SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y
Environmental Health Toward Healthier Environments Across the Lifespan Chemicals Cancer Diabetes Fertility Autism Radiation Research Treatment Prevention Policy
VOL. 85 NO. 5 June 2012
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IN THIS ISSUE
SAN FRANCISCO MEDICINE June 2012 Volume 85, Number 5
Toward Healthier Environments Across the Lifespan FEATURE ARTICLES
MONTHLY COLUMNS
12 Environmental Health: A Decade of Progress Philip R. Lee MD; Steve Heilig, MPH; Michael Lerner, PhD; and Elise Miller, MEd
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Membership Matters
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SFMS Advocacy Activities
Reducing Cancer Risks: Margaret Kripke, PhD, on The Environment and Cancer
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Environmental Chemicals: Large Effects from Low Doses Laura N. Vandenberg, PhD; R. Thomas Zoeller, PhD; J.P. Myers, PhD
President’s Message Peter J. Curran, MD
11 Editorial Gordon Fung, MD, PhD
The Diabetes Epidemic: Environmental Chemical Exposure in Etiology and Treatment Robert M. Sargis, MD, PhD; Sarah G. Howard, MS; Retha R. Newbold, MS; and Jerrold J. Heindel, PhD
OF INTEREST
13 15
17 Considering BPA: State of the Art or Willful Ignorance? William H. Goodson III, MD, and Shanaz H. Dairkee, PhD 18
20 Toxic Matters and Fertility: What Can a Doctor Do? Patrice Sutton, MPH; Tracey J. Woodruff, PhD; Jeanne A. Conry, MD, PhD; Linda C. Giudice, MD, PhD, MSc
23 Scientific Evolution of Autism: Trends and Patient Advice Martha Herbert, MD, PhD 25 Fukushima’s Lessons: The Dangers of Nuclear Power Robert Gould, MD 26
Assessing Toxin Risk: Improvements Needed to Protect Human Health from Chemicals Ted Schettler, MD, MPH; Sarah Janssen, MD, PhD, MPH; Jennifer Sass, PhD; Gina Solomon, MD, MPH; and Tracey Woodruff, PhD
28 The European Example: What Have We Learned about Health and the Environment? Genon K. Jensen and Lisette van Vliet 30 Electromagnetic Fields: The Effect on Human Health David O. Carpenter, MD
31 Biomonitoring Update: Measuring Exposure to Chemicals Davis Baltz and Sharyle Patton
37 Hospital News
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SFMS Launches New Website
32 Classified Ad
SPECIAL POCKET GUIDE ON PAGE 21 For this special issue on environmental health, we’ve included an insert entitled “Healthy Aging and the Environment: A Pocket Guide.” Produced by the Collaborative on Health and the Environment (CHE), it presents many issues in graphic summary and describes the important benefits of a healthy diet, regular exercise, healthy natural and built environments, positive social interaction, stress reduction, and avoidance of toxic exposures. We hope this guide, suitable for both clinicians and patients, will help any reader understand how multiple environmental factors, alone and together, influence the risk of disease and disability across the lifespan.
32 New Online Data Tool: Local Environmental Health Data Now Available Online Paul English, PhD, MPH 33 Ecological Health: Complex Science, New Models, and Public Health Ted Schettler, MD, MPH 35 The Collaborative on Health and the Environment Consensus Statement
Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.
MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members
Support Proposition 29: Cut Health Care Costs, Spur the Economy, and Cure Cancer According to the Centers for Disease Control and Prevention, smoking costs California taxpayers $9 billion every year in health care costs, and much more in lost productivity. Proposition 29, the California Cancer Research Act, will save an estimated 104,500 lives from premature smoking-caused deaths, prevent 228,700 children from becoming adult smokers, and save California taxpayers an estimated $5.1 billion in long-term health costs from declines in smoking. Please join SFMS, California Medical Association, American Cancer Society, American Heart Association, California Hospital Association, Stand Up to Cancer, and the University of California and vote YES on Proposition 29.
Blue Shield of California Fee Schedule Changes Effective June 2012
Blue Shield has notified physicians of changes to its physician fee schedule that will go into effect June 1, 2012. The new rates are available at the Blue Shield website. Physicians can also request a copy of the new fees by calling the Blue Shield Provider Services Department at (800) 258-3091. Physicians are encouraged to carefully review all proposed amendments to health plan or medical group/IPA contracts. Physicians who do not agree with the proposed changes have the option to terminate the contract by providing 60 days’ written notice to Blue Shield. The termination notice must be received by Blue Shield within 45 days of receipt of the notice. It should be noted that if a physician terminates the contract according to these terms, the changes will not apply to that physician during the termination-notice period. SFMS/CMA has developed an action guide for physicians on contract amendments to help our members understand their rights when a health plan has sent notice of a material change to a contract. SFMS members can access this tool by logging into the SFMS website and going to http://www. sfms.org/ForPhysicians/PracticeManagement.aspx.
SFMS Physician Inducted as a Fellow in the American College of Radiology
SFMS board member Roger S. Eng, Jr., MD, MPH, has been inducted as a fellow in the American College of Radiology (ACR). Dr. Eng currently serves as the chief of radiology at Chinese Hospital in San Francisco and as president of the Golden Gate Radiology Medical Group in Orinda. Recognition as a fellow of the American College of Radiology is one of the highest honors the ACR can bestow on a radiologist, radiation oncologist, or medical physicist. ACR fellows demonstrate a history of service to the College, orga4 5
San Francisco Medicine June 2012
nized radiology, teaching, or research. Approximately 10 percent of ACR members achieve this distinction. Please join the SFMS in congratulating Dr. Eng on receiving this prestigious recognition.
SFMS Member a Candidate in June DCCC Election
Justin Morgan, SFMS member and family physician with the San Francisco Department of Health’s outpatient clinics, is a candidate running for one of twenty-four seats on the San Francisco Democratic County Central Committee (DCCC) in the June 5 statewide primary election. Dr. Morgan is the only African-American male and the only physician seeking election in his district, representing the neighborhoods in the eastern half of San Francisco. To learn more about this campaign or for contribution information, please visit http://on.fb.me/JByaBA. Note: SFMS does not endorse any DCCC or SFGOP candidates. However, it is SFMS PAC policy to inform membership of any SFMS members who are running for DCCC or SFGOP so members can decide whether or not to make individual contributions to their colleagues’ campaigns.
Complimentary Webinars for SFMS Members CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/ events.
June 20: Writing Effective Appeals • 12:15 p.m. to 1:15 p.m. July 18: Preparing for a Medicare and/or Medi-Cal Audit • 12:15 p.m. to 1:15 p.m. August 1: Coding for Medical Necessity • 12:15 p.m. to 1:15 p.m. August 15: Program Integrity in Medicare and Medi-Cal • 12:15 p.m. to 1:15 p.m.
The Albert R. Jonsen Bioethics Symposium
Albert R. Jonsen, PhD, senior ethics scholar-in-residence at CPMC’s Program in Medicine and Human Values, is one of the founders of the field of bioethics. His colleagues will honor his vast knowledge, high integrity, and irreplaceable experience with a Bioethics Symposium, a round table with the founding figures in Bioethics, on October 10, 2012, in San Francisco. Following the symposium, there will be a reception honoring Dr. Jonsen. Contact hummell@sutterhealth.org for more information or (415) 600-1645 or to get involved.
www.sfms.org
SFMS Unveils New Website
June 2012 Volume 85, Number 5 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay
SFMS now has a new presence on the Internet with the newly revamped www.sfms.org. The
launch of the new website—which offers quick and easy access to essential information and resources from SFMS—is part of our ongoing efforts to enhance the quality and availability of information to our members and the at-large medical community. The website boasts a modern design optimized for viewing on desktops, laptops, and tablets. Notable features include:
• Physician-finder tool and customizable physician profile page for each SFMS member to help physician members promote their practices and expand their patient base. • New Advocacy Section that includes regional, state, and national updates on priority bills and key wins. • More robust Membership Section that enables online membership renewal, event registration, and member information updates. • SFMS blog for on-demand health care news and events information. The blog includes commenting features to promote two-way communication and better user engagement as well as RSS feed capability. • San Francisco Medicine in e-magazine format. • Featured Member page to highlight SFMS members and their work in the community. • Member-only resources available for immediate download (e.g., 5010 update, new California law update for physicians, etc.).
Visit www.sfms.org today to update your profile, obtain current health care news, and connect with colleagues!
EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD Peter J. Curran, MD Stephen Walsh, MD Sashi Amara, MD SFMS OFFICERS President Peter J. Curran, MD President-Elect Shannon Udovic-Constant, MD Secretary Jeffrey Beane, MD Treasurer Lawrence Cheung, MD Immediate Past President George A. Fouras, MD SFMS STAFF Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Assistant Lauren Estrada
BOARD OF DIRECTORS Term: Jan 2012-Dec 2014 Andrew F. Calman, MD Edward T. Melkun, MD Roger S. Eng, MD Jennifer Gunter, MD John Maa, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD
Term: Jan 2010-Dec 2012 Gary L. Chan, MD Donald C. Kitt, MD Cynthia A. Point, MD Adam Rosenblatt, MD Lily M. Tan, MD Willim T. Prey, MD Joseph Woo, MD
Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Man-Kit Leung, MD Keith E. Loring, MD Terri-Diann Pickering, MD Adam Schickedanz, MD Rachel H.C. Shu, MD
CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate
www.sfms.org
June 2012 San Francisco Medicine
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San Francisco Medicine June 2012
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SFMS Advocacy Activities A PROFESSIONAL VOICE FOR COMMUNITY HEALTH SINCE 1868 The San Francisco Medical Society (SFMS) has been involved in community health issues since the 1800s. As the only medical association in San Francisco representing the full range of medical specialties and interests, SFMS health advocacy has been broad. Via policy-making efforts with state and national medical and political leaders and an award-winning journal, SFMS has often been influential far beyond the city. The SFMS agenda and activities continue to focus on the community and the following areas of involvement: • Forming HealthShare Bay Area (see below) to improve patient care and reduce costs • Working with the physician community to promote the adoption of electronic health records to better serve patients • Advocating against cuts to Medi-Cal and Medicare reimbursement to provide continued access to care for all San Franciscans • Preserving the health care safety net and public health programs in times of severe budget cuts • Supporting antitobacco legislation and San Francisco’s law banning the sale of tobacco in pharmacies, and smoking in restaurants and other businesses, and eliminating tax credits for films showing smoking • Supporting the Healthy San Francisco program and participating in legal defenses to preserve the program, while helping to monitor the program’s progress • Providing physicians for medical consultation for San Francisco schools and for volunteer care at community clinics • Working on legislation to allow minors, without parental consent, to receive vaccines to prevent STIs; to prevent bans on medical procedures such as circumcision; and more • Cosponsorship of the Hep B Free program in San Francisco • Advocacy for improving end-of-life care in the Bay Area via new policies, use of new advance directives (such as POLST), and educational outreach to physicians and patients
HOW SFMS SERVES THE COMMUNITY
HEALTHSHARE BAY AREA Working under the auspices of
the SFMS Community Service Foundation and guided by a diverse board of San Francisco and Bay Area health care industry professionals, the SFMS worked to develop HealthShare Bay Area to provide the infrastructure for a unified electronic health record system. The project originally targeted San Francisco but now includes partners from the East Bay. This service allows providers to have access to secure community-wide patient data. It also permits patients to gain a complete view of their medical records, irrespective of where individual records may reside. HSBA will launch in 2012.
UNIVERSAL ACCESS TO CARE SFMS leaders have long advocated that every San Franciscan should have access to quality medical care. Recent SFMS participation in this effort has included the Mayor’s Health Care Reform Task Force, the San Francisco Health Care Services Master Plan Task Force, and the Mayoral Task Force, which designed the Healthy San Francisco program. SFMS also joined in the lawsuits to preserve that program. SFMS has advowww.sfms.org
cated for community clinics since the founding of the original HaightAshbury Free Clinics in the 1960s.
MEDICAL LIABILITY PROTECTION The CMA and SFMS were
instrumental in passing MICRA, which saves virtually every doctor many thousands of dollars in liability premiums annually and saves hospitals and health systems much more. We have successfully defeated repeated attacks on MICRA by trial lawyers through the years.
REBUILDING/PRESERVING SAN FRANCISCO GENERAL HOSPITAL SFMS spokespersons took a lead in advocating for full
funding of the seismic rebuild and in advising, as members of the Mayoral committee, where and how that would occur.
HIV PREVENTION AND TREATMENT The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, adequate funding, and more.
SCHOOL AND TEEN HEALTH SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, worked on improving school nutritional standards, and provides medical consultation to the SFUSD school health service.
ENVIRONMENTAL HEALTH SFMS established a nationwide educational network on scientific approaches to environmental factors in human health; has advocated on reducing mercury, lead, and air pollution exposures; and much more. REPRODUCTIVE HEALTH AND RIGHTS SFMS has been a state and national advocate for reproductive health and choice.
BLOOD SUPPLY SFMS has long been a partner of the Blood Centers of the Pacific and seeks to help increase donations.
ORGAN DONATION SFMS has been a leader in seeking improved
donation of organs to decrease waiting lists, via education and new polices regarding consent and incentives for organ donation.
OPERATION ACCESS SFMS is a founding sponsor of this local organization providing free surgical services to the uninsured and has provided office space, volunteers, and funds. DRUG POLICY SFMS has been a leader in exploring and advocat-
ing new and sound approaches to drug abuse, including some of the first policies regarding syringe exchange, medical cannabis, and treatment instead of incarceration.
MEDICAL ETHICS SFMS has developed and promulgated for-
ward-looking policies and approaches regarding end-of-life care, patient directives, physician-assisted dying, and other topics of interest to patients, physicians, policy makers, and the general public. June 2012 San Francisco Medicine
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PRESIDENT’S MESSAGE Peter J. Curran, MD
Not Exactly an Erin Brockovich Hollywood Ending: Why the FDA Said No to a Ban of Bisphenol-A in Food Packaging The Food and Drug Administration (FDA) came out in March with a thumbs-down on a ban of the chemical bisphenol-A (BPA) in food packaging, which came as a surprise to environmental groups such as the National Resources Defense Council (NRDC). Sarah Janssen, MD, PhD, senior scientist at the NRDC, says, “The agency (FDA) has failed to protect our health and safety . . . ” Other advocates went further, saying that the FDA is no longer meeting its obligation to protect the public health. Even the Obama administration was pulled into the debate; disappointed activists claimed that a perceived national climate of overregulation by government resulted in apparent apathy by the White House to side against industry in an election year. Why is BPA apparently being relegated to the trash heap of possible-but-not-scientifically-proven environmental toxins, along the lines of cell phones and microwaves? This is no thinly studied chemical. In fact, the government has spent an estimated $30 million studying BPA, first approving its use in the epoxy liners of plastic bottles and soup cans as a “food additive” in the 1960s. Lately BPA has been labeled an endocrine disrupter with serious potential harmful health effects, including cancer, heart disease, and infertility, particularly in children and the developing fetus. An estimated 90 percent of humans are thought to have trace amounts of BPA in their bodies, most likely from leaching of the chemical from food containers. Governor Jerry Brown signed into law the Toxin-Free Infants and Toddlers ACT last year, banning the use of BPA in baby products starting in 2013. Companies have already responded by creating BPA-free products; it has become fashionable to advertise BPA-free alternatives. Campbell’s company has decided to phase out BPA from its soup cans, following the lead of similar corporations. What happened with the latest negative ruling for the ban of BPA by the FDA? In 2008, the agency released a draft ruling that BPA is safe in food contact materials. Later in that same year, a subcommittee of the FDA reexamined the ruling after new information surfaced. An interim update was issued in 2010. The chemical industry argued that the potential exposure levels from BPA products are minimal and that the chemical is quickly eliminated from the human body and that, moreover, the food-safety benefits of epoxy liners greatly outweigh any risk from BPA. Meanwhile, in 2008 the NRDC submitted a citizen petition requesting that the Commissioner of the FDA prohibit the use of BPA in human food packaging and revoke all regulations permitting the use of any food additive that may result in BPA becoming a component of food. www.sfms.org
At one point, the chairman of the FDA committee studying BPA was discovered to have accepted a $5 million unreported grant from a chemical industry supporter. Following a court order, the FDA was compelled to make a final ruling by the end of March 2012. The FDA met the deadline by one day and basically remained unpersuaded by the NRDC’s recommendations, and, probably less reported, its tactics. The FDA said after its ruling that there was not compelling scientific evidence to justify new restrictions. More research and monitoring will continue on one of the most studied chemicals of all time. Another report from the FDA on BPA is expected later this year. Was the FDA’s decision on BPA a failure to ensure the public health, or simply a failure of the NRDC to succeed in the art of negotiation? Dr. Janssen claims, “The FDA is out of step with scientific and medical research. This illustrates the need for a major overhaul of how the government protects us against dangerous chemicals.” Meanwhile, from the FDA camp, spokesman Douglas Karas emphasized in a statement that the agency’s decision is not a “final safety determination on BPA” but rather a “decision on the NRDC petition.” When two sides feel strongly about an issue, there is a need for consensus. If there is fundamental disagreement with an opponent’s position, it is time for compromise. That was the real failure on BPA. Dr. Curran is a cardiologist at Breall & Associates and is director of Cardiovascular Rehabilitation at St. Mary’s Medical Center.
