a friend in need. Dogs are the issues of relevancy; and our current reputation among our incredibly attentive. Dogs are responsible, compassionate, reliable, membership, patients and nonmember physicians, as well as honest, but sometimes anxious, overwhelming, and even nosy. So, ourselves. We looked at our current mission statement and felt with these characteristics as a framework for the coming year, I am that it was no longer relevant to our current activities. A smaller truly excited about serving as your president of the new, improved task group at the retreat took on the job of wordsmithing a new and somewhat leaner SFMS. mission statement so that it summarized the sentiments of the By the time this article is in print, the holidays will have come members present. It was further revised and then voted on and gone. Still, I wish members and their families a wonderful unanimously. holiday season and hope you are looking forward to celebrating I’m pleased to relay that the new mission statement of the the New Year and the Year of the Dog. January 26, 2006, is Chinese
SFMS is as follows: “The San Francisco Medical Society serves New Year’s Day.sfm
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 7 Health Savings Accounts are a fast, convenient way to take care of your health expenses.
The San Francisco Medical Society and the California Medical Association are pleased to provide you with an opportunity to open a federally tax advantaged Health Savings Account (HSA). We’ve teamed with one of the country’s leading providers of HSAs to offer each one of our members a way to help manage their health care costs.
Also, investing HSA funds gives you added control of your health care finances and turns your HSA into a financial planning vehicle.* Top 10 Reasons to Open an SFMS/CMA HSA 1. One stop for all your HSA and high-deductible health plan needs 2. Available to physicians, their families, and their staff 3. No set up fee (for CMA members who enroll on or before January 1, 2006) 4. Enroll online at http://www.cmanet.org/hsa 5. Low monthly fees 6. While you may change high deductible health plan companies over time, you never have to change your CMA HSA 7. Broad array of investment options 8. Higher interest rate than other HSA products 9. More contribution options 10. Complies with federal tax laws
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8 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org Mike Denney, MD, PhD Editor
Editorial
Kant’s Dove
n Critique of Pure Reason, the 18th century philosopher The psychologist James Hillman put it this way: “The ‘bad’ place Emmanuel Kant argues that an a priori direct personal I am ‘in’ may refer not only to a depressed mood or an anxious state of Iexperience of oneself in intimate relationship with one’s mind; it may refer to a sealed-up office tower where I work, a set-apart environment is a necessary foundation for clear understanding. He suburban subdivision where I sleep, the jammed freeway where I says that abandonment of the immediate world of the senses leads to commute between the two.” He might have added that the physical hubris in which one is deceived by isolated reason and deprived of a symptoms that we experience, indeed the cancer and heart disease solid or useful foundation of knowledge. from which we suffer, are also caused partly by the polluted and stressful To emphasize his point, Kant uses the metaphor of a dove that environment in which we live. wants to change its environment: “The light dove cleaving in free Yes, there is a physiological component to these psychological flight the thin air, whose resistance it feels, might imagine that its dynamics of relationship of self to other. Neuroscientists Andrew movements would be far more free and rapid in airless space.” This Newberg, MD, and Eugene D’Aquili, MD, performing PET scans that misguided bird might alter its environment in an attempt to improve detect radioactive tracers, have identified a small area in the posterior its own mobility, even survival, only sadly to discover that the very superior parietal lobe of the human brain that they call the OAA, resistance of the air was what had provided the buoyancy for flight— orientation association area. The PET scans of this OAA show vibrant and the well-meaning dove falls and crashes to the ground. bursts of brilliant reds and yellows as the brain monitors the resting As in this issue of San Francisco Medicine we contemplate subject’s place in relationship to the surrounding landscape, “to generate environmental medicine—the epidemiology of cancer, lead poisoning, a cognition of the physical limits of the self . . . the distinction between chemicals and fertility, pollution and cardiology, biomonitoring of toxins the individual and everything else . . . to sort out the you from the and systems theory in environmental health—is it possible that we infinite not-you that makes up the rest of the universe.” have something to learn from Kant’s dove? Might we find guidance in Newberg and D’Aquili performed these PET scans upon a group the psychology of the relationship of self to other? of Tibetan monks in meditation and a group of Franciscan nuns in The predominant theme of our established body of psychology is prayer. The researchers noted the colors in the OAA area of the brain what some describe as the fallacy of the isolated individual. Freud’s changed to more peaceful cool greens and blues when the monks theories of the id and ego, Adler’s notion of individual psychology, reached a state of meditation in which they experienced a feeling of indeed, almost the whole opus of psychoanalysis and psychotherapy being “part of everyone and everything in existence,” and when the were all focused upon the isolated, inner world of the patient. This led nuns related “a closeness to God” and became “content with initially to the angst of existentialism, developed later into the “me” everything.” generation of the sixties and seventies, and culminated in the self- Perhaps these philosophical, psychological and physiological indulgent dynamics evidenced by the descriptive title of Christopher concepts offer us a way to learn from the error of Kant’s dove. As we Lasch’s book The Culture of Narcissism. Historian and ecologist Theodore seek to change our environment, to create new technology with which Roszak has pointed out that of the thousands of psychological conditions to enhance life, we can take care that we do not destroy the very listed in the medical diagnostic manuals only one, seasonal affective elements that nurture our survival. In that spirit, we can not only disorder, refers to a patient’s relationship to the environment. diagnose and treat patients who suffer from the effects of toxins and However, in his book Ecopsychology, Roszak, together with a diverse pollutants, but we can also prevent illness by protecting and preserving group of psychologists, educators, humanists and environmentalists, our natural habitat. As physicians heeding the critique of pure reason, published a collection of essays that emphasize that the human psyche we can soar in the free flight of intimate relationship with other so that is an integral part of the web of nature and acknowledges that because we and our environment will not fall and crash to the ground as would we eat, breathe and interact, the definition of “self” does not end at our Kant’s misguided dove. sfm skin.
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 9 Letter to the Editor
Dear Editor, On behalf of the Forensic Mental Health Association of California (FMHAC) I would like to thank you for focusing your recent journal (October 2005) on Medicine and the Law. The mission of FMHAC is to foster the provision of mental health services to mentally ill persons in the criminal justice system and to advance the profession of forensic mental health. Untreated mental illness is a social and medical crisis. Budget compromises, lax mandatory civil treatment laws and political neglect have shifted the burden of this crisis onto the criminal justice system. For us to maintain any hope of social change, these issues need to stay in the public view and I appreciate the many fine articles in your journal on this topic. FMHAC sponsors a conference each year focusing on these issues. Some of the authors in your recent journal are presenting at our conference and are actively involved with our association. This year’s conference will be held in Seaside, Calif., from March 15 to 17. We offer continuing education units for MDs, RNs, social workers, psychologists and correctional officers. Additional information is on our website www.fmhac.net. Again, thank you for your excellent work. Sincerely, Officer Joel Fay, PsyD President, Forensic Mental Health Association of California Senator Speier To Receive Dr. Nathan Davis Award
The San Francisco Medical Society is pleased to announce that Honorable Jackie Speier, its nominee for the 2006 American Medical Association Dr. Nathan Davis Awards, has been chosen in the category of State Legislator.
The awards, presented to local, state and federal career and elected government officials, were established by the AMA in 1989 and are one of the most prestigious forms of recognition for outstanding public service in advancement of public health.
The officers of the AMA will present the awards at a banquet in Washington, DC, on March 14, 2006. Generally, over 500 health sector representatives, as well as members of Congress and administration officials attend this dinner each year. SFMS Officers and Executive Director Mary Lou Licwinko will join Senator Speier at the banquet, along with other leaders from the CMA and SFMS.
Anyone interested in joining the SFMS banquet table should contact Mary Lou Licwinko at (415) 561-0850, ext. 237,
as soon as possible. sfm
10 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org Philip R. Lee, MD, and Steve Heilig, MPH
Introduction
The Mainstreaming of Environmental Medicine and Health
his issue of San Francisco Medicine is the third impacts—are fascinating and sometimes revolutionary. This “Environmental Health” edition we have presented research is important. We do need to know more, using T in as many years, following a landmark conference established and new tools, but need not wait for “more research” hosted by the San Francisco Medical Society in 2002. These to take protective actions using accepted public health strategies. special editions of the journal have been very popular among There are many lessons, especially from the tobacco wars, that readers in terms of reprint requests, online access and other could guide policy for environmental chemicals. feedback. Our authors have been drawn from among the nation’s One of the lessons in public health history is that physician leaders in scientific, educational and policy advancement in this leadership can be very effective, even crucial, to improvement field. We are very pleased to continue that standard with this in practice and policy. From the earliest public health initiatives latest installment. Those who seek more information are for cleaner water onward, physicians, both as individuals and in encouraged to visit the information-packed new website of the organizations, have played a crucial, even catalytic, role. national network launched at the SFMS meeting, the The inspiring case of Herbert Needleman, MD, regarding Collaborative on Health and the Environment: lead toxicity in children is an important example in www.healthandenvironment.org. environmental health. The tobacco issue is another. Leading As the evidence gains ever more credibility that environmental health scientist and clinician Ted Schettler, MD, environmental factors—particularly chemicals—are factors in MPH, tirelessly teaches about this issue nationwide and has many human health conditions, previously skeptical scientists observed that no medical association to his knowledge has taken and others lend their support to further the goals of on such an active leading role as the SFMS. environmental health advocates. The American Heart It is our hope that more and more physicians and their Association released a landmark report and initiative on professional organizations will become convinced by the ever- environmental cardiology; reports from publications ranging growing scientific and epidemiological evidence that some of from JAMA to the Wall Street Journal gave credence to arguments the more than 80,000 industrial chemicals in use, many of which that researchers concerned about toxins have been making for have now been demonstrated to be present in all our bodies, years. Physicians and scientists signed on to consensus statements need not and should not be there. And we hope that then, as of concern, including one in Europe signed by some of the world’s happened with tobacco and other such threats, the medical leading researchers—some of them Nobel Prize recipients. profession can lead actions to decrease exposure and improve Europe’s leading medical associations called for a strict legal the diagnosis and treatment of those affected. framework for chemicals as such a policy wound its way toward We are proud to present some of the field’s top voices in approval by the European Parliament and eventually, we hope, this special edition. The SFMS will also, in partnership with the nations of that continent—thus requiring safety testing for other health organizations, hold a major conference on these thousands of compounds widely used in everyday products. topics in October. Please read on, stay tuned, and join the Europe may be ahead of the U.S. in this regard, but our own thousands of concerned professionals who have joined the FDA’s approach to pharmaceuticals, flawed though it may be, Collaborative on Health and the Environment. sets a precedent here as well. Philip Lee is a professor at Stanford University and UCSF The scientific themes underlying such efforts and policies— (where he is also Chancellor Emeritus), a former United States that low-dose exposures can have impacts as significant as higher Assistant Secretary of Health, and Chairman of the exposures; that developmental exposures in utero and in children Collaborative on Health and the Environment. Steve Heilig is can have lasting, delayed lifetime impacts; that mixtures among Director of Public Health and Education for both SFMS and the many chemicals within us can have synergistic negative the Collaborative on Health and the Environment.sfm
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 11 ENVIRONMENTAL HEALTH Toward an Ecological View: Complex Systems, Health and Disease Ted Schettler, MD, MPH
Complex relationships among individuals, populations, and entire work to maintain favorable physiologic genetic, biologic, toxicologic, nutritional, ecosystems. System behavior depends on conditions, but sufficient external stress geologic, economic, political, social, specific circumstances and often fluctuates can exceed the buffering capacity of the cultural and historical phenomena are around a mean. However, exaggerated system or cause adaptive responses with major determinants of health or disease. oscillations or near-threshold conditions their own adverse impacts. In individuals, The dominant scientific approach to can create vulnerability to small the result may be illness or premature understanding this complexity involves death. In populations of people, changes taking it apart in order to examine more in system conditions can cause the manageable pieces. That approach emergence of new patterns of disease or emphasizes the role of parts and de- ❝ Even when corrected, iron behavior. Ecosystem changes may favor emphasizes relationships. Then, in an certain populations, and some species may attempt to understand some larger whole, deficiency in infancy appears find new system dynamics inhospitable. scientists often construct models built of to have long-term conse- These are the driving forces of selected individual variables from the quences, with reduced evolutionary biology. ground up, referring to “independent” mental functioning and Most medical conditions do not have variables that combine to determine the single “causes” or single necessary “dependent” outcome of interest. increased behavioral antecedents. Typically, a number of factors Clinical medicine, and to a large problems in children are linked together in complex causal degree public health practice, favors evaluated at 10 years of age. webs, in a context of susceptibility. At examination of individual risk factors best, we can say that some collection of when trying to understand the causes and Children in poor social factors increases the risk of a disease but distribution of disease. In many instances circumstances seem to be their relative contributions may vary that approach has been enormously particularly affected.❞ considerably from one circumstance to fruitful and has led to important medical another. and technological achievements. The strength of association between However, models built of individual risk an exposure and disease is fundamentally factors have explanatory limits. They are affected by the prevalence of other necessarily impoverished representations component causes in a given context. of profound multidimensional system perturbations that can propel the entire What is unimportant in one set of complexity—in the individual, system into new dynamic operating circumstances may be very important in community, and ecosystem. conditions. Studies that ignore details of another. Commonly used statistical Multiple interactions among system conditions will miss important models intended to describe relationships variables, positive and negative feedback real-world determinants of health in among multiple risk factors, including loops, and nonlinear system dynamics complex interactive systems. multiple regression analyses, are often determine the health and behavior of In humans, homeostatic mechanisms Continued on page 13
12 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org unable to capture the complex between lead exposure and cognitive • Omega-3 fatty acids in fish reduce the heterogeneity of real world circumstances. impacts. Lead also has effects on cognition cardiovascular toxicity of mercury. The combined and independent that are independent of iron status. Iron impacts of dietary iron deficiency, lead is required for neurotransmitter synthesis • Mercury decreases the beneficial exposure and social conditions on brain and myelination. Lead can disrupt cell effects of omega-3 fatty acids on brain development of children illustrate some proliferation, differentiation, synapse development. of these points. These three variables of formation, myelination, and programmed course are not the only determinants of cell death, as well as altering • Omega-6 fatty acids increase childhood brain development, but they neurotransmitter levels. atherosclerosis caused by PCB are important. Awareness of their Studies of the impact of interventions exposure while plant-derived interactive, combined effects is essential that reduce blood lead levels have variable antioxidants protect against this for designing effective public health results. The children who benefit most effect. interventions. from lead level reduction appear to be those whose iron status is sufficient. Lead The prevailing paradigm resists IRON DEFICIENCY, LEAD level reduction in children who are iron framing cognitive impairment, cancer, or EXPOSURE, SOCIAL deficient does not seem to improve birth defects as ecological outcomes— CIRCUMSTANCES AND BRAIN cognitive performance. outcomes inherent in a particular DEVELOPMENT IN CHILDREN Even when corrected, iron deficiency ecosystem—and favors conceptualizing Many studies show that develop- in infancy appears to have long-term these as problems in individuals to be mental low-level lead exposures are consequences, with reduced mental and explained by individual risk factors and associated with persistent cognitive motor functioning and increased understood using primitive models. impacts and behavioral changes. Blood behavioral problems in children evaluated Identifying individual risk factors has lead levels around two or three years of at 10 years of age. Children living in poor been very helpful for understanding major age are particularly important for their social circumstances seem to be determinants of certain diseases like lung impacts on cognitive development. particularly affected, whereas more cancer and heart disease. Perhaps, Iron deficiency is probably the world’s enriched social circumstances tend to however, we should be thinking about most common single nutrient deficiency. blunt the impacts of early iron deficiency diseases that are resistant to a risk-factor About 10 percent of toddlers in the U.S. on mental functioning. approach, such as breast and prostate are iron deficient and the prevalence is This example points to a deeply cancer, many birth defects, or substantially higher in non-Hispanic rooted problem: Focusing on individual neurodevelopmental disorders, as blacks, Mexican-American females and risk factors often does not honor the ecological manifestations of multiple Alaskan natives. Children who are iron complexity of systems of interest. Other changes in the dynamic system in which deficient are at risk for cognitive deficits, examples from animal and human studies people are conceived, develop, live and even if they do not have anemia that is also illustrate the interpenetration of grow old. often associated with this nutritional nutritional status, exposure to toxic It seems unlikely that we will truly deficit. Studies of the impact of treatment chemicals, and mammalian biology: understand the origins and prevalence of of iron dedeficiency anemia are these conditions and be able to design inconsistent though most conclude that • Nutritional status can modify the preventive strategies by looking just at children continue to exhibit lower carcinogenic risk of exposure to individual risk factors. These are academic performance, even after the carcinogens. conditions that emerge from complex anemia is corrected. systems, and we do not understand their A number of studies have • Nutritional status can modify the ecology well enough. Effective prevention documented a correlation between iron teratogenic risk of exposure to is more likely to be realized when top- deficiency and elevated lead levels, teratogens. down systems analyses are added to a particularly in younger children. Iron bottom-up individual risk factor approach. deficiency may amplify the effect of • Dietary selenium reduces the toxic Biologists, epidemiologists, clinicians and environmental lead contamination by impacts of mercury. the general public must be willing to increasing absorption and retention by expand their horizons, learning from increasing absorption and tetention by • Maternal social and economic ecologists and other integrative increasing hand-to-mouth behavior and, deprivation increase the neuro- disciplines. hence, lead ingestion. developmental impact of prenatal New approaches may be fruitful in Despite their correlation, iron exposure to chlorpyrifos in offspring. Continued on page 15 deficiency is not essential in the pathway
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14 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org Complex Systems, understanding. of educational, scientific, medical and civic Traditional clinical medical care tends to institutions? Can we continue to hope that a Health & Disease focus primarily on individual risk factors and haphazard collection of interests, ideologies Continued from page 13 therapies directed at modifying them and civic and governmental institutions individually. A more integrative approach that developed long ago will contribute to simultaneously addresses a number of relevant ecosystem resilience that will remain favorable three areas: how we imagine the world, factors may hold promise for enhancing the to continued human survival on a finite planet how we study the world and how we systemic health of individuals and populations, over time? respond. as well as addressing the health of entire Many different social and cultural ecosystems. Dr. Ted Schettler institutions could address these three areas, Businesses, health care facilities, local and holds a medical degree including education, research, medical care, regional governments, farmers, agricultural from Case Western public health, governmental agencies, institutions and religious organizations, among Reserve University and businesses, religious organizations, the others, could be encouraged through a variety a masters in public health nonprofit sector and philanthropy. of incentives to modify or expand their spheres fromHarvard Univer- Ecology and evolutionary biology should of concern to entire ecological systems in sity. He is science direc- be introduced early into primary, secondary, which they operate. New economic analyses tor of the Science and college and graduate education to supplement that are better indicators of ecological health, Environ-mental Health a reductionist, bottom-up approach with a top- rather than simply monetary growth, are Net-work. (www.sehn.-org). Dr. Schettler also down systems perspective. needed. As it is, “silos” of specialization coauthored Generations at Risk (MIT Press, Efforts at cross-disciplinary research and encourage a focus on single risk factors or 1999) and In Harm’s Way—Toxic Threats to collaboration are likely to offer new insights. metrics, with little attention to entire systems Child Development, (Greater Boston Physicians New epidemiologic and statistical techniques in which those factors operate. for Social Responsibility). He on the medical staff should be employed to deal with system How might we address malnutrition, food of Boston Medical Center and has a clinical prac- interactions, feedback loops, and nonlinear production systems, soil and water quality, tice at the East Boston Neighborhood Health system dynamics. Methods used in the exposure to carcinogens and other toxicants, Center. sfm ecological and social sciences may have much and socioeconomic stress collectively? How to offer the biological sciences in furthering would this change the structure and approach
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 15 ENVIRONMENTAL HEALTH
Air Pollution and Heart Disease: Recent Developments
Michael Lipsett, MD
ardiovascular disease is by Of particular research interest is the in traffic compared with other times when far the largest cause of relationship between traffic emissions and the subjects were not in traffic. This C mortality in the U.S. occurrence of acute events and possibly association was present regardless of population. While several individual chronic illness as well. Traffic emissions whether the subject had been in a car or biological characteristics, such as consist of a heterogeneous mixture of public transportation, or on a bicycle or hypertension, diabetes and cholesterol biologically active gases, such as nitrogen motorcycle. Statistical adjustment for levels, have long been known to represent oxides and carbon monoxide and potential effects from the degree of important risk factors for the development particulate matter (PM), which includes exertion on a bicycle or from getting up of disease, there has been relatively little diesel soot, condensed combustion gases, in the morning decreased the estimate of scrutiny in the clinical literature of the tire fragments and entrained dust and soil. this association by less than 10 percent. role of the environment in the etiology The concentrations of all of these and The observation that the effect was of circulatory disease or in the other traffic emissions vary in both time present for individuals taking public precipitation of acute events. However, in and space, with the highest transportation suggests that the environmental health and epidemiology concentrations near busy roads. Within relationship could not be explained solely journals, scores of studies conducted on the many pollutants associated with by the stress associated with driving a car. five continents have documented traffic, researchers have focused especially consistent associations between acute on fine and ultrafine PM, both of which Another biologically plausible (i.e., 24-hour) exposures to ambient air can easily penetrate to the deep lung and, explanation for at least some of the pollution and daily mortality, especially in the case of ultrafine PM, translocate epidemiological findings linking air among older individuals with preexisting into the blood to be transported pollution and acute cardiovascular events cardiac and respiratory diseases.1 throughout the body. Fine PM is 2.5 concerns disturbances of the autonomic micrometers or less in diameter, while regulation of the heart, which are often These findings are supported by ultrafine PM is even smaller: 0.1 measured as alterations in heart rate numerous reports linking ambient micrometer or less. By comparison, a variability (HRV). HRV describes changes concentrations of several pollutants, human hair is typically 50 to 60 in consecutive normal sinus beat-to-beat notably particulate matter (PM), carbon micrometers in diameter. intervals; decreased HRV has been monoxide and ozone, to hospitalizations associated with sudden cardiac death and for cardiovascular events.1 These Last year German investigators mortality from heart failure. At least half remarkably consistent associations suggest published the results of a study examining a dozen studies have linked ambient fine that exposure to ambient air pollution is the activities of 691 myocardial infarction PM with transiently decreased HRV. One a risk factor for exacerbation of preexisting (MI) survivors during the four days before recent paper found that the black carbon cardiac illnesses, though pathophysi- they had symptoms.2 They reported a fraction of PM2.5, which is primarily ological mechanisms are still incompletely statistically significant near-tripling of the found in vehicular (particularly diesel) understood. risk of MI within one hour of having been exhaust, was more strongly associated with
Continued on page 17
16 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org HRV decrements than other within a single city as across different committees focusing on air pollution and subcategories.3 Other work has shown cities.6 In that study, involving 5,000 health, including the American Heart associations between pollutants and adults followed up for eight years, the Association’s Expert Panel on Population and electrical discharges of implantable authors found that exposure to traffic- Prevention Science, which produced that defibrillators, again with the strongest related air pollutants was more strongly organization’s recent statement on air associations linked to vehicular emissions. related to mortality than were citywide pollution and heart disease. background air pollution levels. While the In contrast to the plethora of investigators measured pollutant REFERENCES environmental epidemiological studies exposures in a variety of ways, the metric 1. U.S. Environmental Protection linking daily mortality or cardiovascular most strongly associated with Agency (U.S. EPA). 2004. Air quality hospital admissions with ambient air cardiopulmonary mortality in this cohort criteria for particulate matter. pollution, there are but a handful was whether a subject lived near a major Washington, D.C., EPA 600/P-99/002aF- examining the relationship between long- road (RR = 1.95, 95 percent CI 1.09 - bF. term exposure to air pollution and 3.52).6 mortality from cardiopulmonary disease. 2. Peters A, von Klot S, Heier M, et The largest of these involved an During the last decade, the state of al. Cooperative Health Research in the examination of the mortality experience knowledge about the relationship of air Region of Augsburg Study Group. of over 500,000 adults in 151 U.S. cities pollution to cardiovascular disease has Exposure to traffic and the onset of who participated in the American Cancer advanced from extensive ignorance to a myocardial infarction. N Engl J Med. Society II (ACS) cohort.4 After point where the American Heart 2004;351:1721-30. controlling for individual risk factors such Association (AHA) could publish a as smoking, occupational exposures, body thorough review of this area, with an 3. Schwartz J, Litonjua A, Suh H, et mass index, alcohol consumption, diet, implicit recognition of a causal al. Traffic related pollution and heart rate and co-pollutants, a 10 microgram/m3 relationship.7 The AHA review found variability in a panel of elderly subjects. increase in the annual average that exposure to air pollution could Thorax. 2005:60:455-61. concentrations of fine particles in these “accelerate the development of coronary metropolitan areas was associated with atherosclerosis and worsen its sequelae,” 4. Pope CA, Thun MJ, Namboodiri significant increases in relative risks (RR) stating further that “some of these effects MM, et al. Particulate air pollution as a for total cardiovascular mortality (RR = may occur over time, as with acceleration predictor of mortality in a prospective 1.12, 95 percent CI 1.08 - 1.15), as well of the progression of atherosclerosis, or study of U.S. adults. Am J Respir Crit Care as for specific cardiac causes of death, rather abruptly, as with the triggering of Med. 1995;151(pt 1):669-674. including ischemic heart disease (RR = an arrhythmia or myocardial infarction by 1.18, 95 percent CI 1.14 - 1.23) and a acute inflammatory responses, altered 5. Pope CA, Burnett RT, Thurston combined mortality category of platelet adhesiveness, or perhaps vascular GD, et al. Cardiovascular mortality and arrhythmia, heart failure or cardiac arrest endothelial dysfunction.” As noted above, long-term exposure to particulate air (RR = 1.13, 95 percent CI 1.05 - 1.21).5 recent work suggests marked increases in pollution: epidemiological evidence of risk for traffic-associated acute events, general pathophysiological pathways of Increased risks of mortality were also such as myocardial infarction. Given that disease. Circulation. 2004;109:71-77. observed in relation to several other motor vehicle exhaust and other sources pollutants, including sulfur dioxide and of ambient air pollution are ubiquitous, 6. Hoek G, Brunekreef B, Goldbohm sulfate particles (both arising mainly from especially in urban areas, it is reasonable S, et al. Association between mortality fossil fuel combustion) and summertime to consider that exposures to PM and and indicators of traffic-related air ozone. Interestingly, however, the other pollutants present a significant risk pollution in the Netherlands: a cohort increased risks of mortality were limited to public health. study. Lancet. 2002;360:1203-1209. to the group without formal education beyond high school, suggesting that one Dr. Lipsett is chief of the Exposure 7. Brook RD, Franklin B, Cascio W, or more factors associated with Assessment Section in the California et al. Air pollution and cardiovascular educational attainment modified the Department of Health Services and an disease: a statement for health care effect of air pollution. Such factors could associate clinical professor at USCF. For professionals from the Expert Panel on include nutrition or residential location nearly two decades he was responsible for Population and Prevention Science of the in relation to busy streets. A smaller Dutch developing the medical basis for California’s American Heart Association. Circulation. cohort study found that an individual’s ambient air quality standards. He has served 2004;109:2655-71sfm exposure to air pollution may vary as much on numerous local, state and national
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Environmental Contaminents and Human Fertility
Linda C. Giudice, MD, PhD, Alison Carlson and Mary Wade
n late February 2005, the elements of a coherent research investigation. The statement is posted in Stanford University School of agenda to help fill gaps and resolve downloadable PDF format at I Medicine’s Women’s Health @ uncertainties; www.healthandenvironment.org/ Stanford Program and the Collaborative • Gather diverse stakeholders in working_groups/fertility as well as on the on Health and the Environment (CHE) environmental reproductive health website of the University of California, convened a workshop titled to promote access to scientific San Francisco Department of Obstetrics, “Understanding Environmental Con- expertise for lay and medical Gynecology and Reproductive Sciences taminants and Human Fertility: Science professional groups, and build a at http://obgyn-nw.ucsf.edu; and in an and Strategy.” This meeting of 40 community of informed voices in interactive format at www.ourstolen- infertility and reproductive health experts, support of enhanced research future.org/consensus/2005/2005- held at the Vallombrosa Center in Menlo programs and funding; and 1030vallombrosa.htm. Park, was the first to bring together • Consider recommendations for researchers in reproductive epidemiology, educational initiatives and Challenged Conceptions: Environ- biology, toxicology and clinical medicine preventive interventions if and where mental Chemicals and Fertility is a with representatives of relevant warranted. companion monograph for lay readers as professional societies and infertility well as health and policy professionals. It patient support, women’s health and The Vallombrosa workshop resulted provides a general introduction to the reproductive health advocacy in publications that together provide a science; tables showing the main organizations from the United States to solid overview of environmental contaminants of concern listed with assess the state of the science on reproductive health (ERH). They are sources of common exposures and environmental contaminant impacts on intended to increase public, patient, associated fertility/fecundity-related fertility. reproductive health professional, effects; a summary of patient advocate and advocate, policy maker, and fellow clinician concerns expressed at The purposes of the meeting were to: scientist attention to the central issues Vallombrosa; and a list of resources for • Review findings from diverse research addressed at the meeting, and move ERH further information. An addendum on disciplines concerning links between research forward. human biomonitoring addresses questions environmental contaminants, that patients and physicians may have specifically chemicals and heavy Vallombrosa Consensus Statement about this method of assessing one’s metals, and fertility compromise, with on Environmental Contaminants and exposures to environmental agents. special attention to critical recent Human Fertility Compromise summarizes Challenged Conceptions is available in hard discoveries in related basic sciences; participant consensus on core points of copy booklet form as well as online at • Identify conclusions that could be scientific agreement, arranged according www.healthandenvironment.org/ drawn with confidence from existing to a hierarchy reflecting what experts are working_groups/fertility. data; confidant or certain of, what is “likely but • Identify critical knowledge gaps and requiring scientific confirmation,” and Continued on page 19 areas of uncertainty, and establish key what is uncertain and a priority for further