June 2012 San Francisco Medicine
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EDITORIAL Gordon Fung, MD, PhD
Environmental Health The State of Science, Practice, and Policy The most recent article on environment and heart health I’ve read was just published in Circulation (2012; 125:2197-2203) by Joshua I. Rosenbloom et al titled “Residential Proximity to Major Roadway and 10-Year All-Cause Mortality After Myocardial Infarction.” The multicenter study concluded that living close to a major highway (< 1000 m, approximately 1 mile) at the time of acute myocardial infarction was associated with increased risk of all-cause ten-year mortality, and that this relationship persisted after adjustment for individual and neighborhoodlevel covariates. This research was supported by the U.S. EPA, the NIH, and Harvard Medical School scholars. It is just one of 1,380,127 research and review articles over the past four years, and one of 4,398,872 articles in the EMBASE database, using the keywords “environment” and “health.” The impact of the environment on the health of the public with regard to asthma- and cancer-related lung health, other forms of cancer, and heart disease has come under increasing scrutiny and government regulation, because detection and measurement of the effects of particle-size pollutants is revealing a direct causative effect on the disease incidence. Even though the exact mechanisms have yet to be elucidated, there is increasing information that demonstrates increased mortality associated with proximity to and levels of environmental pollutants. In order to address this problem head-on, more research has to be done to define the mechanisms of how pollution causes disease. Information is already available on the makeup of environmental pollution, down to particle size and regional measurements, and monitoring is performed in many but not all areas where there are sizable populations. Scientists have already determined the level of pollutants that should be the standard for good air quality, in order to reduce the devastating impact of pollution on health. From a public health standpoint, we need to encourage the EPA to follow the recommendations of its scientific panel to lower pollution. As individuals, we must do our best to modify our activities (for example, driving less or using environmentally safe or preserving transportation, safely discarding waste) to minimize our contributions to environmental pollution. The SFMS has been at the forefront of this issue over the past decade, creating multiple credible resources to help the medical community and the public understand the issues and participate in the solutions. This month’s theme is a recurring update from the field. San Francisco Medicine’s addition to the pool of resources, under the direction of the knowledgeable and thoughtful leadership of Philip Lee, Steven Heilig, Michael www.sfms.org
Lerner, and Elise Miller, is so well respected that 300 copies of this journal will be distributed at a national conference in June 2012 at the New York Academy of Medicine. This edition starts with a look at CHE, the Collaborative on Health and the Environment, established at an SFMS meeting ten years ago. CHE continues to hold meetings, symposia, and monthly teleconferences that involve national participants covering topics related to chemical exposure, air quality, food supply, and health. Dr. Margaret Kripke of the President’s Cancer Panel tells about her experience on that panel and learning that “I was so naive in terms of my belief that we were being protected from things in our environment.” There are other expert discussions on “low-dose” impacts, BPA/cancer research, obesity and diabetes, reproduction/fertility, autism, radiation, chemical policy, American and European chemical policies, and electromagnetic fields. As a clinician, I try to understand all this information to apply it to the care of my patients and family. I have advised my patients who are more mobile to look at regional air-quality maps to consider where to move when they’re thinking of retiring or making a change for their health. As a member of the SFMS, CMA, and AMA, I also look at the public health implications and health impacts of the environment to get organized medicine to support stronger guidelines on pollution levels based on scientific evidence. I hope that if you have similar responses, you will get involved with SFMS to help improve the health of our communities. Dr. Fung is a cardiologist, pastpresident of the SFMS, and clinical professor of medicine at the University of California, San Francisco. At UCSF Medical Center at Mount Zion, he is director of the Cardiology Consultation Service, the Cardiac Noninvasive Laboratory, and the nation’s first Asian Heart and Vascular Center. He has served on the national board of the American Heart Association and American Board of Cardiology.
June 2012 San Francisco Medicine
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Environmental Health
Environmental Health A Decade of Progress Philip R. Lee, MD; Steve Heilig, MPH; Michael Lerner, PhD; and Elise Miller, MEd “CHE fills a critical need at a time of genuine threat and urgency. Thank you for your leadership.” —Richard Jackson, MD, MPH UCLA School of Public Health; former California State Health Officer and director of the CDC National Center for Environmental Health Ten years ago, a group of fifty scientists, clinicians, and advocates concerned about environmental health gathered at the San Francisco Medical Society to discuss ways to advance their fields. The result was a new network called the Collaborative on Health and the Environment (CHE). This partnership, which now includes more than 4,500 people around the world, seeks to advance environmental health science as it informs and guides decision making toward improved public health and disease prevention. CHE’s founding consensus statement emphasizes the state of the environmental health science, the necessary public health response, and the importance of taking a precautionary approach. While our scope has since expanded, the cornerstone of our mission continues to be “science and civility,” and collaboration among our members. CHE’s primary activities include sharing emerging scientific research on various environmental factors that can contribute to disease and disability, fostering interdisciplinary and inclusive collaboration among diverse constituencies, and facilitating effective actions to improve health across the lifespan. Over the past ten years, CHE has made a number of contributions to the environmental health field by working closely and collaboratively with a range of partners. Some highlights include developing the CHE Toxicant and Disease Database, a searchable database that summarizes links between chemical contaminants and 180 human diseases or conditions, a database noted by government agencies and leading researchers as an unprecedented and essential resource; organizing seminal scientific conferences and workshops around the nation, including one that resulted in the establishment of the first U.S. program on reproductive health and the environment at the University of California-San Francisco; coordinating multiple working groups and listservs on key issues including cancer, diabetes, fertility, aging, learning and developmental disabilities, cumulative impacts, electromagnetic fields, and many others—proving instrumental in prioritizing environmental health in sectors that had not previously considered environmental health science or prevention; hosting ten years of monthly teleconferences on a full range of environmental health issues, featuring leading researchers from around the world; organizing environmental health science trainings for 12 13
San Francisco Medicine June 2012
various constituencies concerned with promoting stronger public health policy; presenting testimony on cancer prevention for the 2011 President’s Cancer Panel, contributing to a landmark final paper summarized in this issue and cohosting presentations of the report after it was published, both online and in person; maintaining a widely used and authoritative website featuring a vast array of scientific articles, reports, our teleconferences, fact sheets, and more. The weight of the evidence linking chemical contributors, including very low-dose exposures, to a vast range of chronic diseases and disabilities has increased enormously. CHE has worked to amplify our collective understanding of these environmental threats to health across the lifespan. Since our inception, we have also realized that articulating the impact of multilayered, interacting environmental factors—including the food, built, natural, technological, psychosocial, and socioeconomic environments—in addition to chemical exposures is essential if we are to implement effective interventions and make lasting strides toward a healthier future for all. From the molecular level to the street, the science states more clearly than ever: Our environment is us and we are our environment. But our work is far from over. The feedback CHE consistently receives—from seasoned scientists to parents-to-be— indicates that so many are hungry for the latest science and new ways to share information and collaborate on their work, particularly in a forum that prioritizes civility. We are honored that some leading figures in the environmental health field share their latest perspectives in this issue of the SFMS journal. And we invite you to join the growing ranks of those who depend on CHE as a unique and essential resource. We can be found at www.healthandenvironment.org.
“I am inspired by CHE and all whose passions are to prevent and understand environmental effects on reproductive health and development and to make a difference in the public health. Keep up the good work!”
—Linda C. Giudice, MD, PhD, MS Professor and chair, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, UCSF
Philip Lee, MD, is chairman of the Collaborative on Health and the Environment, UCSF Chancellor Emeritus, and former United States Assistant Secretary of Health. Steve Heilig is a director at both the SFMS and CHE. Michael Lerner is president of CHE and Commonweal, and Elise Miller is executive director of CHE. www.sfms.org
Environmental Health
Reducing Cancer Risks Margaret Kripke, PhD, on The Environment and Cancer
Dr. Margaret Kripke is professor of immunology and Vivian Smith Chair Emerita at the University of Texas MD Anderson Cancer Center, one of the world’s leading cancer research and treatment institutions. Dr. Kripke was also one of two panelists, along with Dr. LaSalle Leffall of Howard University College of Medicine, who served on the President’s Cancer Panel, which in 2010 produced the report “Reducing Environmental Cancer Risks: What We Can Do Now.” The report sparked unprecedented attention, as well as some controversy. Her remarks below come from an interview done for the Collaborative on Health and the Environment. The President’s Cancer Panel consists of three people who are appointed by the United States President to survey the landscape in cancer research and treatment, and to try to point out what gaps there are and what could be done to accelerate the agenda of reducing cancer. I was appointed in 2003 by George W. Bush, and I served on the panel until 2011. I was nominated to serve in the role of basic scientist; typically the panel has a cancer advocate, a scientist, and a clinician. We focus on a different topic every year, do an extensive review of the science, and conduct hearings around the country. This topic was extremely controversial. Part of the reason is that environmental carcinogenesis is a topic where there’s a lot of uncertainty. So you have to consider what is going to be the public message and what conclusions could we draw when there are so many things where there’s just not enough information. The second issue was that this is a very emotional issue for a lot of people, who are concerned about why they got cancer and are convinced that their cancer was caused by something in the environment. I was concerned that we would be diverted from an objective analysis to an emotional issue. The third issue was that there is a stated figure about how many cancers are caused by environmental agents, and that figure is 6 percent. And it wasn’t clear to me that the President’s Cancer Panel should be focusing on an issue that only affected perhaps 6 percent of cancers. So I was not wildly enthusiastic about this as a topic at the outset. But one of the reasons I agreed that we should do this is that 6 percent is still 20,000 deaths per year—40,000 people with cancer and 20,000 deaths per year. Those people deserve a voice. A second argument is that this is a subject of huge public interest at the moment. And the third argument is that cancer research has not focused on this area. I’ve been a cancer researcher for my entire career. I go to all the cancer meetings, and hardly ever do you hear anything about environmental carcinogenesis. It’s just not part of the mainstream of cancer research. I was so naive in terms of my belief that we were being protected from things in our environment. And I was left with a sense that we have very little knowledge about what really is gowww.sfms.org
ing on in our environment, and we need much more information. This was an enormously eye-opening experience. I always assumed that if you have something in the workplace that’s regulated, the regulations would be enforced. And this turns out not to be true in all cases. So we have carcinogens in the workplace that are regulated—and the regulations may be very unevenly enforced. I always assumed that if something was a known human carcinogen, that it would be regulated. This is clearly not the case. There are carcinogens in our environment that have been banned in Europe and Canada but still remain unregulated here. Second, I always assumed that before things were put on the market, they would be tested. And that, too, is absolutely not the case. We test very few things for cancer-causing properties. The United States has not regulated much of anything since the 1990s. And the third point is that it’s estimated that there are somewhere around 80,000 man-made chemicals that are currently in our environment, most of which have been put there since the end of World War II. And only around 2 percent or fewer of those have actually been tested for cancer-causing properties. Now, some of them obviously are not candidates for cancer-causing agents, but others are, and we seem to espouse the “reactionary principle,” which is that until something is demonstrated to be harmful, we don’t worry about it; whereas in other places in the world people say, “If we think it’s going to be a problem and there’s uncertainty, we should take a precautionary approach to putting things into the environment.”
Our first recommendation is that a precautionary, prevention-oriented approach should replace current reactionary approaches to environmental contaminants in which human harm must be proven before action is taken to reduce or eliminate exposure.
It’s the thing that would probably have the most impact on future generations—to quit putting things out there that are untested and then have to bring them back. It was described to us as looking at the end of the pipeline. You have a process—a manufacturing process—that produces a chemical or something that goes into the environment and it comes out of the end of the pipeline and is distributed. To put it back in is very difficult. The remediation of things that are already out in the environment is much more costly than having engineered the process from the beginning to not create toxic by-products and toxic products at the end. In those cases where there is a high potential for risk, we ought to be thinking about that at the beginning, not at the end after it’s
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Reducing Cancer Risks Continued from previous page . . . already on people’s carpets and on their lawns. We then included some other recommendations: 1. We need to determine the full extent of environmental influences on cancer. 2. The nation needs a comprehensive, cohesive policy regarding environmental contaminants and protection of human health (not just cancer). 3. Children are at special risk for cancer due to environmental contaminants and should be protected. 4. Continued epidemiologic and other environmental cancer research is needed. 5. An environmental health paradigm for long-latency disease is needed. 6. Existing regulations for environmental contaminants need to be enforced and updated; stronger regulation is needed. 7. Radiation exposure from medical sources is underappreciated. 8. Medical professionals need to consider occupational and environmental factors when diagnosing patient illness. 9. Workers, other populations with known exposures, and the general public require full disclosure of knowledge about environmental cancer risks. 10. The military needs to aggressively address the toxic environmental exposures it has caused. 11. Safer alternatives to many currently used chemicals are urgently needed.
One of our major conclusions from the report is that children are certainly at greater risk, and the evidence is accumulating that there is an increase in cancer in children for no apparent explainable reason, and also an increase in the number of birth defects in children. I think that’s an extremely important canary in the mine, if you will. The gratifying part is that there are so many people who are interested in the report, and that people who are interested in environmental issues have been very supportive. On the other hand, there have been a lot of critics of the report —saying that it focuses specifically on environmental causes of cancer and does not include “lifestyle” factors such as tobacco, nutrition, exercise, and so on. But our report two years previously had been on lifestyle factors and their role in cancer causation. We spent half of the report looking at tobacco and half of the report looking at nutrition and exercise, obesity, and those factors in cancer. And number one, of course, is getting rid of tobacco. So we felt we had looked at that issue fairly comprehensively. And I don’t think that this report detracts from other issues. I think people understand multicausality of diseases, and I don’t think that saying there are things in your environment that might be dangerous keeps people from thinking tobacco is bad for you also. It’s relatively easy to generate a lot of concern and support for curing cancer. We have talked for decades in this country about the war on cancer, the cure for cancer. That has been the focus, and people are energized around that agenda, as they should be. It’s much more difficult to say, “Let’s look at causation of cancer,” because the immediate effects are not apparent. It has to come from the American public. It will only change if there is 14 15
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public pressure to do so, because there are a lot of economic interests in the world that are geared toward not having that happen. There is a separate section in the report that asks, “What can individuals do to reduce their personal risk of cancer?” Because you can’t put out a report like this and not give people some clues as to what they might do. If you work in an industry with chemicals, wash your clothes and take your shoes off before you come into the house—little practical things that people can do, which I think are very important. I participated in an interview and a questioner said, “I’ve never smoked in my life, I’m extremely healthy, I run marathons, there is no one in my family who has ever had cancer, and I have cancer. What about me?” And so to people who say, “Don’t look at environmental causes of cancer because there are other things that are more important,” I say, “What about these people?” People do need to have their concerns addressed, and I hope the report does that.