18 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org Seminars in Reproductive Medicine compared with 10 percent (6.1 million) smaller number of human studies reveal will publish proceedings of the scientific in 1995 and 8 percent (4.9 million) in associations between environmental overview presentations at Vallombrosa in 1982 and 1988. While self-reported toxicants and parameters known to affect an early 2006 issue. impaired fecundity is up in all reproduction and fertility. The workshop program was cochaired reproductive age groups, the most Collectively, effects associated with by University of Rochester–based ERH dramatic rate of increase is actually in environmental chemical exposures in researcher and reproductive epidemi- younger women, under age 25: a 42 percent wildlife, lab animals and humans include ologist Shanna H. Swan, PhD, and Linda rise between 1982 and 1995, as compared increases in medical conditions or C. Giudice, MD, PhD, who then was with a 12 percent increase in women ages anatomical defects associated with director of Women’s Health at Stanford 25 to 34, and only 6 percent in women 35 infertility; reduced sperm count and and the Stanford OB/GYN department’s and older over the same time period. quality; sperm DNA damage; sterility; Center for Research on Reproduction, These data suggest that delays in alterations in ovarian function and Women’s Health and Genomic Medicine. childbearing may not fully explain the menstruation; oocyte quality and Dr. Giudice has since become professor apparent upward trend. cytogenetic damage; longer time to and chair of the Department of Obstetrics, pregnancy; altered implantation rates and Gynecology and Reproductive Sciences GROWING EVIDENCE OF embryonic development; and increased at University of California, San Francisco, ENVIRONMENTAL IMPACTS rates of spontaneous miscarriage, preterm where she is establishing a program on A growing body of research is birth and stillbirth. Population-level shifts Reproductive Health and the revealing that a larger portion of human have also been correlated with Environment. A list of Vallombrosa health problems may be related to environmental exposures, for instance, participants and the workshop environmental contaminant exposures alterations in twinning rates or sex ratios description, program and bibliography can than was thought possible even a decade in specific populations. also be found at www.healthand- ago. Scientists are now concerned not While a handful of the impacts environment.org/working_groups/ only about high-level exposures (related observed are frank, many—such as fertility. mostly to certain occupations or industrial increased time to pregnancy and reduced accidents), but also about lower sperm counts—are better characterized as IS INFERTILITY ON THE RISE? “environmentally relevant” exposures subtle “hits” on reproductive robustness. In recent years there have been sharp commonly experienced by humans But this still raises a question: What might increases in the number of annual doctor worldwide. Environmental health be the consequences to our species of visits for fertility problems; of couples researchers are looking at questions of multiple subtle reproductive system insults diagnosed with infertility; and of people whether and specifically how over the longer haul? Especially given seeking infertility treatments. contaminants might be contributing to that: Demographers attribute these increases to human fertility problems—perhaps even • Some 80,000 or more chemicals have greater reporting as a result of the contributing to an actual rise in the been registered for commercial use in availability of ever more effective assisted incidence of infertility—and biological the United States over the last 80 reproductive technologies as well as plausibility is increasingly being years; a growing number of them are voluntary delays in first pregnancy in a demonstrated. being identified as reproductive large generation of baby boomers at Striking evidence of environmental toxicants; and some of the “bad reproductive age over recent decades. chemical impacts on reproductive health actors” are notably persistent in the There are indications, however, that and fertility came first from observations environment and our bodies—while the actual incidence of infertility itself of wildlife over recent decades, amply others are nonpersistent but may also be on the rise. Rates of certain described in the 1996 book Our Stolen ubiquitous/chronically present. medical conditions that can contribute to Future. Hundreds of wildlife studies • In contrast to regulation imposed on infertility, such as testicular cancer, strongly link manmade endocrine- the pharmaceutical manufacturers, cryptorchidism, hypospadias and disrupting chemicals with declines in there is no requirement that chemical endometriosis, are rising—and the most reproductive rates and a host of manufacturers health-test their recent (2002) National Survey of Family reproductive abnormalities in a wide products—other than new kinds of Growth from the National Center for range of bird, reptile, fish and mammalian pesticides and some food additives— Health Statistics indicates that 12 percent species. Numerous studies in laboratories in advance of bringing them to of the reproductive-age population in the around the world confirm that synthetic market. United States (7.3 million couples) now chemicals at environmentally relevant • Measurement, or biomonitoring, of reports experiencing difficulty conceiving levels can cause reproductive damage in contaminants in people shows that and/or carrying a pregnancy to term—as experimental animals. More recently, a Continued on page 22
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 19 ENVIRONMENTAL HEALTH
Standing Up to the Lead Industry: An Interview with Herbert Needleman, MD
Note: This interview is excerpted from a as well as opening new areas of research that studying lead is very clear in my mind. I longer original version that appeared in Public have shown that lead exposure, at virtually was working on the infant ward at the Health Reports 2005:120; 330-337. It was any level, has negative, life-altering Children’s Hospital, and a child was bought conducted by David Rosner, PhD, and Gerald consequences for children. This interview, up from the ER with severe acute lead Markowitz, PhD, of Columbia University. conducted on the eve of his 75th birthday, toxicity. I did what I’d been trained to do. I The full version, with references, is available recounts a small part of Herbert gave her EDTA [chelation therapy]. She at: http://www.public-healthreports.org. Needleman’s experiences over the course was stuporous and very ill. Slowly she got of the last half century. better. It was a gratifying experience and I Herbert Needleman, MD, is a pioneer felt very smug. I told the mother that she in the history of medicine who has helped Let’s start with a little background had to move out of that house: “You cannot transform our understanding of the effect about your family and your education. go back to that house because if she has a of lead on children’s health. In the 1970s, second episode she’s going to be retarded.” he revolutionized the field by documenting I’m a Philadelphian by birth. I was the This was what I’d been trained to do in the impact of low lead exposure on the first person in my family to go to college. I medical school. She looked at me and said, intellectual development and behavior of went to Muhlenberg College in Allentown, “Where am I going to move to? All the children. Pennsylvania, and then to the University houses I can afford are the same age.” I Not surprisingly, Needleman became of Pennsylvania Medical School. I interned suddenly realized that the issue was not just the focus of the lead industry’s ire. at Philadelphia General Hospital. I had making diagnoses and treating them. The Beginning in the early 1980s, the industry’s initially intended to be an internist, but I issue was in the life story of people. This attacks on his research and use of public discovered I was having much more fun in was a very powerful learning experience. relations firms and scientific consultants to pediatrics. I thought, how many of these kids who undermine his credibility became a classic In those days, the government was are coming to the clinic are in fact a missed example of how an industry seeks to shape subsidizing general practitioners and case of lead poisoning? My office looked out science and call into question the credibility pediatricians to go into psychiatry because on a school playground. I watched the kids of those whose research threatens the they thought we needed more psychiatrists. every morning line up and go to school. I industry’s economic interests. I was going to be a child psychoanalyst. I said, “I’m going to go into that school and On the one hand, the industry was very unhappy with the training, and identify the children who have elevated explicitly showed the power it had to disrupt the theoretical basis of child psychoanalysis lead and see what their IQs are.” Then it researchers’ lives if they dared to question didn’t satisfy me. I kept thinking, “How occurred to me that the blood lead at 6 years the safety of its products. On the other many of these kids who are coming in with of age might by then be normal if the hand, Needleman’s experience galvanized learning problems have lead poisoning?” exposure had occurred at less than 2 years a generation of researchers who were The inner city neighborhood we served had of age. So I began to think: “What can I profoundly influenced by the implications a lot of lead. People thought that was a crazy use to read back in their exposure history?” of his studies. Others have built on idea. Needleman’s work, confirming his findings The experience that turned me toward Continued on page 21
20 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org Then it occurred to me there’s a way files? They put bars on my file cabinets. The It raises the question of what effect to do a spontaneous bone biopsy. It’s inquiry committee was composed of three you think the assault on you had. Was it universal, spontaneous and painless. You people from the University of Pittsburgh: meant to scare younger scholars away from just have to catch a deciduous tooth. I two epidemiologists and a statistician. They doing controversial research? collaborated with a dentist in the dental looked at my data tapes and regressions and school. [We] collected a lot of teeth from got the same results. They reported that I wrote about that in a piece in inner-city and suburban kids. The tooth they found no evidence of scientific Pediatrics. If this is what happens to me, lead levels in the inner city kids were five misconduct but they could not rule out what is going to happen to somebody who times what they were in the suburban kids. scientific misconduct. But the university doesn’t have tenure? I’m worried that people said there was enough reason to go ahead who are trying to get a niche and don’t have How did you publicize your findings? with an investigation, which is the second tenure are asked—and I’ve seen it as a phase of a scientific misconduct inquiry. member of the TAFC—to do things that We talked to the city, and we published they question the ethics of. They are in the New England Journal of Medicine. Did you have a group whom you were intimidated. It’s a real force. Years later there was a lawsuit on behalf of supported by? Other professors and the people who lived there. A Washington medical people? What were the repercussions after law firm won an award of a million dollars. 1991? Were you able to continue your Well, it is a very clarifying moment work? Were there any issues with the when this happens. You learn who your industry other than at government friends are. My friends were not people in I think, all in all, that throwing light meetings? the medical school, but the faculty in the on [my experience] was healthy for the university at large, in the liberal arts and medical community—to see the way that In 1979, when I published that paper, sciences, etcetera. They really stood behind certain people operate. So I think that was the lead industry was silent. They didn’t say me. The major issue was having an open good. anything for about six months. I expected hearing. I knew that if we went into that there would be a big response, but there executive session, I was through—I mean, Do you think we are ever going to find was nothing. Then they started to call for just judging by the report that the inquiry a threshold below which lead has no effect my data, my printouts, and I said, “No. I’ll committee wrote. on children? share them with any legitimate scientist, It went on for a day and a half. It took but I’m not going to share them with the a long time for the committee to turn it Most of the damage is done at very low lead industry because they don’t qualify.” around. They said there was no evidence levels, which is what we showed in our study [In 1991], I got a brief that accused me of scientific misconduct in terms of false in 1987. It’s a very intriguing physiological of scientific misconduct. It was submitted application or plagiarism; however, the way problem. Why is it that the toxic effect of by a guy named David Geneson. He is an I reported my control group was lead is stronger at lower doses? I have a attorney with Hunton and Williams. misrepresented. The industry trumpeted couple of ideas. I think there is an early Hunton and Williams is interlocked with that I had deliberately misrepresented the mechanism that is important and powerful Ethyl Corporation of America through its data. that can be saturated by only a little bit of board of trustees. So he was the person who lead; you do that damage and then you need sent the charges down to NIH. The next So you are at the university and some more lead to get the other targets activated. thing I know, I was called by a reporter from of your colleagues have abandoned you— I think that’s what some smart molecular Science magazine. I said, “Come on, this is what’s happening? biologist will be able to show. I think that just the industry trying to get me.” I didn’t at very small doses, these things happen realize how serious it was. The university The faculty senate really backed me up because you don’t need much. Then the called me and said, this is nothing to worry completely. I felt I had friends. The dean of next damage occurs on a different about. It will pass. The next thing I know the School of Public Health at that time mechanism at a different level. All along they’re going to have an inquiry. The NIH was a good friend of mine. Months had gone there are different mechanisms that come referred the investigation to the university. by of absolute silence, and now he took me into play that end in the neurophysiologic That’s their procedure. My files were locked, out to lunch and we talked. I said, “Hey, deficit. I don’t think there is a threshold. and I could only look at my data in the Don, how come you never spoke to me Barry Commoner, who made me see this, presence of a representative of the Office when I was in the middle of all that says that we’ve had a billion years to adapt of Scientific Integrity of the university. I had melodrama?” He said, “Well, my wife to natural molecules. By contrast, we’ve had to call her up and say I wanted to look at thought I should, but I guess I was afraid.” only a couple thousand years to adapt to some data: can you come and unlock the At least that was honest. Continued on page 22
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 21 Interview with Herb Contaminants and reproductive tract infections and nutrition. It will be challenging to Needleman, MD Human Infertility pinpoint what proportion of human infertility is causally attributable to Continued from page 21 Continued from page 19 environmental exposures. Better prevalence/incidence tracking of infertility and its related conditions—and lead. Fifty years to adapt to pesticides. All average Americans have hundreds of greatly expanded ERH research—will of these are toxic at some level. But we have manmade chemicals, including a help. What is clear is that more complete developed no adaptive biological significant number of reproductive understanding is critical. For if some mechanism for lead, which has no purpose toxicants, in their tissues (including proportion of infertility is at all in the body. There is no biological amniotic fluid and umbilical cord environmentally induced, then that function, so any amount is going to be blood) at levels high enough to be of proportion is also, in theory, preventable. deleterious. concern. • There are critical windows of JANUARY 2007 NATIONAL So you’re still working away. You’re vulnerability, and it is very likely that MEETING ON REPRODUCTION, now 75 years old. You certainly started a some of the most significant FERTILITY AND THE school. reproductive compromise is what ENVIRONMENT occurs as a result of in utero The Vallombrosa workshop began an I didn’t start it. There were maybe six exposures—the effects of which may intriguing cross-discipline conversation. or seven papers before mine. What I did not become evident until decades To continue it, CHE and UCSF and are was develop a tooth assay, which was very later when an individual attempts to now planning a larger “Summit on useful. It answered the questions that were become a parent. Reproductive Health, Fertility and the around at that time. • Rapid recent advances show that low Environment” in January 2007. A key goal doses and mixture of chemical will be to expand health professionals’ Does that explain in some sense why exposures matter—and that some awareness of and engagement in ERH you became such a focus for the industry? chemical exposures may cause science and practice. adverse intergenerational effects Yes! Sure. It’s very clear to me that in (through epigenetic alterations). For further information, contact Mary 1990 there were already 30 papers from Wade at [email protected] or around the world all saying the same thing. PATIENTS RAISE QUESTIONS, Alison Carlson, at alison@healthand- The [lead industry] couldn’t contest that, PHYSICIANS NEED ANSWERS environment.org. so what were they going to do? If they could Infertility support organizations and discredit my work, the whole thing would physicians at the Vallombrosa workshop Dr. Giudice is the collapse or be fundamentally revised. I’m voiced concern that increasingly, professor and chair of sure that was it. That’s why they kept saying reproductive health patients are asking the Department of they had to have my original data, because whether environmental factors could be Obstetrics, Gyne- they had planned to make a concerted affecting their ability to conceive and bear cology and Repro- attack on [my findings]. Then all the other children, or account for menstrual and ductive Sciences, work that grew out of it would be . . . other reproductive irregularities—yet UCSF. Alison Car- most physicians are uncertain about how lson is a research Suspect? to respond, or even where to access fellow at the Commonweal Health & reliable information on the subject. There Environment Program and facilitator of the Discredited. sfm is an obvious need for far greater CHE Fertility/Early Pregnancy Compromise environmental health content in medical Work Group. Mary Wade is the coordinator school curricula and continuing medical for the program on Reproductive Health and The SFMS Administrative Offices education programs. the Environment, Department of Obstetrics, will be moving to the Presidio at It should be noted, however, that Gynecology and Reproductive Sciences, the end of January. Our new infertility is distinguished by complexities UCSF. sfm address will be: that defy easy understanding, and multiple San Francisco Medical Society interacting factors are likely to contribute, 1003 A O’Reilly, including age, heredity, lifestyle choices, San Francisco, CA 94129. socioeconomic status, underlying disease,