The President’s Cancer Panel Report
http://deainfo.nci.nih.gov/advisory/pcp/annualReports/index. htm
Environmental Chemicals: Evaluating Low-Dose Effects
Linda S. Birnbaum, PhD Director, National Institutes for Environmental Health Sciences and National Toxicology Program, National Institutes of Health, Department of Health and Human Services
Around the world, large-scale biomonitoring programs have provided extensive information about human exposure to a large number of environmental chemicals As these programs extend to look at vulnerable populations, including pregnant women, fetuses, and the elderly, our knowledge of the widespread distribution of many of these chemicals—including hundreds that have been classified as endocrine disruptors—continues to climb. However, the mere presence of a chemical in humans is not necessarily cause for concern. What is concerning is the increasing number of epidemiological studies showing associations between the concentration of these chemicals in the general population and adverse health end points. Although high exposures following accidental or occupational exposures to endocrine disruptors, industrial chemicals, pesticides, and pharmaceuticals have shown striking effects, epidemiological studies suggest that low doses may also be unsafe, even for populations that are not typically considered “vulnerable.” For several decades, environmental health scientists have been dedicated to addressing the “low-dose hypothesis,” which postulates that low doses of chemicals can have effects that would not necessarily be predicted from their effects at high doses….Now, a diverse group of scientists has reexamined this large body of literature, finding examples of low-dose effects for dozens of chemicals across a range of chemical classes, including industrial chemicals, plastic components and plasticizers, pesticides, phytoestrogens, preservatives, surfactants and detergents, flame retardants, and sunblock, among others. Their study provides important insight into the effects of environmental chemicals on health-related end points and addresses the mechanistic questions of how chemicals with hormonal activity can have effects at external doses that are often considered safe by the regulatory community. It is time to start the conversation between environmental health scientists, toxicologists, and risk assessors to determine how our understanding of low-dose effects and nonmonotonic dose responses influence the way risk assessments are performed for chemicals with endocrine-disrupting activities. Together, we can take appropriate actions to protect human and wildlife populations from these harmful chemicals and facilitate better regulatory decision making. Excerpted from: Birnbaum LS, 2012 Editorial: Environmental Chemicals: Evaluating Low-Dose Effects. Environ Health Perspect 120(4): doi:10.1289/ehp.1205179
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Environmental Health
ENVIRONMENTAL CHEMICALS Large Effects from Low Doses Laura N. Vandenberg, PhD; R. Thomas Zoeller, PhD; J.P. Myers, PhD Virtually all safety standards for chemical exposures are determined through a process that assumes that high-dose testing will reveal relevant risks because “the dose makes the poison.” For many
well-studied contaminants this is a reasonable assumption, but for compounds that behave like hormones, it is demonstrably false.1 The public health implications of this conclusion are enormous, because it means that many—likely dozens, plausibly hundreds, possibly thousands—of today’s chemical safety standards are too weak by orders of magnitude. The basis for this conclusion derives from endocrinology. In endocrinology, it is well established that the impacts of hormones (such as estrogen) at high doses can differ from those in the “physiological range” of normal circulating levels of hormones in serum; it is at these concentrations that hormones interact with their receptors to cause physiological and developmental changes by altering gene expression. Indeed, hormones at abnormally high doses are often overtly toxic, through mechanisms that have nothing to do with receptor action. As research has expanded into the effects of endocrinedisrupting chemicals (EDCs), it has been shown that they follow the same rules that hormones follow.1 Unfortunately, this runs counter to the core assumption that forms the basis for all toxicological testing done to establish regulatory standards: High-dose testing will be informative about low-dose impacts. The EPA defines an EDC as “an exogenous agent that interferes with the synthesis, secretion, transport, binding, action, or elimination of natural hormones in the body that are responsible for the maintenance of homeostasis, reproduction, development, and/or behavior.”2 Although Rachel Carson examined the effects of many environmental chemicals on health and reproduction in her landmark book Silent Spring,3 work on EDCs really took shape in 1991, when a group of scientists met at the Wingspread Conference Center in Racine, Wisconsin, to discuss research on the effects of environmental chemicals on sexual development. The Wingspread attendees produced a consensus statement stating, “We are certain of the following: A large number of man-made chemicals that have been released into the environment, as well as a few natural ones, have the potential to disrupt the endocrine system of animals, including humans.”4 EDCs are now understood to be any chemicals that interact with the endocrine system, including chemicals that act as agonists and antagonists of hormone receptors, including estrogen, androgen, thyroid, glucocorticoid, retinoid, and others. To determine the mode of action of these chemicals, both www.sfms.org
in vivo (animal) and in vitro (cell culture) assays have been developed. While most chemicals on the market today have never been tested for safety, much less for endocrine disruption, these assays could be used to test new chemicals for hormonal activity prior to their entry into the environment through the food supply, packaging materials, or as waste; they are also widely used to test for their hormonal activity many chemicals that are already in use. Chemicals with a wide range of uses, including detergents, plastics, cosmetics, pesticides, pharmaceuticals, and flame retardants, among others, have been shown to have endocrine-disruptor activities. In 2002, the National Toxicology Program (NTP) examined evidence for what has been termed “the low-dose hypothesis,” i.e., the theory that EDCs could have actions at low doses.5 What is meant by “low doses”? Typically, these are doses in the range of what humans experience in their every-
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Environmental Chemicals Continued from previous page . . . day lives—residues on food, in the air, in dust, and in drinking water. Low doses are often within the range that traditional toxicological testing has determined to be “safe.” The question is whether EDCs are safe at the doses the typical person experiences. To determine what doses are safe, regulatory toxicology usually starts by administering large doses of a chemical to animals, identifying the highest dose at which no effect is found, and then extrapolating downward to calculate a safe dose. Those “safe” doses are rarely tested. Yet EDCs, like hormones, defy the toxicological dogma: Low doses can have effects that are not expected from high-dose exposures. In fact, these effects can be observed at doses orders of magnitude beneath the highest dose that produces no effect using traditional approaches. The mechanisms by which chemicals cause high-dose effects usually are completely unrelated to mechanisms that EDCs employ at low doses, and the effects of high and low doses can be on completely different endpoints. In our review of the EDC literature, we found hundreds of examples of these types of responses, termed nonmonotonic responses, in cultured cells, animals, and even human populations.1 Many of these chemicals have effects at low doses, providing strong evidence that calculated “safe” doses of these chemicals are not, in fact, safe.1 Are these chemicals adversely affecting human health? Many of the earliest epidemiology studies examining the effects of EDCs studied occupationally or accidentally exposed individuals, i.e., people who were exposed to relatively high doses, either acutely or over longer periods of time. Now a large number of epidemiology studies have focused on environmentally exposed individuals, i.e., people who are exposed to EDCs from everyday life. These studies show that many of the effects observed in cultured cells and controlled animal experiments accurately predict what epidemiologists are observing in human populations: associations between human exposures and disease endpoints consistent with the “low-dose hypothesis.” So where do we go from here? As scientists, these findings suggest for us that EDCs, as a chemical class, act very similarly to the hormones they mimic or block: They act at low doses, with effects that are more pronounced when exposures occur during critical periods of development. Just as hormones have nonmonotonic relationships between dose and effect, nonmonotonic effects of EDCs are expected. This means that high-dose testing is insufficient to establish the safety of low doses. In our review,1 we propose some changes to the way risk assessors determine safety of EDCs: 1) “safe” doses of chemicals, and chemicals in the range of human exposures, should be tested; 2) regulators should assume that EDCs produce nonmonotonic dose responses; 3) more sensitive endpoints should be included in chemical testing. What can the average person, or patient, do to reduce EDC exposures? This is, of course, an important issue for health care practitioners and others invested in improving public health. Several studies suggest that making small lifestyle changes can have dramatic effects on exposure levels.6
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Patients should be encouraged to make lifestyle choices that reduce known EDC exposures. However, the lessons learned from the published literature seem to be clear: Even low doses, including reduced exposures from changes in consumer behavior, cannot be considered safe. Thus, widespread changes to chemical safety regulations are likely to have the widest effects on human health. We encourage physicians, nurses, public health administrators, and others working in the medical field to read our recent review and to get involved with the many scientific societies that support new approaches to chemical regulation that better reflect current scientific understanding than do standard toxicological procedures.7 Your expertise provides an important voice to help the risk assessment community develop new approaches to chemical risk assessment, especially as it pertains to EDCs. Hormones are important signaling molecules that dictate the health of individuals throughout the life course, and therefore the effects of EDCs simply cannot be ignored. Laura N. Vandenberg, PhD, is with the Center for Regenerative and Developmental Biology and Department of Biology at Tufts University. R. Thomas Zoeller, PhD, is with the Department of Biology at the University of Massachusetts in Amherst. J.P. Myers, PhD, works for Environmental Health Sciences in Charlottesville, Virginia.
References 1. Vandenberg LN, Colborn T, Hayes TB, Heindel JJ, Jacobs DR, Lee D-H, Shioda T, Soto AM, Vom Saal FS, Welshons WV, et al. (2012). Hormones and endocrine disrupting chemicals: Low dose effects and non-monotonic dose responses. 2012. Endocrine Reviews. Online 2012 Mar 14. 2. Kavlock RJ, Daston GP, DeRosa C, Fenner-Crisp P, Gray LE, Kaattari S, Lucier G, Luster M, Mac MJ, Maczka C, et al. Research needs for the risk assessment of health and environmental effects of endocrine disruptors: A report of the U.S. EPA-sponsored workshop. 1996. Environ Health Perspect. 104;715-740. 3. Carson R. Silent Spring: 25th Anniversary Edition. 1987. New York: Houghton Mifflin Co. 4. Wingspread Consensus Statement. In Chemically Induced Alterations in Sexual and Functional Development: The Human/Wildlife Connection. T. Colborn and C. Clement, eds. 1992. Princeton: Princeton Scientific Publishing, pp. 1-8. 5. Melnick R, Lucier G, Wolfe M, Hall R, Stancel G, Prins G, Gallo M, Reuhl K, Ho SM, Brown T, et al. Summary of the National Toxicology Program’s report of the endocrine disruptors low-dose peer review. Environ Health Perspect. 2002. 110;427-431. 6. Rudel RA, Gray JM, Engel CL, Rawsthorne TW, Dodson RE, Ackerman JM, Rizzo J, Nudelman JL, Brody JG. Food packaging and bisphenol A and bis(2-ethylhexyl) phthalate exposure: Findings from a dietary intervention. Environ Health Perspect. 2011. 119;914-920. 7. Hunt PA. Assessing chemical risk: Societies offer expertise. Science. 2011. 331;1136. www.sfms.org
Environmental Health
CONSIDERING BPA State of the Art or Willful Ignorance? William H. Goodson III, MD, and Shanaz H. Dairkee, PhD “The Food and Drug Administration said Friday that it lacks scientific information to ban the chemical bisphenol A from food containers.” —Wall Street Journal, March 31, 2012
“ . . . FDA supports reasonable steps to reduce exposure of infants to BPA in the food supply. . . . FDA will support changes in food can linings and manufacturing to replace BPA to minimize BPA levels . . . ” —U.S. Food and Drug Administration website, March 30, 2012
While it is technically correct that the FDA did not ban bisphenol A (BPA), the Wall Street Journal misled readers
when it ignored the clear FDA statements that we need to reduce BPA exposure of our most vulnerable citizens. This is a prototype example of the spin-versus-spin arguments that characterize most of the environmental chemical debate. These arguments are not about truth. They are about control of public perception. It is time for willful efforts to skip the spin, outline the challenges, and answer the questions that affect the safety of our children and grandchildren.
The BPA debate centers around three types of data:
1. BPA promotes breast cancer in animals. Animals exposed to BPA, either in utero or through nursing from dams fed BPA, develop breast epithelial abnormalities and are more susceptible to breast cancer induction by the carcinogen dimethylbenzanthracene (DMBA). Like natural estrogen, BPA stimulates growth of human breast cancer cells transplanted into mice. This is not unexpected, because BPA has been known since the 1930s to act as an estrogen. Note: The concern is not that BPA by itself causes cancer but rather that, through excessive estrogenic stimulation, it promotes cancer. The debate centers on the relation of animal doses to human exposure. 2. In cell culture studies, BPA causes nonmalignant human breast epithelial cells (obtained by fine needle aspiration from women volunteers) to grow faster and evade apoptosis (programmed cell death), a necessary step for radiation and drugs to kill tumor cells. These changes are referred to as hallmarks of cancer because they are prerequisites for cancer to occur. BPA by itself is sufficient to induce these abnormalities. It is especially relevant that they occur in nonmalignant cells, because these are the target cells that must undergo the required changes for breast cancer to occur. These changes occur in concentrations that are found in fetuses, mothers, and mother’s milk. 3. Although most of us ingest BPA daily, it is metabolized quickly. Recent studies have shown that BPA in canned soups and similar products causes a spike in serum BPA, followed by a rapid fall back to preingestion levels. Some critics conclude from this that BPA cannot be around long enough to cause harm. www.sfms.org
The real situation, however, is more complicated. First, clearance may not be functionally permanent. Most clearance is by conjugation to glucuronate, a frequent mechanism to clear hormones, chemicals, and drugs from the blood. However, the enzyme glucuronidase can deconjugate BPA from glucuronate, and significant levels of glucuronidase are present in many tissues. In the case of the breast, biologically active glucuronidase is present in mother’s milk and, for example, contributes to neonatal jaundice by deconjugating the baby’s bilirubin in the gut. It is difficult to expect that the BPA known to be in human breast milk would not be activated the same way. Second, it is argued that BPA rises and falls too quickly to cause harm, but this ignores what reproductive endocrinologists have known for years. Reproduction responds to spikes in hormone levels as much or more as to constantly elevated hormone levels. It may be that spikes, such as from a preadolescent eating BPA-rich food, would pose a greater risk. These studies do not imply that BPA by itself causes breast cancer but rather that the estrogenic activity of BPA causes changes that promote breast cancer. The cancer-promoting properties of estrogens are the reason millions of women discontinued menopausal hormone replacement therapy after the Women’s Health Initiative showed that combination estrogen plus progestin therapy increased breast cancer. Unfortunately, women living in the United States cannot decide to discontinue their exposure to BPA. BPA is present in food packaging, house dust, cash register receipts, etc., such that 95 percent of Americans and 90 percent of Canadians test positive for BPA in their urine. Thirty years ago, Lippman and Bolan recognized the importance of cell culture “ . . . in the analysis of estrogen action in nonmalignant tissue . . . ” In our work with nonmalignant cells, we have identified six different major cell features that are altered by BPA in ways that promote hallmark, cancer-like behavior in previously benign cells. The irony in this battle of spin is that if we had a drug that turned off cancer cells in culture as much as BPA turns them on, if we had data showing a clear mechanism of action like we have for BPA, and if we had as much supportive animal exposure data as already exists for BPA, the hypothetical drug would be expeditiously lined up for clinical trials. It is time for responsible parents and grandparents to demand an end to the battle of spin. Calm minds must sort through the facts objectively and design and perform the studies needed to resolve pertinent questions. William H. Goodson III, MD, is a breast cancer specialist, senior clinical research scientist at CPMC Research Institute, and former a SFMS president. Shanaz H. Dairkee, PhD, is senior scientist, CPMC Research Institute. A full list of references is available online at http://bit.ly/JfSTIS. June 2012 San Francisco Medicine
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Environmental Health
the Diabetes epidemic Environmental Chemical Exposure in Etiology and Treatment Robert M. Sargis, MD, PhD; Sarah G. Howard, MS; Retha R. Newbold, MS; and Jerrold J. Heindel, PhD The last several decades have witnessed a dramatic deterioration in human metabolic health, with the rap-
idly increasing prevalence of type 1 (T1DM) and type 2 (T2DM) diabetes mellitus.1,2 In 2011, 366 million people worldwide had diabetes, and this number is projected to reach a staggering 552 million by 2030.3 The tremendous burden of diabetes contributes significantly to health care spending, amounting to $174 billion in the U.S. alone.4 To address the individual and societal burdens of diabetes, efforts to uncover its causes and develop interventions to limit its development are critical. The rise in worldwide diabetes prevalence has paralleled the dramatic increase in global obesity rates. The reasons underlying increases in body mass are incompletely understood and are not fully explained by diet and physical inactivity.5 Nor is diabetes completely accounted for by obesity; among U.S. adults, nearly 20 percent of those with diabetes are neither overweight nor obese.6 It is time to develop a more holistic view of the causes of diabetes. Interestingly, rates of both T1DM and T2DM correlate with the dramatic increase in synthetic chemical production since World War II.7 Indeed, several epidemiology studies have shown that adults exposed to a mixture of lipophilic and persistent chemicals have a higher T2DM rate than controls.8,9 Furthermore, animal studies suggest that chemical exposure can promote the development of a diabetic phenotype (reviewed in Neel and Sargis 2011, Sargis et al 2012, and Batista et al 2012). Collectively, these findings suggest that exposure to a specific class of environmental chemicals, endocrine-disrupting chemicals (EDCs), which interfere with hormone action,12 may contribute to the diabetes epidemic and should be considered targets for intervention to limit development of the disease (see Table: Chemical Exposures Associated with Diabetes in Human Studies for a list of chemicals associated with diabetes in epidemiological studies).
Diabetes as a Disease of Development
While existing epidemiological studies that evaluated EDCs and T2DM only examined the body burden of chemicals during adulthood, the risk of developing T2DM clearly starts during development (in utero and in early postnatal life)13, 14 and continues throughout life, with puberty and pregnancy being additional sensitive periods for environmental effects. In animal models, in utero exposure to EDCs results in metabolic derangements in the offspring, including increases in fat mass15 and disturbances in glucose homeostasis.16 For the developing fetus, there is the potential for two insults to metabolic programming, namely disturbances in maternal energy homeostasis and direct effects of transplacental EDC exposure. To better understand the development and progression of diabetes in patients, clinicians should become aware of the potential diabetogenic nature of chemical exposures, the 18 19
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sensitive periods for their effects, and the precise sources of human exposure. Clinicians will then be able to provide anticipatory guidance to their patients regarding the adverse effects of chemical exposures on metabolic health.