22 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org ENVIRONMENTAL HEALTH
Chemical Exposure and Parkinson’s Disease: A Plethora of Suspects
Jackie Hunt Christensen and Deborah Cory-Slechta, PhD
Parkinson’s disease (PD) affects TOXIC CHEMICALS neurological problems. Those include approximately 1.5 million Americans, making In a world with more than 80,000 aluminum, copper, iron, lead, manganese, and it the second most common degenerative chemicals in commerce, it should surprise no mercury. neurological disease. Although there are four one that some of these substances are suspected primary signs—tremor, rigidity, bradykinesia of causing Parkinson’s disease. Most studies are SIGNIFICANCE OF IN UTERO, and postural instability—symptoms present conducted on a chemical-by-chemical basis, CHILDHOOD EXPOSURES differently in each patient. This complicating or at best, mixtures of two or three compounds. Scientists often use the maxim, “The dose factor, combined with the lack of a biomarker This approach is unlikely to provide answers makes the poison.” Too often this is construed or diagnostic test, makes it difficult for anytime soon, nor does it reflect the complex to refer only to the amount of a substance. But clinicians to diagnose the disease. “soup” of chemicals to which people are the timing of the exposure also plays an The majority of patients—around 95 exposed on a daily basis. essential role in the effects, or lack thereof. A percent—have no prior family history of The first chemical connected with growing body of evidence indicates that Parkinson’s. This point, along with a growing Parkinson’s disease was MPTP. In 1982, some exposures or insults occurring during childhood body of research, suggests that most cases of San Francisco Bay Area drug users who were or even in utero may set the stage for the onset PD are caused, at least in part, by nongenetic attempting to synthesize heroin produced of cancers and chronic diseases in adulthood. factors. Most neurologists tell their patients, MPTP. Seven of these individuals developed PD may be no exception. Before adulthood, “Genetics loads the gun, but the environment Parkinson-like symptoms within weeks of their the organ systems are not fully formed or pulls the trigger.” exposure to this compound. Today, MPTP is developed. An exposure or event coinciding Several life experiences or demographics used in the laboratory setting to induce PD- with a developmental milestone could seem to increase the likelihood that a person like symptoms in research animals. It is also drastically alter the body’s response during later will develop PD. These nongenetic risk factors the standard against which other chemicals milestones or insults. include: suspected of causing PD are measured. This hypothesis has been tested in rodents • Age Several classes of pesticides—bipyridyls, exposed to maneb and paraquat shortly after • Living in a rural area organochlorines, pyrethroids and birth. The animals challenged as juveniles • Viral infections carbamates—have been associated with effects experienced more neuronal damage than • Working as a welder on the brain that may contribute to PD. adults that were similarly exposed. They show • Estrogen deficiency Certain particular pesticides—rotenone, a progressive neurodegeneration across their • Drinking well water paraquat, maneb—have been found to damage life, and as with human PD, males are at greater • Significant head trauma or destroy dopamine-producing neurons in risk. • Pesticide exposure laboratory animals. (See the chart on page 24.) • Working as a farmer Several heavy metals have also been MECHANISMS OF ACTION identified as having the potential to contribute There are many ways in which substances For the purposes of this discussion, the to Parkinson’s disease or increase the risk of in our environment or events that we focus will be on chemical exposure in the home developing it. All of these metals are associated experience can affect our brain and lead and workplace. with other health impacts, especially to PD. Continued on page 24
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 23 Chemical Exposure and Parkinson’s Disease Continued from page 23
• They create free radicals that destroy neurons or affect the body’s system of dealing with free radicals. • They affect mitochondria, which are like the battery or power center in a cell. • They kill neurons outright. • They cause the production of alpha- synuclein, the protein that can build up to form Lewy bodies. • They affect the apparatus of the cell that recycles proteins. • They create inflammation that makes Wood Johnson Medical School. Dr. Cory-Slechta dopamine-producing neurons vulnerable to to a certain threshold amount of a chemical has served on numerous national research review other insults. at a particular stage of development is the and advisory panels, including committees of the • They affect cell receptors, which act as reason that only some individuals who are National Institutes of Health, the National Institute locks or gateways. The job of a receptor may exposed to a substance go on to develop of Environmental Health Sciences, the Food and be to open at a particular time to allow an Parkinson’s disease. Drug Administration, the National Center for enzyme or neurotransmitter to enter the cell Environmental exposures do not offer a Toxicological Research, the Environmental and trigger a series of chemical reactions. Or it clear picture of PD causation, but they do fill Protection Agency, the National Academy of may be responsible for keeping out other brain up enough of the frame to warrant continued Sciences, the Institute of Medicine, and the Agency chemicals. Any disruption in this gatekeeping and more in-depth scrutiny. for Toxic Substances and Disease Registry, Centers process could have dire consequences, such as for Disease Control. Her research has focused blocking instructions telling neurons to Jackie Hunt Christensen, BA, of largely on the contribution of environmental produce more dopamine. Minneapolis, is co-coordinator of the Collaborative chemical exposures to developmental disabilities and In fact, exposure to multiple substances on Health and the Environment’s Working Group neurodegenerative diseases, particularly on the role that produce different effects may result in a on Parkinson’s Disease. She has been involved in of pesticides in the Parkinson’s disease phenotype. synergistic response that produces PD. numerous environmental and health-related collaborative efforts for nearly 20 years. She is a REFERENCES cofounder and former coordinator of Health Care 1. Brown TP, Rumsby PC, Capleton AC, et EXPOSURE PATHWAYS Without Harm: The Campaign for al. Pesticides and Parkinson’s—Is There a Link? Environmentally Responsible Health Care. She Environ Health Perspect. http://ehp.niehs.nih.gov/ Ingestion seems to be the most likely members/2005/8095/8095.pdf, online 7 September, exposure pathway. Food, groundwater, and also served as codirector of the Food and Health 2005. surface water may all contain pesticide residues. Program at the Institute for Agriculture and Trade 2. Cory-Slechta DA, Thiruchelvam M, Some parts of the country have high levels of Policy—a position she left in July 2004 because of Barlow BK, and Richfield EK. Developmental Models of the Parkinson’s Disease Phenotype. heavy metals that are naturally occurring in Parkinson’s disease. In October 2005, her book, Environ Health Perspect. 2005 Sep;113(9):1263-70. their water supply. Workers in some The First Year: Parkinson’s Disease, an Essential 3. Kamel F, Hoppen JA. Association of occupations, such as welding and farming, may Guide for the Newly Diagnosed, was published Pesticide Exposure with Neurologic Dysfunction by Marlowe and Company. and Disease. Environ Health Perspect. 2004 incur exposure via inhalation or skin contact. Jun;112(9):950-8. Many of the chemicals linked to PD are Dr. Deborah Cory-Slechta is director of the 4. Liu Bin, Hui-Ming Gao, and Jau-Shyong very persistent, meaning that the human body Environmental and Occupational Health Sciences Hong. Parkinson’s Disease and Exposure to Institute, a joint institute of the Robert Wood Infectious Agents and Pesticides and the cannot break them down into smaller pieces Occurrence of Brain Injuries: Role of and get rid of them easily. Everyone may be Johnson Medical School of the University of Neuroinflammation. Environ Health Perspect. 2003 exposed to some pesticides on a daily basis, Medicine and Dentistry of New Jersey and Apr;111(4):531-5. although in very small amounts. Some of these Rutgers, the State University. She is also chair of 5. Marjama-Lyons, Jill, MD, and Shomon, Mary J. What Your Doctor May Not Tell You About compounds build up (bioaccumulate) in the the Department of Environmental and Parkinson’s Disease: A Holistic Program for Optimal body, often in fatty tissues. Perhaps exposure Occupational Medicine at the UMDNJ–Robert Wellness, (New York: Warner Books, 2003).sfm
24 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org ENVIRONMENTAL HEALTH
The Real Rx: Slow Food, Lively Places, Real Vitality
Richard J. Jackson, MD, MPH, Megha Doshi and Monica Rai
lthough Bob is a new patient, a confounding system and patients who are percent is spent on prevention. Prescribing you feel like you’ve seen him more depressed then ever. Almost two- and operating our way through depression, Aa hundred times. His chief thirds of Americans are now overweight or diabetes, heart disease, and obesity is no complaint: “Doc, I just feel lousy. I’ve gained obese, up from 24 percent in 1960, and rates golden ticket to better health. In public weight, I’m always tired, I hardly exercise of heart disease, stroke, high blood pressure, health, the patient is the population. When and life isn’t much fun.” You learn that his arthritis and diabetes have increased at the patient has a systemic disease, one relationships are struggling: he feels similar rates. aggravated by his or her environment, we disconnected from his wife and kids, his sex need to find and treat the root cause, not life is absent, and his bosses are demanding just the rash or the fever. Pills and surgery and ungrateful. His BMI is over 30, his may protect health in the short term, but cholesterol and blood glucose are elevated, ❝ quality health care depends on and he fits the criteria for depression. You Today’s are overwhelmed environments in which the healthy choice start by recommending modest lifestyle with staggering rates of obesity is the easy choice. changes but end up prescribing four and associated chronic diseases, Good health requires more than different medications. Worst of all, you skyrocketing health care costs, regular check-ups, immunizations and doubt this would benefit him as much as preventive screenings. Prevention is bigger managing his diet, losing weight, exercising a confounding system and than individual health behaviors and begins more, spending more time with family, patients who are more earlier than an office visit. Prevention starts working less, and getting enough sleep. As depressed then ever. Almost in our communities, is embedded in our a doctor, you may feel helpless. Your patient two thirds of Americans are social values, and should be essential to how is living in an environment and culture that we build our environments. The average now overweight or obese. . .and make all your healthful advice futile and patient spends only about four hours a year expensive medications with numerous side rates of heart disease, stroke, with you. The remaining 8,756 hours are effects the norm. high blood pressure, arithtis and spent out in his or her environment trying Today’s health care pages boast plenty diabetes have increased. . .❞ to apply what you teach. of good news. Compared to a generation Sadly, most Americans live and work ago, we have better treatment for in environments in which healthy eating, hypertension, heart attacks and depression exercising and enjoying leisure time— and better surgical techniques. We can important tools for preventing most health prevent many illnesses, and biotech- Medicine has tried to respond with conditions—are not easy or convenient nological breakthroughs detect diseases “fixes” like bariatric surgery for the morbidly choices. The built environment is the long before they strike. Meanwhile, today’s obese and prescription drugs for the foundation of our lives and cannot be doctors are overwhelmed with staggering depressed and diabetic. In fact, 97 percent neglected as we develop new solutions to rates of obesity and associated chronic of health care dollars is spent on illnesses and health conditions. diseases, skyrocketing health care costs in downstream treatments, while only 3 Continued on page 26
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 25 The Real RX capital, is home to nine of the nation’s 10 environments don’t support the healthy most smog-suffocated counties.9 choices we need to make. Few Californians Continued from page 25 Our environments force us to spend live in walkable, bikeable communities. more than half our lives sitting in a car or Most spend their days inside buildings and sitting at work, leaving less time and energy cars and have precious little access to open Let’s go back to our new patient Bob. for physical activity. Eighty percent of trips green space. Every commodity needed is just If he’s like most Americans, his days consist of less than a mile are made by car.10 When two freeways and three exits away. Meals of working and driving an increasing we can get out of our cars, there are few are concoctions of processed fats, sugars and number of hours, eating fast and safe places to walk and often nowhere preservatives hawked by cartoons at school, prepackaged convenience foods, and coping within reasonable distance to walk to. Our grocery store check-out displays, and fast- with too much stress. He probably drives poorest patients live in “food deserts” that food restaurants. American adults are about 440 hours each year—equivalent to lack places to buy fresh fruits and vegetables overworked and take far fewer vacation days 11 work weeks.1 Soaring home prices leave but are saturated with fast-food restaurants than their European counterparts. We him no choice but to live miles from work, and corner liquor stores. We tell our patients spend twice as much on health care but schools and shopping. Only 10 percent of to exercise and eat well, but if their have lower life expectancies and quality of Bay Area residents can afford a home here, environments make it impossible to walk life. Expensive medical treatments may while approximately 60 percent can buy a or play outside and to buy affordable healthy create the illusion of a healthier population, home in Fresno and other Central Valley foods, our prescription goes unfilled. but we spend more to treat and manage cities.2 As a result, Bob drives over 10,000 Car-crazy communities also erode preventable diseases than we do to prevent miles a year, 250 percent more than his family life and mental health. A May 2001 them in the first place. parents drove in the 1960s.3 While US News and World Report article described For example, obesity, overweight, and Americans may continue dreaming of the struggles of balancing family and social inactivity among California adults will cost suburban utopia, the reality is white- life with work and long commutes. $28 billion just in 2005. Paying for the 1.7 knuckle commutes, too little time with Stockton psychologist Timothy Miller million Californians who qualify for those who love and care about us and the estimated that half the married couples he bariatric surgery would cost $52 billion, five numerous related health problems counseled suffered from “commuter-related times the state budget deficit. We literally encountered in almost every routine stress.” Many had moved to the Central cannot afford to operate and medicate our check-up. Valley to escape high Bay Area home prices. way out of these serious health conditions Bob’s environment makes driving so The less expensive housing, however, came that are exacerbated by poorly designed routine and necessary that it’s easy to at a cost—couples argued more, spent less environments. overlook the inherent health risks time with their kids, exercised less and were Our deteriorating health and associated with it. Motor vehicle crashes generally unhappy.11 Community deteriorating environments are not isolated cause more than three million injuries and engagement and socialization also suffer conditions. Health is inextricably linked to claim some 42,000 lives each year.4 Adults when people drive more. In his book our broader environment and with long commutes and busy lives are tired, Bowling Alone, Harvard professor Robert institutions—schools, workplaces, frustrated and distracted drivers. Over half Putnam found that every 10 additional hospitals, neighborhoods and local of Americans admit to driving while minutes spent driving to work corresponds governments. Hundreds of studies confirm drowsy,5 and studies indicate that falling to a 10 percent drop in community this connection, but the findings are asleep at the wheel may cause one in five involvement. unintelligible to most people unless crashes.6 Traffic has reached such annoying America’s health is in bad shape. Our communicated by health experts they and epidemic levels that even mild- patients are more diabetic, more overweight respect. mannered Bob becomes an aggressive, lane- and obese, more depressed and more prone That’s where doctors can enter the swerving tailgater in the car. to heart disease and back pain. More than equation. We have the power to impact Then there are the less obvious 1 million children and teens take health, both in and out of the office. With driving-related health hazards. Too much antidepressants. Over 50 percent of our patients, we can measure BMI at every driving can trigger high blood pressure, Californians are overweight, and 1.7 visit. Write a prescription for exercise. abnormal heart rhythms, sleep disorders, million Americans qualify for bariatric Emphasize the importance of reducing work depression, and neck, shoulder, and back surgery. One of three children born today and commute hours and spending more pain.7 It makes us more vulnerable to colds will suffer from diabetes, a disease that time with family. Sex and exercise are better and flu and less productive at work. It makes degrades their quality of life and can cost than Zoloft and caffeine for depression. us spend more time in the hospital and take them their eyes, feet, kidneys and eventually And, most important, we can ourselves be more sick days.8 And it makes our air almost their lives. unbreathable. California, the nation’s ozone Unfortunately, our lifestyles and Continued on page 31