Bringing the Clinic to the Forefront of Environmental Diabetology
Clinicians are critical in the detection and treatment of diabetes, but they also play an important role in disease prevention by becoming engaged in understanding how diabetes can arise from the pernicious chemical cocktail to which an individual is exposed. Through careful examination of a patientâ&#x20AC;&#x2122;s history, a clinician may be able to identify individuals likely to have had a chemical exposure that contributed to their diabetes, such as slender individuals diagnosed with T2DM without a strong family history of the disease, or those with clear exposure to a known diabetogenic chemical (e.g., Agent Orange). Importantly, these chemical exposures should be considered as one of many contributing factors, in addition to diet and physical inactivity, in the pathogenesis of diabetes. While the data linking chemical exposure to T1DM lags behind that for T2DM (see Table), specific exposures could be contributing to the observed increase in T1DM through either direct beta cell toxicity or via modulation of the immune system. Indeed, there are chemicals with EDC activity that could directly affect beta cell development and also have immunomodulating effects. We suggest that physicians maintain a high level of suspicion concerning chemicals as etiologic agents in T1DM. The seasonality and geographical clustering of T1DM cases have suggested to investigators that viruses may play an important role in the development of this disease. It is, however, equally likely that chemical exposures unique in timing or location could also trigger the disease. It may be necessary for the Centers for Disease Control and Prevention (CDC) to develop an environmental detective service to specifically track T1DM incidence, including investigating geographical and seasonal clustering, akin to current approaches for infectious disease outbreaks, in order to identify specific chemical exposures that promote development of the disease. An additional paradigm of metabolic disruption that may help identify chemical-mediated metabolic disruption is gestational diabetes (GDM) (Table). Studying links between EDCs and GDM has the advantage that all women should receive assessments of glucose homeostasis during pregnancy. Further, the inherent insulin resistance of pregnancy may make pregnant women acutely sensitive to chemical disruptions in metabolic homeostasis. A greater appreciation for the contribution of chemicals in the pathogenesis of GDM is critical given the potential long-term metabolic impact on the children of those with the disease. Addressing exposure to EDCs during pregnancy may also have additional health benefits for the www.sfms.org
offspring, unrelated to the mother’s metabolic state, including limiting the deleterious effects mediated by EDCs interfering with other hormonal axes. To understand the role EDCs play in the pathogenesis of clinical diabetes, physicians should be equipped with skills to obtain thorough occupational and environmental histories. Several publications provide guidance on obtaining such a history,17,18 and recent publications for health care providers have outlined potential reproductive consequences of chemical exposures;19,20 however, more must be done to facilitate physicians’ assessments of chemical contributions to metabolic diseases. As in most diseases, clinical suspicion is the fundamental tool for establishing a diagnosis. Clinicians’ awareness of potential links between environmental exposures and diabetes could provide critical insights into the contribution of pollutants to metabolic diseases. Through interactions at clinical meetings, publications, or eventually a centralized, Internet-based notification system, clinicians will be able to share potential cases of environmentally mediated diabetes with public health professionals to prompt further study. Where this is not possible or not yet established, referral to an academic center with physician-scientists interested in environmental health is critical. Together, clinicians and scientists may provide the “smoking gun” evidence necessary to implement policies aimed at reducing exposure to EDCs.
Bringing Environmental Science to the Clinic
Critical to appreciating the role of chemical exposures in diabetes is a better understanding of which chemicals pose the greatest risk and during which developmental periods that risk is highest. Of particular interest to the clinical community is the possibility that environmental pollutants may modify the efficacy of diabetes
treatments. This unexplored area of environmental diabetology requires significant study. Chemical exposures may also play an additive or synergistic role in the pathogenesis of diabetes complications as suggested for organochlorine pesticides and peripheral neuropathy. 21 Of critical interest is whether reducing exposure to EDCs prevents or mitigates the severity of diabetes. Given that many potential diabetogenic chemicals are lipophilic, accumulate in body fat, and are released during weight loss, this is clearly an area of concern. Interactions and collaborations between basic science researchers and clinicians will be fundamentally important for addressing many of these lingering issues. Capitalizing on the insights of clinicians in close contact with their patients could greatly aid researchers in the study of environmental diabetology. Formal mechanisms could facilitate communication between these often disparate groups, such as centralized databases, translational publications, and conferences. While entirely eliminating exposures to EDCs may be impossible, some exposures can be reduced via lifestyle interventions across the lifespan and especially during pregnancy, lactation, and early childhood (for example, by avoiding animal fats; mercurycontaminated fish; and EDCs in plastics, cans, cosmetics, etc.). (For specific suggestions, see Sathyanarayana et al 2012, Sutton et al 2012.) The emerging links between chemical exposures and diabetes warrant efforts to decrease and potentially eliminate exposure to diabetogenic pollutants whenever possible, likely resulting in additional health benefits.
Synthesizing the Chemical-Diabetes Story
In conclusion, emerging scientific evidence implicates EDCs as potential contributors to the diabetes epidemic. Bringing an appreciation of this association to the clinic will be critiTable: Chemical Exposures Associated with Diabetes in Human Studies cal for identifying new risks that threaten patient health and developing novel strategies for preventT2DM or Insulin Resistance Sources of Exposure ing and treating diabetes. To reach this point, cliniFood (animal fats, fish)22,23 Persistent organic pollutants22,23 cians must appreciate the emerging importance of Agent Orange (Vietnam war)24 Dioxin24 EDCs in the development of T1DM and T2DM, and 25 26 researchers must aggressively fill the gaps in our Drinking water, food (fruit juice, rice) Arsenic scientific knowledge to improve clinical care. WorkPolycarbonate plastics, canned food, thermal Bisphenol A (BPA)27-29 paper, dental sealants28,30 ing together, we may be able to seize this unique op31,32 31 portunity to reverse the disturbing trends in global PVC plastics, cosmetics, medical equipment Phthalates metabolic health. 33 33 Traffic-related air pollution
Residential proximity to traffic
Cadmium36
Food (oysters, oilseeds, offal), tobacco37
Applying pesticides34
Agricultural pesticides
34
Consumer products, furniture, electronics35
Brominated flame retardants35
T1DM or Autoimmunity
Nitrite/nitrate/nitrosamines38,39
Processed meat, drinking water, cosmetics39
Mercury42
Fish42
Air pollutants ozone and sulfate PCBs41
Tricholorethylene43
40
GDM or Impaired Glucose Tolerance During Pregnancy Agricultural pesticides44 Arsenic45
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Ambient air40
Food (animal fats, fish)22
Drinking water, occupational43 Applying/mixing pesticides44 Drinking water45
Robert M. Sargis, MD, PhD works at the Kovler Diabetes Center, Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Chicago. Sarah G. Howard, MS, is with the Collaborative on Health and the Environment in Bolinas, California. Retha R. Newbold, MS, and Jerrold J. Heindel, PhD, work at the National Institute of Environmental Health Sciences, National Institutes of Health, in Research Triangle Park, North Carolina. A full list of references is available online at http://bit.ly/JfSTIS. Disclaimer: This article is the work of an employee of the National Institute of Environmental Health Sciences (NIEHS), NIH. However, the statements, opinions, or conclusions contained therein do not necessarily represent the statements, opinions, or conclusions of NIEHS, NIH, or the U.S. government. June 2012 San Francisco Medicine
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Environmental Health
Toxic Matters and Fertility What Can a Doctor Do? Patrice Sutton, MPH; Tracey J. Woodruff, PhD; Jeanne A. Conry, MD, PhD; Linda C. Giudice, MD, PhD, MSc About eight years ago, an infertility patient asked her physician whether her exposure to environmental chemicals as a child growing up near a chemi-
cal waste site was a factor in her inability to conceive a child. The patient’s inquiry was a wake-up call for her physician, who knew that scientific barometers of reproductive function among the U.S. population (ranging from reduced sperm counts through difficulty in conceiving and maintaining pregnancy) and increasing rates of various reproductive illnesses point to declines in our reproductive capacity.1 Her physician also knew these adverse trends in reproductive health have occurred in roughly the same time frame in which human exposure to both natural and synthetic chemicals has dramatically increased.2 Today, virtually all pregnant women in the U.S. have measurable levels of multiple environmental chemicals in their bodies that can be harmful to human reproduction and/or development.3 A rapidly expanding body of scientific evidence has upended assumptions about the benign nature of such “low-level” environmental exposures.4,5 This is because the human reproductive system is particularly vulnerable to ambient levels of environmental chemicals when these exposures occur during “critical or sensitive windows of development,” i.e., in utero and during infancy, childhood, and adolescence.6-8 Preconception and prenatal exposure to environmental chemicals may have a profound and lasting impact on health across an individual’s entire lifetime.9
What Can a Doctor Do?