26 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org ENVIRONMENTAL HEALTH Choosing Sustainability: Paths to Green Chemistry in California
Michael Wilson, PhD, MPH
Green chemistry — developing materials in this arena. Strategies to address public and The chemical industry has played a key and processes that are safer and more efficient, environmental health concerns related to role in economic growth, employment and have less environmental impact and, most chemicals can and should be linked with efforts improvements in life expectancy, health and important from an industry standpoint, are more to improve California’s productive capacity in living conditions. profitable — is a potent concept supported by the design, manufacturing and use of cleaner Chemicals policy is challenging because business, industry and academia. It is changing chemical technologies, known collectively as the chemical industry produces fundamental how America lives and works. green chemistry. Green chemistry products are benefits to society as well as a number of (less less toxic, they do not accumulate in the body, tangible) problems that affect downstream William F. Carroll, Jr. PhD and they break down more readily in the businesses and industry, public health, and President, American Chemical Society1 environment. Green chemistry processes government. The contributions of the industry generate less hazardous waste and use less to economic growth, employment and Over the next 45 years, the population energy. A number of leading California firms improvements in life expectancy, health and of California is expected to grow by about 50 are already employing elements of green living conditions over the last 150 years are percent, from 36 to 55 million residents. chemistry in various forms, from innovative widely acknowledged.2-5 Since the early 1900s, During this period, we will face a growing set environmental stewardship programs to the the U.S. chemical industry has been the largest of social, economic and environmental design and use of chemical feedstocks and in the world2 and now accounts for about 26 problems. The magnitude of these problems— products that appear to be inherently safer for percent of total global chemical production.6 particularly as experienced by Californians in human biology and ecosystems. In 2002, U.S. businesses purchased $288 2050—will be determined by the kinds of While the science of green chemistry is billion in U.S. chemical products, and the decisions we make in the coming years. If our in its infancy, and the business case for green industry’s exports totaled $81 billion—more desire as a society is to reduce the magnitude chemistry has yet to be fully established, it is than for either agriculture or aircraft/ of these problems over time, it will become becoming clear that cleaner technologies, aerospace.7 increasingly important in public policy, including green chemistry, will play a key role In 2002, the U.S. chemical industry business planning and other areas of decision in the future of industrial activities among the directly created more than one million high- making to link economic growth with actions nations of the world, both developed and paying jobs, each of which generated five that advance environmental and social developing. Global leadership has already additional jobs elsewhere in the economy.7 sustainability. In practice, this means that begun in the form of substantial new policy The industry paid $24.5 billion in federal, state strategies to expand industrial capacity and directives related to electronic and electrical and local taxes.7 employment in the state must simultaneously equipment—and most recently, to In California the chemical industry solve social and environmental problems. chemicals—in the largest, richest market in employs about 81,000 people;3 another Policy strategies that support and motivate the world: the European Union.1 By 500,000 people are employed in sectors that industrial investment in cleaner technologies implementing strategies that support and depend on chemical industry activity in represent one path that begins to meet this motivate investment in green chemistry California and other states. Together, these objective. technologies, California could become a global jobs produce $28.6 billion in earnings and $1.7 Chemicals policy is a fundamental player leader in this arena. Continued on page 28
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 27 Choosing substances disrupt biological processes is still Development in scientific understanding largely unknown; however, a 2005 study of chemical toxicity and ecotoxicity has far Sustainability: Paths reported that fetal exposure to a class of outpaced government and public oversight of to Green Chemistry chemicals used in a variety of consumer the 81,600 chemicals in commercial products—a class of common chemical circulation—and the 2,000 new chemicals in California plasticizers—known as phthalates—were the introduced in the U.S. each year—as listed in Continued from page 27 likely cause of statistically significant changes the inventory of the federal Toxic Substances in the sexual characteristics of a study group of Control Act (TSCA).4 The scope of U.S. 134 boys aged 2 to 36 months.8 These changes and California chemical statutes remains were consistent with those seen in animal surprisingly limited. Together, five federal billion in state and local tax revenues each studies and were reported to occur at maternal statutes5 capture only 1,134 chemical year. Overall, industries for which 10 percent phthalate blood levels below those found in substances, or about 3 percent of Class I or more of material inputs are derived from one-quarter of the female population of the chemicals in the TSCA inventory.6 The design chemicals employ more than 4.3 million U.S. This study will need to be replicated; it is and implementation of TSCA has prevented Californians, or about 29 percent of all conceivable, however, that the reported effects the U.S. EPA from gathering—and employment in the state. represent one outcome in a cascade of other, distributing—basic toxicity and ecotoxicity Because economic status is a key driver as yet unidentified, forms of endocrine information for about 99 percent of chemicals of health, and most benefit programs—such disruption. in commercial circulation, by volume. as health insurance—in the U.S. are tied to There is a substantial body of literature The U.S. Occupational Safety and employment, the contribution of the chemical regarding chemically induced diseases among Health Administration (OSHA) has adopted industry to health status in the U.S. is workers and other highly exposed individuals workplace exposure limits for only 193, or substantial. and populations. Some portion of the 35,000 about 7 percent, of the 2,800 synthetic Clearly, as feedstock or as finished new cases of occupationally related disease chemicals produced or imported at more than products, synthetic chemicals—organic diagnosed each year in California (excluding one million pounds per year in the U.S.; the chemicals, metals and inorganic chemicals musculoskeletal disorders) are related to U.S. EPA reported in 1994, however, that created by humans through chemical chemical exposures, as is some portion of the about 16,000 chemicals in commercial processes—play a role in nearly all forms of 4 to 10 percent of cancer deaths and 10 to 20 circulation are potentially of concern on productive activity; they constitute the percent of deaths resulting from chronic account of their design and volume in material base of society and are involved in obstructive pulmonary disease (COPD) that commerce. In September 2005, the California some way with nearly every aspect of life. For are attributed to occupation.9 Division of Occupational Safety and Health these reasons, the properties of chemicals— For a variety of reasons, however, the true (DOSH) employed about 200 compliance particularly their toxicity and ecotoxicity— burden of chemically induced disease is officers to address worker health and safety are of great public significance. unknown. Board-certified occupational matters for the state’s nearly 20 million physicians, for example, constitute only about workers.13, 14 The Hazard Evaluation System THE PROPERTIES THAT MAKE 0.2 percent of U.S. physicians, and only half and Information Service (HESIS), a California SYNTHETIC CHEMICALS USEFUL of U.S. medical schools require an average of state agency responsible for anticipating and TO SOCIETY CAN ALSO MAKE six hours of instruction in occupational preventing chemical hazards in California THEM HAZARDOUS TO HUMAN medicine.10, 11 The full scope of health effects workplaces, currently employs three full-time BIOLOGY AND ECOLOGICAL associated with the great majority of chemicals staff members. PROCESSES in commercial circulation, even as isolated Each year, more than $1 billion is spent There is ongoing scientific concern over entities, are unknown. The drop in union on cleaning up hazardous waste Superfund sites the biological implications of chemical density—now less than 10 percent in the U.S. in the U.S.15 Assuming current industrial and exposures that occur over the course of the private sector—has likely produced a decline regulatory practices remain the same, the U.S. human life span—in workplaces, homes and in vigilance among workers with respect to EPA expects 217,000 new hazardous waste the ambient environment—particularly work-related diseases, particularly among low- sites to appear and require mitigation by 2033, during the sensitive period of fetal and child income, minority and immigrant workers, who on top of a current burden of 77,000 sites. development. It has become apparent that are at greatest risk.12 As noted below, there Mitigation is expected to cost about $250 many synthetic chemicals persist in the are still wide gaps in government protections billion. In assessing the top 50 chemicals at environment and accumulate in human for worker health and safety. hazardous waste sites on the basis of both tissues. One group of brominated flame toxicity and exposure potential, the U.S. retardant chemicals, for example, showed a U.S. AND CALIFORNIA CHEMICAL Agency for Toxic Substances and Disease doubling time in human milk of only five years. REGULATORY APPROACHES ARE The extent to which bioaccumulative IN NEED OF MODERNIZATION Continued on page 29
28 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org Registry (ATSDR) reported that 38 (76 regulatory system. At the same time, many It is not surprising, therefore, that the percent) are “reasonably anticipated,” business leaders recognize that deficiencies in Committee on Grand Challenges for “possibly” or “probably” capable of causing industrial policy can present a key barrier to Sustainability in the Chemical Industry, cancer in humans; 28 (56 percent) are new technology investment, including in the convened by the National Academy of expected to cause developmental defects in design, production and use of chemicals. Sciences, concluded in its December 2005 children; and 27 (54 percent) are suspected of report that in “going forward, the chemical causing acute and/or chronic neurotoxic THE U.S. CHEMICAL INDUSTRY IS industry is faced with a major conundrum— effects. FACING UNPRECEDENTED the need to be sustainable (balanced The lack of a strategic, comprehensive GLOBAL AND DOMESTIC economically, environmentally, and socially federal chemicals policy is adversely affecting PRESSURES in order to not undermine the natural systems California businesses, industry, public health A combination of market and regulatory on which it depends)—and a lack of a more and government. pressures is creating extraordinary challenges coordinated effort to generate the science and Constraints on the ability of the federal for the U.S. and California chemical industry. technology to make it all possible.”17 The government to gather and distribute chemical Producers are facing rapidly rising domestic committee included academic scientists as well toxicity information—and to assure that the natural gas costs (with very limited capacity as representatives from Dow, PPG Industries, most hazardous chemicals are adequately to pass those costs on to global customers), ConocoPhillips and Agraquest, Inc. controlled—has produced fundamental declining availability of nonrenewable The committee’s findings echo those of problems for businesses, industry, public health petroleum feedstock, ongoing regulatory costs, a 2003 study by Rand, which identified four and government in California. It is extremely and a proliferation of state-based chemicals key barriers to the development and difficult for downstream businesses and policy initiatives. For the first time historically, implementation of green chemistry and industry to identify the safest chemicals for the U.S. chemical industry is operating with a engineering principles in the U.S.:18 their operations. Small and medium-sized global trade deficit. The European Union is 1) Lack of research, technology firms in particular need better information— implementing far-reaching chemical development and new process engineering; and technical support—to improve chemical regulatory policies that will significantly affect 2) Industrial infrastructure problems and accounting and to evaluate safer chemicals and U.S. producers, as well as the global chemicals integration barriers; processes. Each day in California 82,000 tons market. Some large downstream users of 3) Up-front investments required; and of chemical consumer and commercial chemicals in the health care and consumer 4) Lack of coordinated actions by means products are sold for which the toxicity is products sectors are implementing purchasing of regulations, incentives and government largely unknown. Green chemistry leaders find regimes that include criteria to screenout the purchasing. it difficult to differentiate their products in the use of certain classes of chemicals. These firms market. State agencies do not have the include Kaiser Permanente, the largest private- Clearly, given the importance of the information they need to identify, prioritize and sector employer in the San Francisco Bay Area chemical industry, the pressures facing U.S. mitigate chemical health risks in the state; as and the largest private health care provider in producers warrant a concerted policy response. a consequence, during the 2004-2005 the U.S. California has a unique opportunity to consider legislative session, the California Legislature The U.S. chemical industry recognizes chemicals policies that would support and faced 35 bills pertaining to health and the three pillars of economic, environmental motivate U.S. chemical industry leaders to environmental problems with chemicals. and social sustainability represent the long- expand their investments in green chemistry In its present form, chemical regulation term answer to these challenges. The websites technologies within the state of California. in the U.S. and California is experienced by of the top 50 U.S. chemical companies all This will require a comprehensive many businesses as a labyrinth of unintegrated contain a statement of commitment to approach that employs both incentives and rules enforced by a wide array of governmental achieving sustainability goals. At the same regulatory tools to meet four overarching agencies. There is no single public entity in time, however, spending on research and chemicals policy goals: California, for example, to which businesses development by the top 50 firms has decreased (1) Reward chemical producers, can turn for comprehensive information on or remained flat since about 2000,16 and there distributors and end users to invest in best regulatory requirements or technical support are no indications of substantive federal practices and environmental stewardship. in other aspects of chemicals management. leadership to advance a long-range, (2) Reward investment in a broadly Not surprisingly, while most business and comprehensive plan to support the viability defined set of green chemistry and industry leaders in California share universal and competitive position of the U.S. chemical sustainability, initiatives, such as: societal values of healthy working conditions, industry. a. implementing life cycle analyses of a clean environment and safe chemical products; products, they often object to new chemicals CALIFORNIA HAS AN b. providing robust, standardized policy initiatives in California because they OPPORTUNITY FOR LEADERSHIP see these in the context of the present IN CHEMICALS POLICY Continued on page 30
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 29 Choosing conundrum” raised by the National Academy Business of Chemistry. Alexandria, VA:American of Sciences, and in the long run it could provide Chemistry Council, 2003; p. 9. Sustainability: Paths the framework for rebuilding U.S. 7. American Chemistry Council. op cit., 2003; p. to Green Chemistry competitiveness in chemicals. Clearly, 10. chemicals policy is central to California’s future 8. Swan S, Main K, Liu F, Stewart S, Kruse R, Calafat A, Mao C, Redmon J, Ternand C, Sullivan in California and the extent to which it emerges along lines S, Teague L. Decrease in anogenital distance that are economically, environmentally and Continued from page 29 among male infants with prenatal phthalate socially sustainable. exposure. http://ehp.niehs.nih.gov/members/2005/ 8100/8100.html (access July 1, 200). Environ chemical toxicity and ecotoxicity Michael Wilson is an assistant research Health Perspect 113:1056-1061(2005). information to downstream users; Scientist at the Center for Occupational and 9. Leigh, J Paul, Cone J, Harrison B. Costs of c. introducing cleaner chemical Environmental Health (COEH) at UC Berkeley. occupational injuries and illnesses in California. processes; The Northern California COEH includes faculty Preventive Medicine 32:393-406(2002). 10. LaDou J. The rise and fall of occupational d. designing chemical products that are from the campuses of Berkeley, San Francisco and medicine in the United States. Am J Prev Med 22 inherently compatible with biology; Davis. Dr. Wilson conducted his doctoral and (4):285 - 295(2002). e. using renewable chemical feedstocks master’s studies in environmental health sciences at the University of California, Berkeley, from 11. LaDou J. Occupational medicine: The case for and renewable fuels; reform. Am J Prev Med 28 (4):396 - 402(2005). 1996 to 2003. On December 13, 2005, Dr. f. reducing energy intensity of 12. Robinson, James C. Toil and Toxics: Workplace Wilson presented the main body of this article at processing; Struggles and Political Strategies for Occupational g. separating, sequestering and utilizing the annual conference of the Industrial Health. Berkeley, California: University of carbon dioxide; and or Environmental Association and California California Press, 1991. h. advancing green chemistry and Manufacturers’ and Technology Association in 13. Bar-Cohen L, Carrillo D. Labor Law sustainability education and research. San Diego. The theme of the conference was Enforcement in California, 1970 - 2000, p 167. (3) Implement measures to improve the “Leading Change: Toward a Sustainable Future.” The State of California Labor (Milkman, R, ed). flow of chemical toxicity, ecotoxicity and other He is currently drafting a report on chemicals policy Berkeley, CA:The University of California Press, 2003. critical data through the supply chain and to issues in California at the request of the Senate 14. Heza, Vicky. Cal-OSHA Advisory Committee appropriate public bodies. Environmental Quality Committee and the Minutes of Meeting, p. 2, Cal-OSHA (4) Implement measures to improve the Assembly Committee on Environmental Safety and Toxic Materials, sponsored by the University Administrative Enforce-ment Report. Los capacity of government to identify, prioritize Angeles, CA, September 8, 2005. of California Office of the President. and reduce genuine chemical hazards in 15. Government Accountability Office. Hazardous California. Waste Programs: Information on Appropriations REFERENCES and Expenditures for Superfund, Brownfields and Each of these objectives raises myriad 1. American Chemical Society. ACS Green Related Programs. GAO-05-746R., June 30, 2005. Chemistry Institute and its director named to technical questions that will require 16. NSF (National Science Foundation), InfoBrief Scientific American 50 for 2005. http:// deliberation by a broad range of stakeholders (NSF 04-320). Largest Single-year Decline in U.S. acswebapplications.acs.org/applications/ccs/ Industrial R&D Expenditures Reported for 2002. to resolve. Expertise will be needed particularly application/index.cfm?pressreleaseid-=2560&- from leaders in the chemical industry. This May 2004. categoryid=2, November 28, 2005. 17. National Academy of Sciences, National approach, however, is preferable to the reactive 2. Ashish, Arora, Ralph Landau, Nathan Research Council, Board on Chemical Sciences environment that currently characterizes Rosenberg. Chemicals and Long-Term Economic and Technology. Sustainability in the Chemical chemicals policy decision-making in Growth: Insights from the Chemical Industry. John Industry: Grand Challenges and Research Needs: California, particularly with regard to the Wiley & Sons, Inc., 1998. A Workshop Report http://www.nap.edu/books/ legislative process. 3. Aftalion, Fred. A History of the International 0309095719/html/ (accessed October 24, 2005) Given the critical role of the chemical Chemical Industry. Philadelphia: Chemical p. 3, Executive Summary. Wash. DC: National industry in all forms of industrial activity, a Heritage Press, 2001. Academy Press, 2005. thoughtful, comprehensive chemicals policy 4. National Research Council, National Academy 18. Lempert R, Norling P, Pernin C, Resetar S, S of Sciences. Critical Technologies: The Role of has the potential to improve long-term Mahnovski. Next generation environmental Chemistry and Chemical Engineering. Washington, productive capacity and employment technologies: benefits and barriers. Rand, DC: The National Academy Press, 1992. Arlington, VA(2003). opportunities in California—while also 5. Organization for Economic Cooperation and addressing chemical problems currently facing Development (OECD). Environmental Outlook FOOTNOTES: downstream businesses and industry, public for the Chemicals Industry, 2001; pp. 21-39. 1 These include the E.U. Waste Electrical and health and government in the state. This 6. American Chemistry Council. An Overview: Electronic Equipment (WEEE) Directive, the approach begins to address the “central What is the Business of Chemistry? Guide to the Continued on page 31
30 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org Restriction of Hazardous Substances in Electrical and population begins with healing the Electronic Equipment (RoHS) and the Registration, environment. Some Educational Evaluation and Authorization of Chemicals (REACH) Resources Online initiative. Dr. Richard Jackson is a pediatrician and 2 Assuming separate nation states of the public health officer who has held many European Union. positions in the California Department of For peer-reviwed resources on specific diseases 3 Includes producers of basic chemicals, Health Services including state health officer. and contaminants, see the Collaborative on specialty chemicals, consumer products, He was also center director for Environmental Health and the Environment:www.healthand- pharmaceuticals and pesticides. environment.org. 4 According to the American Chemistry Health at the CDC in Atlanta for 10 years. Council, there are about 9,000 chemicals in the Ms. Doshi was an executive fellow and Ms. GREATER BOSTON PHYSICIANS inventory that are currently produced or imported Rai was a graduate assistant when this article FOR SOCIAL RESPONSIBILITY: IN at more than 10 tons per year. was written. HARM’S WAY: TOXIC THREATS TO 5 These are the Clean Air Act (1970), the CHILD DEVELOPMENT Occupational Safety and Health Act (1970), the REFERENCES http://psr.igc.org/ihw-project.htm Clean Water Act (1972), Resource Conservation 1. Spake A. “Building illness: what do local and Recovery Act (1976) and the Emergency zoning codes have to do with obesity and Planning and Community Right-to-Know Act asthma? Maybe lots.” US News and World PEDIATRIC ENVIRONMENTAL (Toxics Release Inventory) (1994). Report, 20 June 2005. HEALTH TOOLKIT 6 TSCA Class I chemicals are considered to 2. Johnson HB, Moller RM, Dardia M. In short http://psr.igc.org/ped-toolkit-project.htm be discrete chemicals with a definite structure. supply? Cycles and trends in California housing. Public Policy Institute of California, ENVIRONMENTAL HEALTH IN 2004. Available at www.ppic.org/main/ FAMILY MEDICINE: CURRICULUM publication-.asp?i=339. FOR TEACHING AND LEARNING 3. United States. Department of Transportation, ENVIRONMENTAL HEALTH, 2001 The Real Rx Bureau of Transpor-tation Statistics, 2004 Written by physicians and environmental National Transportation Statistics Annual Continued from page 26 health specialists for health care professionals Report. Available at: http://www.bts.gov/ working with children and family medicine. publications/transportation_- Module topics cover lead, indoor and outdoor role models for these healthy behaviors. statistics_annual_report/2004. air quality, pesticides, water quality and Take your knowledge and influence 4. Subramanian R. “Motor Vehicle Traffic persistent organic pollutants (POPS). 167 into the community. Some physicians, like Crashes As Leading Cause of Death in United pages. Free. Download at http://www.ijc.org/ Redding’s Dr. Ron Reece, have become States, 2002,” National Highway Traffic Safety Administration, Traffic Safety Facts Research rel/boards/hptf/modules/content.html politically active in city planning and Note. January 2005. Available at: http:// development. Reece’s involvement has www.bts.gov/publications/transporta- HANDBOOK OF PEDIATRIC created a buzz around Redding’s Open Parks tion_statistics_annual_report/2004. ENVIRONMENTAL HEALTH and Trails Vision, a proposal to get people 5. National Sleep Foundation. Beware of Drowsy Ruth A. Etzel, ed. out of their cars and into their communities. Drivers, and Don’t be One of Them! 27 May American Academy of Pediatrics. Discusses This plan would fund open space and trails, 2004. Available at: http://sleepfoundation.org/ preventable environmental hazards, including enable children to safely walk or bike to press/index.php?id=81. tobacco, ultraviolet light, water pollution, school, and establish other healthy 6. Frumkin H, Frank L, and Jackson R. Urban pesticides, lead and mercury. Addresses issues guidelines for development. Some of your Sprawl and Public Health: Designing, Planning such as nitrates in water, asthma triggers and patients are influential community leaders: and Building for Healthy Communities. food contamination and identifies specific mayors, city managers and school board (Washington, D.C.: Island Press, 2004), p. 111. settings in which children might be exposed members. Some are schoolteachers and 7. Ibid., pps. 140-147. 8. Ibid., p. 143. to environmental hazards. Contact American PTA members. They can contribute to 9. American Lung Association State of the Air Academy of Pediatrics, http://www.aap.org/bst/ healthy, well-planned communities with 2005. Available at: http://www.lungusa.org/ showdetl.cfm?&DID=15&Product_ID=1697 parks, sports fields, farmers’ markets and 10. Healy M. “Places to Park and Stride: good public transportation. Neighborhoods are being designed to get ONTARIO COLLEGE OF FAMILY We Americans love our independence, people out of their cars and onto their feet.” PHYSICIANS HEALTH EFFECTS OF but we also crave more choice. We need Los Angeles Times, 14 March 2005. PESTICIDE ANALYSIS healthier choices to be healthier people. 11. Longham PJ. “American Gridlock.” US News http://www.ocfp.on.ca/English/OCFP/ And yes, we physicians will continue to and World Report, 28 May 2001. sfm Communications/CurrentIssues/Pesticides/ treat the patient. But healing our default.asp?s=1sfm
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 31 ENVIRONMENTAL HEALTH
Our Stolen Future: A Decade Later
John Peterson Myers, PhD, Dianne Dumanoski and Theo Colborn, PhD
ho would have predicted ten and from studies of wildlife, but few studies to development; the specific effects will Wyears ago that: test for effects in people that the animal depend upon gene, tissue and timing of • An environmental contaminant, research predicted could be happening. The exposure.7, 15, 19 bisphenol A, would cause insulin issues raised by the animal research were so • The range of hormonal signaling systems resistance in adult mice after only four serious that governments in Asia, North vulnerable to endocrine disruption has days’ exposure1 at concentration levels America and Europe over the next decade been widened dramatically, well beyond comparable to that found in tissue and invested hundreds of millions of dollars in the initial focus on steroid hormones such fluid of virtually every American tested research on endocrine disrupting chemicals as estrogen. Every component of the by the Centers for Disease Control? 4 (EDCs) in the environment. endocrine system that has been studied • Or that this same molecule is equipotent In the aftermath of those research carefully has been shown to be affected. with estradiol at stimulating calcium investments, new scientific discoveries like Specific contaminants are known to alter influx and prolactin release in pituitary those described above are now flooding into signaling pathways controlled by tumor cells in vitro, in concentrations of the scientific literature.8 Thousands of estrogens, androgens, glucocorticoids, less than one part per billion.18 (Increasing scientists have become engaged in research on thyroid, progesterone, insulin and calcium can initiate signaling cascades endocrine disruption, from university and retinoids. that lead to a variety of cellular changes.) government laboratories around the world, • Recent research has also demonstrated • Or that the gene that produces amyloid and thousands of research papers have been that a new class of receptors associated precursor protein—a protein implicated published. The laboratory studies of animals with cell membranes can be disrupted by in Alzheimer’s disease—would be and mechanistic studies using cell culture estrogenic contaminants. This has been upregulated during old age in mice after strongly confirm the scientific results we especially important because several of behaving normally throughout most of reviewed in Our Stolen Future and raise many the contaminant molecules studied, like the animal’s life, following perinatal additional concerns that were not perceived bisphenol A, are just as powerful as exposure to environmentally-relevant just 10 years ago. And some human studies estradiol (a natural form of human levels of lead? And that the same lead are now finding patterns consistent with the estrogen) at changing cell signaling via exposure in adulthood has no comparable predictions that we made based on animal this pathway.9, 18 In this context, these effect?2 research. contaminants are not just weak estrogens, Taken together, these studies are the as critics of endocrine disruption have We published Our Stolen Future in 1996, building blocks of a scientific revolution, with asserted; they are equally as powerful as drawing widespread attention to the scientific profound implications for public health. There endogenous estradiol and estrogenic discovery that low doses of some contaminants are many elements to this revolution: drugs. can interfere with hormonal signaling, thereby • Very low doses of some contaminants can • A recurring pattern in animal and cell altering fetal development. alter hormone signaling and, by doing research is dose-response curves that are When we wrote Our Stolen Future, there that, alter gene expression. These changes non-monotonic, that is, shaped like a U was strong evidence from laboratory animals can have wide-ranging impacts upon or an inverted U. These demonstrate that Continued on page 33
32 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org low doses can have qualitatively different can be produced in laboratory action is highly likely to be putting people at effects than high doses, and that the low experiments by exposing fetal male risk. dose effects cannot be predicted on the rodents to a class of plasticizers call Some epidemiologists are responding to basis of high dose results.17 phthalates, which suppress testos-terone this challenge by changing their study designs • The range of health end points of concern synthesis and interfere with genes to reflect the advances in animal science. has broadened dramatically beyond the involved in testicular descent in fetuses. These new studies are beginning to show initial focus on reproduction and Recent epidemiological work confirms strong effects in people.13, 14 infertility. Intellectual development, associations in baby boys with phthalate One disturbing pattern that has emerged behavior, disease resistance, autoimmune exposure in the womb, using techniques in these studies is that the source of funding is disease and even weight regulation designed explicitly to test predictions in associated with the likelihood of finding (obesity) are now areas of research on the people based on results from animals.14 adverse effects.6, 16, 17 Work funded by industry impacts of EDCs. • Chemical mixtures of environmental is much less likely to report adverse impacts • It had traditionally been thought that one hormones are ubiquitous, and they have compared to that funded by government. This contaminant was likely to influence a greater impacts than single contaminants. pattern has been reported in scientific studies relatively small number of health end Several careful laboratory studies show across a wide array of economic sectors, not points, for example, the ability of asbestos that mixtures of contaminants, each at just the chemical industry. to cause meso-thelioma. This is now concentrations where they individually While these scientific results raise clearly a false assumption. Because some cause no detectable effect, in questions about the safety of many products endocrine disrupting compounds affect combination cause large effects.10, 3 These in widespread use today, they are also a source the expression of a wide array of genes, it experiments, conducted typically with up of hope. They point toward a future in which would not be unexpected to see them to a dozen contaminants simultaneously, steps to reduce exposures may help prevent emerge as causal agents in disease end have begun to explore what it may mean diseases that until recently many may have points that are associated by human for people to be exposed simultaneously never imagined were preventable. genetic studies with those genes. Research to hundreds of chemicals. For example, a with bisphenol A, for example, shows this recent study tested human umbilical cord Theo Colborn, John Peterson Myers and Dianne compound alters the expression of many blood for contaminants and found 287 Dumanoski coauthored Our Stolen Future, first different genes involved in multiple chemicals of the 413 contaminants that published in 1996, the book that first brought widespread biochemical pathways.12 Genetic were measured.5 attention to the ability of some contaminants to interfere research has established links between with hormone signaling. Dr. Myers is chief scientist for Environmental Health Sciences, based in Charlottesville some of those genes and a wide array of One of the most important implications VA. He chairs the board of the National Environmental human health problems, including of the laboratory studies has been that most Trust and the Science Communication Network. Dr. infertility, behavioral abnormalities, human studies into the effects of Colborn is president of The Endocrine Exchange, or memory problems, senility and obesity. environmental hormones have been TEDX, located in Paonia, Colorado, and professor of • Fetal development is the most vulnerable conducted in ways that weaken their ability the Department of Zoology, University of Florida, period of life, and impacts on the fetus to find effects. Few epidemiological studies Gainesville. Dr. Colborn has received numerous can cause effects all through life, with the incorporate the scientific points summarized awards, including the Blue Planet Prize, for her work effects sometimes not visible until above, especially: possible effects of fetal on endocrine disruption. Ms. Dumanoski is a noted adulthood. A new field of research has exposures on adult diseases; simultaneous environmental reporter, with many years covering the emerged, called fetal origins of adult exposures to many different chemicals; and environmental beat for the Boston Globe. She is now disease. Testicular cancer is one example, effects at low levels of exposure differing writing a book about human prospects and the emerging where hormonal imbalances in the womb qualitatively from effects at high levels. They environmental crisis. appear to cause abnormal development also usually ignore human and animal data For a copy of the references for this article of cells within the fetal testes. These showing large differences within populations email the managing editor at ecarroll- abnormal cells then become cancerous in sensitivity to exposure, a failure that further @sfms.org. sfm in adulthood. weakens the power of epidemiological • Mounting evidence indicates that research. Because of these and other study testicular cancer is one part of a syndrome design failures, it is highly likely that the The new SFMS Website is of male reproductive disorders in people epidemiological literature is full of what currently under construction. called testicular dysgenesis syndrome statisticians call false negatives: concluding a Please excuse any inconvenience (TDS).11 Other elements of TDS are compound is safe when it really is not safe. as we continue to update reduced sperm quality, undescended testes Insisting that there be conclusive evidence all information. and hypospadias. Animal experiments from human studies before taking regulatory The site can be accessed at show close parallels with a syndrome that www.sfms.org.
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 33 ENVIRONMENTAL HEALTH
Biomonitoring: Measuring Environmental Contaminants in the Body Davis Baltz, MS
iomonitoring studies demonstrate Parkinson’s disease, and hormonally mediated Human Exposure to Environmental Bwithout doubt that everyone, no cancers that affect increasing numbers of Chemicals,” using data collected under the matter where they live or what they do for a families around the globe. This in turn is National Health and Nutrition Examination living, is exposed to environmental chemicals. stimulating profound policy discussions about Survey (NHANES). The first report in 2001 To health advocates, what we are learning how chemicals and their risks should be documented the presence of 27 chemicals in about exposure to chemicals in the managed. the blood and urine of a cross section of environment is a good reason to gather more Americans throughout the U.S. The 2003 data to support policies that reduce exposure, WHAT HAVE WE LEARNED FROM report examined 116 chemicals, and the most while acknowledging that biomonitoring by BIOMONITORING? recent report, released in July 2005, further itself is not a predictor of disease or indicative Biomonitoring is not a new technology. expanded the list to 148 chemicals. of an exposure pathway. Blood lead levels have been measured for many Subsequent studies will report on Biomonitoring, or biological monitoring, years, for example, producing data that approximately 310 chemicals in 2007 and 475 is the actual measurement of environmental provided the impetus to ban lead from gasoline chemicals in 2009. chemicals in the body. It has frequently been and paint. These developments have The CDC reports are important because in the news over the past year as interest in its indisputably improved health by lowering they signal attention at the federal level for public health applications rises. Advances in exposure, especially for children. Similarly, the biomonitoring data. The 2003 study2 found analytical laboratory techniques are making prevalence of Breathalyzer tests to determine that Mexican Americans had three times the it possible to test for more chemicals at lower exposure to alcohol is a common and long- levels of the metabolite of the insecticide DDT concentrations. Chemicals can be detected in standing practice that measures a chemical in (DDE) as other participants, despite the fact a growing number of biospecimens, including the body. that DDT has been banned in the United blood, urine, hair, bone, umbilical cord blood, What can biomonitoring tell us? There States for over 30 years. The study also found breast milk and meconium. are several valuable uses: it closes gaps in that children had twice the level of the Significantly, because of the growing exposure data and helps establish trends in pesticide chlorpyrifos as adults did. These kinds number of health conditions now linked by chemical exposure; identifies particularly of findings are both startling and useful for peer-reviewed research to exposure to exposed or vulnerable communities; expands many researchers, policy makers, and environmental contaminants,1 biomonitoring biomedical, epidemiological and behavioral advocates. studies are emerging as important new tools public health research; assesses the Among the findings of CDC’s 2005 for public health and medical professionals, as effectiveness of current regulations; sets report3 is the continued decline of exposure to well as for community-based groups interested priorities for legislative and regulatory action; lead among children, as 1.6 percent of children in environmental health advocacy, and informs first responses to emergencies. We had measured blood lead levels above 10 community safety and environmental justice. can expect biomonitoring to be used micrograms/deciliter. By contrast, in the late Evidence is mounting that environmental increasingly often as lab costs drop in the future. 1970s, 88.2 percent of children had levels factors likely play a role in the rise in chronic Beginning in 2001, the Centers for above this same threshold of 10 micrograms/ and acute diseases such as asthma, autism, Disease Control and Prevention (CDC) has deciliter. This stunning reduction can be traced developmental and learning disabilities, published biennial “National Reports on Continued on page 35
34 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org to the elimination of lead from gasoline, and the substances we are finding in the human carry toxic chemicals in their bodies that may demonstrates biomonitoring’s value both in body, we are only able to look for less than 1 be impairing their ability to fully achieve establishing exposure trends and as a policy percent of the total to which we may be physical health and intellectual development. driver to reduce exposure. exposed. We all carry a chemical body burden that has Other studies have confirmed the Beyond this, we have a shocking dearth been imposed without our knowledge, much particular vulnerability of certain populations of safety information about chemicals already less our consent. to chemical exposure, such as the young child in use. It comes as a disturbing surprise to people How can we ensure that the right to be and fetus. A July 2005 report by the to learn that most chemicals are essentially born free of toxic chemicals is provided to all? Environmental Working Group4 tested untested before entering the marketplace. To begin, we need to recognize our ignorance umbilical cord blood samples for a total of 413 Nearly all the synthetic chemicals now and require that chemicals be comprehensively chemicals and found an average of 200 per ubiquitous in the environment have been tested before they are introduced into sample, including pesticides, consumer product developed and disseminated worldwide over commerce, the wider environment, and our ingredients and wastes from burning coal, the past 60 years. They simply did not exist bodies. garbage and gasoline. If there was any question until the explosion of the petrochemical Biomonitoring is a credible scientific tool that the placenta might be an impervious industry in the aftermath of World War II, that has an important role to play in the fight barrier for environmental contaminants, this much of it sited on the U.S. Gulf Coast. against disease. We monitor our air, our water, study demolishes the notion. The only federal law that regulates our soil and even our fish to learn which A study mounted by Commonweal in industrial chemicals, the Toxic Substances chemicals are polluting the environment. 20055 biomonitored a dozen prominent Control Act (TSCA), is utterly inadequate Biomonitoring offers the opportunity to Californians and gave them the chance to to test chemicals for toxicity before approval. actually measure these same levels of pollution speak about their personal reactions. The study Of the 62,000 chemicals in existence in people. These important data provide the was released while the California Legislature when TSCA was enacted in 1977, only 2 scientific evidence needed for a paradigm shift was considering Senate Bill 600, the “Healthy percent have been fully examined by the EPA. toward more precautionary chemicals Californians Biomonitoring Program.” The bill Of the 18,000 introduced since that time, no management. would have created the nation’s first statewide health data have been provided to EPA for 85 biomonitoring program to measure percent. Some 65 percent of new chemical Davis Baltz, MS, is special project advisor environmental contaminants in state submissions submitted to the EPA by industry for the Collaborative on residents. It attracted broad support from are claimed as “confidential business Health and the Environ- medical, public health, scientific, information” and hence do not include safety ment and serves as a environmental and community health testing information. Of greatest concern are senior program associate advocates, including the California Medical the 2,800 high-volume chemicals produced at Commonweal for the Association. The California Legislature passed in volumes of more than 1 million pounds per measurement of chemi- the bill, but Governor Schwarzenegger year. These compounds are widely dispersed cals in the human body. subsequently vetoed it. in homes, schools, communities, consumer He is a cofounder of products and the environment. Fewer than Health Care Without Harm and the Bay Area IMPLICATIONS FOR CHEMICALS 20 percent have been tested for their potential Working Group on the Precautionary Principle POLICY to cause developmental toxicity. Absence of and was a 2004 Mesa Refuge fellow. Biomonitoring studies have clearly this information makes risk assessment established that every population worldwide impossible and prevention difficult. Absence REFERENCES is exposed to some mixture of chemicals in of testing is not absence of harm.6 1. See the Collaborative on Health the environment. The cord blood study cited The critical take-home message is that and the Environment for peer-reviewed above found an average of 200 chemicals we need systematic, comprehensive data papers and database summarizing the contaminating the womb before the mother gathering programs so the extent of exposure links between environmental gave birth. These high numbers are alarming, can be more fully understood and the relative contaminants and disease. http:// and yet consider that labs today can only detect safety of chemicals can be better assessed before www.healthandenvironment.org/science/ approximately 600 chemicals in human widespread exposure occurs. peer_reviewed. biospecimens. 2. The data from CDC’s Second By contrast, there are some 80,000 CONCLUSION National Report on Human Exposure to industrial chemicals registered for use in the Biomonitoring studies, by offering Environmental Chemicals (2003) was United States, with an additional 1,000 to definitive proof of exposure, demonstrate the incorporated into the Third Report. http:/ 2,000 new chemicals added every year. Despite disquieting truth that all people, including the /www.cdc.gov/exposure-report/. the grave concern we rightly have for many of developing child in the womb and the infant, Continued on page 38
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 35 ENVIRONMENTAL HEALTH
Toxicants and Disease Database Update
Sarah Jannsen, MD, PhD, MPH
second edition of the Toxicants such as IARC Group 2A chemicals, susceptibility to toxic effects, depending Collaborative on Health and those with limited evidence for causing cancer on the timing and duration of exposure, Athe Environment’s (CHE) in humans and sufficient evidence in animals, are not addressed. For example, a fetus or “Toxicants and Disease Database” has been also are included in this category. developing child is often more susceptible made available in a web-based format at http:/ The “limited/conflicting evidence” than an adult. For details such as the dose, /database.healthand-environment.org/. The category contains toxicants weakly associated timing, duration and route of exposure, newly updated database summarizes with human disease by case reports, from the reader is referred to the textbooks, associations between primarily chemical conflicting human epidemiological studies references and the attached online links contaminants and approximately 180 human with mixed or equivocal results or, in a few in the database. diseases or conditions. While it is not a cases, from animal data with no human data 3. The database makes no attempt to comprehensive or exhaustive review of all existing. Also included in this category are quantify the proportion of disease caused toxicants and diseases, the database does reflect chemicals that show limited or inadequate by a specific toxicant. For example, the most up-to-date science on their evidence of causing cancer in people and mesothelioma, a rare form of cancer, stems associations. limited animal evidence of causing cancer. almost entirely from exposure to asbestos. The database is searchable by toxicant, As more scientific research is done, some In contrast, the proportion of lung cancer disease category or individual disease. Each toxicants in the database may be deemed to cases caused by asbestos exposure is disease or condition is listed with associated show stronger evidence for causing disease, relatively small compared to the number toxicants, grouped by strength of evidence. new toxicants may be added, and others may of cases caused by tobacco smoking or The groupings of “strong,” “good,” or “limited/ be found to have no association with a disease radon. conflicting” evidence are easily recognized by and fall off the list entirely. 4. Finally, this is a work in progress. In many color-coding. The new format also allows for This database has significant limitations cases, the authors exercised judgment searching by individual toxicants, chemicals that are important to keep in mind. when considering the strength and or exposures. 1. Agents listed are a representation of categorization of evidence. The “strong evidence” category is toxicants that contribute to human reserved for toxicants where a causal disease. This is not an exhaustive or Comments from readers are welcome and association with disease has been verified and comprehensive list and includes primarily should be sent to Sarah Janssen at is well accepted by the medical community. chemicals and diseases found in major [email protected]. For example, agents listed as Group 1 human textbooks and medical literature reviews. carcinogens by the International Agency for 2. The database does not address the route, Sarah Janssen received her MD and her PhD Research on Cancer (IARC) are in this timing, duration or amount of exposure in physiology from the University of Illinois, category. Other chemicals are drawn from required to result in a particular condition. Urbana-Champaign. She recently completed her recent prospective or retrospective cohort Some toxicants may only be harmful if MPH as part of her training in the Occupational studies. inhaled, whereas others need to be and Environmental Medicine residency program The “good evidence” category includes ingested in order to cause harm. Some at the University of California, San Francisco. toxicants associated with a disease through diseases result from only high dose Sarah is one of three authors of the CHE Toxicants smaller epidemiological studies (cross- exposures, whereas low-level exposures and Disease Database. Her coauthors are Gina sectional, case-series, or case-control studies). may be safe. Moreover, variations in the Solomon, MD, MPH, and Ted Schettler, MD, MPH.sfm
36 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org ENVIRONMENTAL HEALTH
Green Guidelines for Health Care
Charlotte Brody, RN
ealth Care Without Harm, in alternatives. Tyrone B. Hayes, PhD, and Paul sustainable and nutritious food purchasing at partnership with Healthy Hawken will be presenting. For more their facilities and learn cost-effective strategies HBuilding Network and the information go to www.cleanmed.org. that emphasize health concerns that meet the Center for Maximum Potential Building unique needs of the health care systems. Health Systems, has developed a new tool for health ELECTRONICS Care Without Harm is working with Kaiser care construction called the Green Guide for HCWH is working with the Computer Permanente to develop a comprehensive food Health Care (GGHC). This is the first ever Take Back Campaign and with the nation’s policy that supports sustainable agriculture and metric guidance tool for health professionals, largest Group Purchasing Organizations for locally sourced organic food. KP has 25 architects and designers. Formally released in health care to require manufacturers to offer different hospitals in its systems using farmers’ November 2004, the GGHC has already computers without lead, brominated flame markets and is working with HCWH to received the endorsement of Hospitals for a retardants, cadmium and other toxic inputs. implement a farm-to-hospital purchasing Healthy Environment (which includes the In the last year, Kaiser, Catholic Healthcare program for organic food. U.S. EPA, the American Hospital West and many other systems have adopted a Association, the American Nurses Association recycling pledge to ensure that their used PVC ELIMINATION and HCWH), Kaiser Permanente, Brigham electronics equipment is responsibly recycled In November 2005, Catholic Healthcare and Women’s Hospital, Ascension Healthcare using credible companies. West awarded a new $70 million contract for and other major systems nationwide. PVC/DEHP-free IV bags and tubing to B. Moreover, in just the last five months, 25 GLOBAL MERCURY-FREE AND Braun. Dioxin is released when PVC plastic is hospitals have agreed to pilot the GGHC. The DIOXIN-FREE MEDICINE produced and when it is incinerated after use. Green Guidelines for Health Care are HCWH has initiated the second stage of Unlike most other plastics, PVC is brittle and available for viewing and downloading at a project with the World Health Organization must have plasticizers added to it to make it www.gghc.org. and the United Nations to develop model soft, clear and pliable. The phthalate DEHP is programs in seven countries to eliminate the plasticizer used in PVC medical products. CLEAN MED IN SEATTLE mercury and dioxin from the health care sector. DEHP is a reproductive toxin. On April 19 and 20, 2006, Health Care In the U.S., 95 percent of pharmacy chains In its press release, CHW noted that it is Without Harm will host the fourth U.S. Clean have stopped selling thermometers that the first major integrated delivery network to Med Conference. Clean Med is the premier contain mercury. A similarly dramatic phase- take such a strong position on the use of PVC/ national conference for environmental leaders out of syphygmomanometers with mercury is DEHP-free products. The CHW decision adds in health care. The agenda for 2006 includes expected within the next two years. to the significant movement away from PVC a preconference workshop on green building and DEHP in health care, following the FDA (April 18, 2006); design and operation of green HEALTHY FOOD IN HEALTH CARE public health notification on PVC with DEHP. buildings; environmentally preferable products In November 2005 HCWH, Kaiser Recently Consorta (which buys for 480 for health care; reducing waste and toxicity Permanente (KP) and Catholic Healthcare Catholic hospitals) collaborated with HCWH and ensuring healthy food in health care. West (CHW) hosted the first-ever FoodMed, to make a decision to adopt a PVC-free flooring The keynote speakers for Clean Med a one-day conference in Oakland. FoodMed contract for its entire system. KP also expanded 2006 are leaders in defining emerging was designed to help its target audience of environmental problems and promoting safer hospital food service managers to incorporate Continued on page 38
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 37 ENVIRONMENTAL HEALTH Green Guidelines for Health Care Methlymercury in Continued from page 37 the market for PVC-free carpets when it persuaded Collins & Aikman to develop and introduce an entirely new PVC-free carpet Fish: An Update called Ethos.
Charlotte Brody is a registered nurse. She is Jane M. Hightower, MD the executive director of Commonweal, a 30-year- old health and environmental research and education institute in Bolinas, California. She is also a founder and former executive director of Health Care Without Harm. Health Care Without Harm is an international coalition of 431 he methylmercury-in-fish which methylmercury will increase organizations in 52 countries working to transform debate continues to show atherosclerosis, canceling out the good the health care industry so it is no longer a source T that the economics of effects of omega-3 fatty acids. of harm to people and the environment. The mother industry and the health of the consumer As of November 2005, the California of two sons, Charlotte also serves on the boards of are at odds. Despite this, the AMA passed Attorney General and the tuna industry Smith Farm and the Environmental Working a resolution recognizing methylmercury as are in court arguing the state’s right under Group, the Advisory Boards of the Environmental a hazard in food in 2004. Proposition 65 to place mercury warnings Health Strategy Center and the Environmental The coal mining industry (coal has on labels of canned tuna. This will allow Stewardship Council of Kaiser Permanente and mercury in it), the power companies that the consumer ready access to the FDA the Steering Committee of the Safe Cosmetics burn the coal and release mercury into the methylmercury advisory through a Prop. Campaign. air, the fishing industry that sells fish 65 warning. Although the wording for the containing significant mercury content, Prop. 65 warning is the same as the FDA the food companies that sell canned tuna advisory, the tuna industry’s argument Biomonitoring and other fish products, and the against it is that the Prop. 65 warning is Contaminants restaurants and grocery stores that sell not within the FDA guidelines, as the fish—all have economic interests in this FDA does not require warnings at the Continued from page 35 issue. point of sale. For over 25 years, some in these 3.http://www.cdc.gov/ exposurereport/. industries paid to have studies conducted, Dr. Hightower is an internist in San concluding that mercury is not a health Francisco and a member of the SFMS Board 4.http://www.ewg.org/reports/ bodyburden2/ The Environmental concern. Bias there is now in question, as of Directors. fishing personnel and their family Working Group has also conducted a study of flame retardants found in breast members were used as study subjects in REFERENCES milk, highlighting unsafe exposures for these industry-funded studies. 1. Hightower JM, Moore D. 2003. Mercury Adverse effects from mercury have Levels in High-End Consumers of Fish. newborns to industrial chemicals: http:// www.ewg.org/reports/bodyburden. been reported in many controlled studies Environ Health Perspect 111(4): 604-608. not funded by industry. In infants and http://ehp.niehs.nih.gov/members/2003/ 5. The Commonweal report “Taking children, mercury has been correlated 5837/5837.pdf It All In” is available at: http:// www.commonweal.org/programs/brc/ with damage to the developing fetal brain 2. Hightower JM, O’Hare A, Hernandez and autonomic system. For adults, GT. 2005. Blood mercury reporting in Taking_It_All_In.html. 6. Comments to ABC News by methylmercury has been correlated with NHANES: Identifying Asian, Pacific adverse neuropsychiatric effects, male islander and multiracial groups. Environ Philip Landrigan, MD, of Mount Sinai infertility, autoantibodies and subjective Health Perspect [epub ahead of print] http:/ School of Medicine concerning the EWG cord blood study, July 14, 2005sfm complaints. The issue of most concern is /ehp.niehs.nih.-gov/members/2005/ that there appears to be a threshold at 8464/8464.pdf sfm
38 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org 2005 SFMS Election Results
2006 OFFICERS Lily M. Tan, MD (one-year term): President-Elect: Stephen E. Follansbee, MD DELEGATES TO THE CMA HOUSE OF DELEGATES Secretary: Charles J. Wibbelsman, MD (First five are delegates; next six are alternates; Stephen E. Treasurer: Steven H. Fugaro, MD Follansbee, president-elect, will serve as the sixth delegate Editor: Mike Denney, MD according to the SFMS bylaws) for a two-year term 2006-2007: Delegates: BOARD OF DIRECTORS Alan G. Greenwald, MD (seven elected for three-year term 2006-2008): Brian J. Lewis, MD Mei-Ling E. Fong, MD Dexter Louie, MD Thomas H. Lee, MD Judith L. Mates, MD Carolyn D. Mar, MD George P. Susens, MD Rodman S. Rogers, MD Alternates: John B. Sikorski, MD Lucy S. Crain, MD Peter W. Sullivan, MD Carolyn D. Mar, MD John I. Umekubo, MD Rita Melkonian, MD Rachel Hui-Chung Shu, MD NOMINATIONS COMMITTEE Peter W. Sullivan, MD (four elected for two-year term 2006-2007): John I. Umekubo, MD Kenneth J. Hammerman, MD Richard M. Naidus, MD Congratulations to all those who were elected and many Daniel M. Raybin, MD thanks to all who participated. sfm Charles J. Wibbelsman, MD
AMERICAN MEDICAL ASSOCIATION DELEGATE (two-year term 2006-2007): H. Hugh Vincent, MD
AMERICAN MEDICAL ASSOCIATION ALTERNATE (two-year term 2006-2007): Judith L. Mates, MD
CALIFORNIA MEDICAL ASSOCIATION TRUSTEE (two-year term 2006-2008): Robert J. Margolin, MD
YOUNG PHYSICIANS SECTION DELEGATE (two-year term 2006-2007): Jordan Shlain, MD We’re Moving!The mansion at 1409 Sutter Street has been sold and the administrative offices of the San Francisco Medical YOUNG PHYSICIANS SECTION ALTERNATE Society are in the process of moving to our new headquarters as (two-year term 2006-2007): we go to press. Our new offices (shown above) will be located in the Presidio at 1003 A O’Reilly, San Francisco, CA 94129.
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 39 HOSPITAL NEWS
■ ■ ■ Chinese CPMC Kaiser Fred Hom, MD Damian Augustyn, Bruce Blumberg, MD MD
The recipient of Chinese Hospital’s 32nd CPMC has opened a Stroke Care Center. Kaiser Permanente San Francisco is Annual Award was Dr. George King, director Adults with cerebrovascular disease now have committed to supporting the San Francisco of research at the Joslin Diabetes Center and easily accessible expert brain care with David Asthma Task Force with technical and professor of medicine at Harvard Medical Tong, MD, medical director. The center is financial assistance, as well as leadership. The School. Dr. King lectured on the topic staffed by neurological experts specializing in citywide task force was created in 2001, and has three subcommittees: Schools/Childcare, “Designing New Treatments for Diabetes in the evaluation and management of individuals Environmental and Clinical. The 20-member Asian Americans and All Patients—from with stroke and cerebrovascular diseases, task force has representatives from public and Cells to Bedside.” Thanks go to Dr. Nick Jew, providing comprehensive care to patients private health care groups, as well as members chair of the continuing education committee, whether they have suffered a stroke or transient representing the school district and child care for helping to organize the successful event. ischemic attack (TIA) or are at risk for these workers. The task force grew out of a project disorders, helping with disease management in the 1990s to control the increase of asthma Dr. Roger Eng, chief of radiology, reported and reducing the risk of future events. at George Washington Carver Elementary that the hospital has entered into a strategic The Stroke Care Center provides expert School in the Bayview Hunters Point area. relationship with Kodak to build and guidance concerning the most appropriate At the time, the principal of the school noticed demonstrate Kodak’s latest integrated digital medical and surgical therapies to treat an alarming increase in asthmatic episodes imaging department. When the department cerebrovascular disorders, as well as preventive among students. Kaiser Permanente provided is completed in the first half of 2006, Chinese therapies to minimize disease and an asthma education program for staff and students. A community group on asthma Hospital will serve as Kodak’s showcase site rehabilitation options for those who have education was formed and it grew into the task for digital imaging across the western U.S. and suffered a stroke. force. Kaiser San Francisco staff members who Asian markets. In addition, the hospital Stroke Care Center services include state- have been involved since the early days include became the first private hospital in the city to of-the-art brain imaging and diagnostic tools, Deborah Harper, now an RN Manager of offer a SPECT/CT fusion camera. The CT a wide range of disease management and Orthopedics and the Injury Center, Dr. Peg portion of the machine will allow greater preventive therapies, guidance concerning Strub, Chief of KPSF’s Allergy Department, diagnostic accuracy for cardiac nuclear advanced surgical interventions and treatment and Kathy Thomas-Perry, a community and medicine studies. The fused CT image will options, and a knowledgeable, experienced government relations specialist and former then allow more precise localization of any team of health care professionals. To learn chair of the task force. abnormal activity in studies such as bone and more about the CPMC Stroke Care Center, Today, the task force conducts many WBC scans. visit www.cpmc.org/stroke. ongoing projects. The clinical committee is Last month CPMC opened a working to improve the care and quality of life of children and adults with asthma. This month’s JCAHO tip: Surgical or Preregistration and Learning Center at 1825 Members are working on a project providing invasive procedure sites must be marked with Sacramento Street. The new facility was asthma education and certification to dozens a check mark in ink or indelible marker.sfm designed to streamline the preregistration of health care providers in hospitals and health process for patients scheduled for surgery and care groups. A website with links to health other procedures and is equipped to deliver a care resources for both patients and providers broad range of services in one location. These is planned. The Environmental Committee services include preregistration online, by is reducing environmental risk factors for phone or in person (most patients are not asthma in public housing. Housing inspectors required to register in person); appointments will get training and state-of-the-art cameras for those who do need to come in to register, to identify sources of moisture in public minimizing waiting; and many other services. housing.sfm sfm
40 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org HOSPITAL NEWS
■ ■ ■ Saint Francis St. Luke’s St. Mary’s Guido Gores, MD Jerome A. Franz, MD Kenneth Mills, MD
Saint Francis has been on the move of The boards of St. Luke’s and CPMC Last month the FDA approved a new late—renovating and improving several approved a merger of the two institutions in spinal implant invented at St. Mary’s. The X environments of care. In early December, we October. It will be effective when approved STOP is an innovative device and a minimally hosted the grand opening of our new site for by the Attorney General of California, making invasive procedure that offers another option the San Francisco Spine Center. The center St. Luke’s a fourth campus of CPMC. Our to those suffering from age-related spinal has been relocated across the street from the medical staff is getting to know new faces as stenosis. Dr. James Zucherman and Dr. Ken main hospital at the 1199 Bush Street Medical the administration shuffles in anticipation of Hsu invented the device and St. Mary’s will Office Building. With over 5,000 square feet the merger. be the training center for this low risk medical of space, the center can now offer additional Dr. Martin Brotman, CEO of CPMC, procedure. This is an excellent option for services in its comprehensive care model. The became CEO of St. Luke’s November 1 and patients who fail to improve with conservative upgrade includes space for fluoroscopy-guided brought Grant Davies with him as senior vice therapies, are unable to undergo the risks of injections, digital x-ray and electromylography. president of operations. Dr. Brian Goodell of major surgery and want to return to Navigant will be with us for 90 days as interim functioning pain-free as soon as possible. The In October, we hosted another grand chief administrative officer in an effort to financial impact of health care costs as well as opening of our new and improved location of implement changes recommended by his lost work hours as a result of back pain is our satellite Center for Sports Medicine in consulting firm. Jim Strong, our capable and enormous. Typically, the hospital stay for this Walnut Creek. The center, which originally admired CFO, will continue in that role and procedure is less than 24 hours. The procedure opened in 1986, has moved to a significantly also that of director of operations. John can be performed under local anesthesia in larger location at 1777 Botelho Drive in Williams has moved to the Sutter corporate about one hour. Prior to approval here, X Walnut Creek. With a space of 7,000 square office. He deserves much praise for the many STOP has been approved and implanted in feet, the clinic is 57 percent larger than the improvements seen at St. Luke’s during his more than 4,000 patients in Europe and Japan former complex a few blocks away. The tenure as CEO. with excellent results. The Spine Center at additional space allows for more exam rooms, The new team is committed to St. Mary’s has been providing comprehensive digital radiology and offices for sports strengthening the finances of St. Luke’s while services for people with spine conditions for psychology and nutrition. maintaining its mission as provider of care to over 30 years. The center is composed of both a large underserved population in the South surgical and non-surgical specialists as well as Here at 900 Hyde Street, construction is of Market area. Members of the medical staff, physical therapy and acupuncture. underway to complete our new state-of-the- under the guidance of Dr. William Miller, chief As San Francisco’s oldest community art Emergency Department with a target medical executive, are participating in this hospital, founded in 1857, St. Mary’s Medical opening date of October 2006. The new facility process as part of Project Turnaround. We hope Center prides itself on commitment and will include increased bed capacity, an to attract new doctors and new patients, who endurance. One of our favorite celebrations is improved environment for patient privacy and will be pleased by what they find at our jewel Employee Recognition and it is always a lively, safety, upgraded medical evaluation area, of a hospital: dedicated workers, upgraded robust and emotional event. On December 2 decontamination area and amenities for facilities and a multiethnic patient base that our awards ceremony was held at the Marriott hospital and EMT staff. looks to St. Luke’s for culturally sensitive, Hotel with Brother George Cherrie, our vice excellent care. president of mission and community services, On behalf of my colleagues and the staff St. Luke’s Julie McKown, respiratory as master of ceremonies. Employees from all of Saint Francis Memorial Hospital let me wish therapist, stands out for her extensive outreach walks of the medical center celebrated the entire Medical Society a very prosperous to the community. She is the winner of the anniversaries with family and friends from St. and healthy New Year. sfm Ritz E. Heerman Memorial Award for 2005 Mary’s. An impressively produced video from the California Hospital Association. sfm honored employees who had given 25 to 45 years of continuous service. sfm
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 41 HOSPITAL NEWS
■ ■ UCSF Veterans Linda M. Reilly, MD Diana Nicoll, MD, PhD, MPA
There has been an explosion of The San Francisco VA Medical Center knowledge about Alzheimer’s disease recently. (SFVAMC) assesses and treats veterans for Evidence suggests that a protein called beta- medical conditions related to occupational amyloid accumulates in the brain in AD and and environmental hazards associated with causes brain damage. Early-onset AD leads to service in the military. Veterans exposed to specific environmental health hazards dramatic increases in brain amyloid, and (including ionizing radiation from atomic transgenic mice that overproduce beta amyloid weapons, nuclear submarines and depleted develop an AD-like syndrome. Many uranium shells, Agent Orange in Vietnam, researchers believe that blocking amyloid or pesticides, toxins, desert sand and dust production, preventing its aggregation, or in the Persian Gulf) are entitled to free removing brain amyloid may prevent AD- relevant physical examination, X-rays and associated brain damage. laboratory tests and treatment for Although there are FDA-approved conditions linked to service-connected treatments available, they offer only a transient, exposure. symptomatic benefit and do not affect the Environmental medicine database underlying brain damage. Knowledge about evaluations are electronically linked with AD has allowed researchers to develop new the VA’s national Environmental medicine registries that provide epidemiologic medications that target amyloid. One approach assessment of medical conditions associated was a vaccine against amyloid. This vaccine with exposure to military environmental was tried in humans and ultimately failed due hazards. to a toxic side effect. Nonetheless, study of The SFVAMC occupies a unique patients who received the vaccine suggest this position among the San Francisco health approach may work to clear brain amyloid and care community—we care for veterans. improve clinical function. Some of these veterans, whether young or UCSF Medical Center, under the old, whether they served in Iraq or in World direction of Dr. Adam Boxer, is currently War II, have been exposed and negatively running a trial of a monoclonal antibody that affected by environmental contaminants. was designed, based on the vaccine experience, Environmental medicine at SFVAMC is to remove brain amyloid but avoid the toxic responsible for identifying and treating the conditions and diseases manifested by side effect. UCSF is the only site in the Bay environmental health hazards. Many Area conducting the study. Subjects receive veterans seeking care for health problems an infusion of the antibody every 13 weeks for resulting from environmental health 1.5 years. In addition to safety, other outcome hazards are from the Vietnam War era. measures include neuropsychological tests and Diabetes type II, prostate cancer, lung caregiver questionnaires. More novel outcome cancer, lymphoma and chronic measures are serum and brain beta-amyloid myelogenous leukemia have been levels, and analysis of brain MRI scans. epidemiologically linked to Agent Orange This is the first of three planned treatment and are presumptive conditions for which trials of anti-amyloid therapies at UCSF over veterans may receive financial the next year. Interested referring physicians, compensation, medications and health benefits directly from VA or through co- patients or family members should call (415) sfm managed care with their community health 476-1681 for more information. sfm care providers.sfm
42 SAN FRANCISCO MEDICINE / JANUARY - FEBRUARY 2006 http://www.sfms.org SFMS Welcomes JANUARY 21 (SATURDAY) Town Hall Meeting In Memoriam New Employees “Communities Coming Together to Explore Nancy Thomson, MD, MPH Environmental Links to Breast Cancer” The San Francisco Medical Society is Kaiser Permanent Medical Center pleased to welcome our newest employees, Oakland, CA Therese Porter and ERNESTO J. PULETTI, MD Galen Foster. MARCH 15 - 17 Dr. Ernesto J. Puletti passed away Therese Porter Foresnsic Mental Health Association of CA unexpectedly of a replaced Thomas ruptured brain Annual Conference Young as the SFMS aneurysm, October Seaside, CA membership director CME for MDs, RNs. social workers, 8, 2005 at age 73. when he moved to He was born in psychologists and corrections officers. New York in Nov- Formore information go to: www.fmhac.net Argentina on Janu- ember to be closer to ary 2, 1932, and was Therese Porter his family. APRIL 4 (TUESDAY) a graduate of the Therese Porter Legislative Leadership Day 2006 will be at the University of Buenos is a third generation native San Francis-can. Aires. He trained at Sheraton Grand, Sacramento sfm She worked for many years in the the University of department of ophthalmology at California San Francisco and Pacific Medical Center. In the course of her practiced internal medicine in the Mission career she has been a choreographer, a ENVIRONMENTAL JUSTICE District of San Francisco since 1961, stand-up comedian, a writer, and an INITIATIVE: specializing in gastroenterology. He was a executive assistant in the financial services SAN FRANCISCO FOUNDATION member of St. Luke’s Hospital staff since industry. In her spare time she performs and 1966 and had served as chief of staff since directs at historically themed events such Bay Area residents are often exposed to 2004, having previously served as vice chair. as the Renaissance and Dickens Faires. poor air quality, pollution generated from He was also on the staff of Seton Medical Galen Foster hails from Anchorage, traffic, power plants, industrial sites, and toxic Center. He was a member of many medical Alaska, and has previously worked in the chemicals in consumer products. These organizations including the San Francisco advertising and food service industries. He environmental hazards disproportionately Medical Society, the CMA, and the Pan will apply his computer tech skills by fine- effect communities of color and low-income American Medical Society of which he is tuning the newly installed SFMS database neighborhoods and are increasingly being past president. system and assisting Porter in the linked to a range of conditions such as asthma, Dr. Puletti’s passion for medicine membership department. cancer, and birth defects. and love and dedication to his patients and Anyone with membership questions The San Francisco Foundation the community in the Mission were always may contact Therese Porter at (415)561- established the Environmental Health and indicated in his readiness to serve whoever 0850, ext. 268, or by email at [email protected]. Justice Initiative in 2000 to address the impact needed him. He was loved by his patients Galen Foster may be reached at (415) 561- of environmental factors on local and highly respected by his colleagues. He 0850, ext. 269, or by email at communities. The Initiative works on and was a valiant supporter of St. Luke’s [email protected]. funds in three issue areas: Hospital and the medical staff, always • Reducing the impact of toxins and striving to preserve the mission of providing chemicals on human health; care for all in need, regardless of their ability • Advancing and promoting the to pay. In addition to English, he spoke Calendar of “precautionary principle” as a useful framework Spanish, Portuguese and Italian. for improving and protecting public health; He is survived by his wife, Maria Events and Cristina Vicente-Puletti; his brother • Improving the Bay Area’s air quality Hector, his sisters Esther and Amelia Puletti JANUARY 26, 2006 (THURSDAY) and addressing the effects of air pollution on of Buenos Aires; mother and father-in-law, SFMS Annual Dinner human health. Catalina and Leoviglido Vicente; brother- Installation of 2006 President For more information about the Initiative in-law Jorge Vicente and numerous nieces Gordon L. Fung, MD or to learn, support, apply, or partner with us, and nephews.sfm Delancey Street Catering Town Hall please contact the Foundation’s Environment 600 Embarcadero Program staff at (415) 733-8500.sfm Call (415) 561-0850, ext. 260, to RSVP
http://www.sfms.org JANUARY - FEBRUARY 2006 / SAN FRANCISCO MEDICINE 43 PRSRT STD San Francisco Medical Society U.S. POSTAGE 1409 Sutter Street PAID San Francisco, CA 94109 TUCSON, AZ PERMIT NO. 271 Return Service Requested
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