In light of the growing scientific evidence about the health impacts of developmental exposure to environmental toxics, the aforementioned patient’s question also sparked her doctor’s recognition that reproductive health professionals are uniquely poised to intervene in critical stages of human development to prevent harm. However, while taking steps to prevent preconception and prenatal exposure to toxic substances can have a lifetime of health benefits, there were many barriers to incorporating this new information into clinical practice. Nascent efforts to seize the largely untapped opportunity to engage reproductive health professionals in prevention efforts began by drawing on the experience of the pediatric community, which has long recognized the impact of the environment on children’s health and has responded by developing prevention-based clinical guidelines1 and professional policies.10,11 Over the last decade, the Collaborative on Health and the Environment (CHE) and partners have figured prominently in advancing these efforts. 20 San 21 SanFrancisco FranciscoMedicine Medicine June June2012 2012
How Health Professionals Are Responding Selected highlights of milestones in crafting an evidencebased response by health professionals to the science linking the environment to reproductive and developmental health include: • 2005 Vallombrosa Consensus Statement on Environmental Contaminants and Human Fertility Compromise. CHE was a coorganizer of a meeting that brought together, for the first time, researchers in reproductive epidemiology, biology, toxicology, and clinical medicine; representatives of professional societies; and infertility support and women’s health and reproductive advocacy organizations to review the state of environmental health science as it pertains to infertility. Meeting participants issued and disseminated a consensus statement to help scientists, medical professionals, and public health advocates understand, with a broad brush, the current state of scientific understanding in the field and to identify important research areas that will be crucial to further advances.12 • 2007 Summit on Environmental Challenges to Reproductive Health and Fertility. Cosponsored by CHE and the University of California, San Francisco (UCSF) Department of Obstetrics, Gynecology, and Reproductive Sciences, the summit convened 400 community group members, clinicians, researchers, and policy makers from around the world and was allied with eighteen leading professional societies in the field of reproductive health.13 The summit led to a series of recommendations for advancing the field of environmental reproductive health, including agreement that the scientific evidence warrants the active engagement of reproductive health professionals in prevention. • 2007 Program on Reproductive Health and the Environment (PRHE). UCSF founded PRHE with the goal of creating a healthier environment for human reproduction and development through advancing scientific inquiry, clinical care, and health policies that prevent exposures to harmful chemicals in our environment. As exemplified in the resources developed for clinicians listed in Table 1, since its inception PRHE has tackled head-on the question, “What can a reproductive health professional do to prevent toxic environmental exposures?” Since many harmful environmental exposures (i.e., air and water pollution) cannot be prevented by individual action alone, engaging the influential voice of health professionals and their institutions and organizations in advancing environmental health policy has gone hand in hand with PRHE’s efforts to integrate the science into clinical practice. • 2009 From Advancing Science to Ensuring Prevention (FASTEP) Alliance. In collaboration with CHE and many www.sfms.org
other allies engaged at the CHE/UCSF Summit, PRHE formed and has subsequently nurtured the FASTEP Alliance.2 FASTEP is an innovative and diverse alliance of partners impacted by the lifecycle of developmental and reproductive toxicants. In addition to collaboration on many of the resources in Table 1, many FASTEP partners have also been deeply engaged in larger policy efforts to reform the national regulatory structure for chemicals in commerce. 14 • 2009 Endocrine Society Statement on EndocrineDisrupting Chemicals. The Endocrine Society examined the evidence linking exposure to endocrine-disrupting chemicals that are ubiquitous in our environment, food, and consumer products, to adverse male and female health effects.15 Among its findings, it concluded, “The evidence for adverse reproductive outcomes (infertility, cancers, malformations) from exposure to endocrine-disrupting chemicals is strong, and there is mounting evidence for effects on other endocrine systems, including thyroid, neuroendocrine, obesity and metabolism, and insulin and glucose homeostasis.” The Society also recommended that the precautionary principle inform decisions about exposure to, and risk from, potential endocrine disruptors, and emphasized the role of scientists and health professionals in communicating and implementing changes in public policy and awareness. • 2011 Navigation Guide. One of the many roadblocks to timely preventive action is that the available science is voluminous, of variable quality, complex, and largely unfamiliar to decision makers, including clinicians, health-impacted populations, advocates, and policy makers. Methods to synthesize the science into guidelines and decisions have been developed and validated in clinical arenas.16,17 But due to differences between environmental and clinical health sciences, these methods are not seamlessly applicable to environmental exposures. To bridge this gap, PRHE undertook a multiyear collaboration with CHE and 21 other clinical and environmental health scientists and/or practitioners, from governmental and nongovernmental organizations in the U.S. and Europe, to craft the Navigation Guide, a methodology that proceeds from well-established methods in the clinical sciences but accounts for the differences between environmental and clinical sciences.18 The Navigation Guide was published in 2011 and PRHE is currently collaborating with scientists at the U.S. Environmental Protection Agency (EPA) on the first application of the method. Uptake of the Navigation Guide will result in evidence profiles that provide simple, transparent summaries, such as clinical practice guidelines or other evidencebased recommendations for prevention. • 2011 American Congress of Obstetricians and Gynecologists (ACOG). Founded in 1951, ACOG has more than 52,000 members and is the nation’s leading group of professionals providing health care for women. In collaboration with PRHE and FASTEP partners, ACOG District IX (California) has been engaged for several years in championing the role of reproductive health professionals in preventing exposure to toxic substances. The year 2011 marked the first time that national ACOG lent its voice to improved environmental health policy, when ACOG President James N. Martin, MD, sent a letter to the EPA stating the group’s concerns about www.sfms.org
the reregistration of the insecticide chlorpyrifos related to the health of pregnant women and children. In 2011 ACOG also collaborated with PRHE to gather the first empirical evidence about obstetric practice and environmental health. Preliminary results show that obstetricians are concerned about the impacts of environmental chemicals on pregnant women and are looking to trusted evidence-based sources for guidance on how to advise their patients. Our results will inform the design of clinical interventions to prevent exposure to environmental chemicals and provide baseline data against which we can measure progress over time.
Future Directions
From their beginnings, CHE and PRHE recognized that efforts to prevent developmental exposures to environmental chemicals would benefit greatly from the active participation of reproductive health professionals in clinical and policy arenas. As only briefly outlined above, there has been exciting progress on this front. While many challenges lie ahead in integrating reproductive environmental health into the clinical mainstream, there are harbingers of change: The content of PRHE’s brochure “Toxic Matters” has been incorporated into UCSF’s electronic medical records system so that obstetric patients routinely receive information and resources about how to avoid toxic environmental exposures, and ACOG has undertaken writing a Committee Opinion on reproductive environmental health. The next steps will be to identify, secure, and/ or sustain the required leadership, investment, and broad support to transform the science that describes the health impacts of environmental toxics into healthy pregnancies, healthy children, and healthy future generations.
Reproductive Environmental Health Resources for Health Professionals
Except as noted, all of these resources are available at http://www.prhe.ucsf.edu/prhe/clinical/index.html.
Peer-Reviewed Articles about the Role of Reproductive Health Professionals in Preventing Exposure to Toxic Substances
• Sathyanarayana S, Focareta J, Dailey T, Buchanan S. Environmental exposures: How to counsel preconception and prenatal patients in the clinical setting. Am J Obstet Gynecol. 2012. • Sutton P, Giudice LC, Woodruff TJ. Reproductive environmental health. Curr Opin Obstet Gynecol. 2010; 22(6):517-24. • Sutton P, Wallinga D, Perron J, Gottlieb M, Sayre L, Woodruff T. Reproductive health and the industrialized food system: A point of intervention for health policy. Health Aff (Millwood). 2011; 30(5):888-97. • Sutton P, Woodruff TJ, Perron J, Stotland N, Conry JA, Miller MD, Giudice LC. Toxic environmental chemicals: The role of reproductive health professionals in preventing harmful exposures. Am J Obstet Gynecol. 2012.
Textbooks for Health Professionals on Reproductive Environmental Health
• Perron J, Sutton P, Woodruff TJ. Reproductive environ-
Continued on the following page . . .
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Toxic Matters and Fertility Continued from previous page . . . mental health. In The University of California Obstetrics and Gynecology Women’s Health Review. Di Sai PJ, Chaudhuri G, Giudice LC, Moore TR, Porto M, Smith LH, eds. 2012. • Sutton P, Perron J, Giudice LC, Woodruff TJ. Occupational and environmental exposures. In Glass’ Office Gynecology. Curtis MG, ed. (in press) • Sutton P, Perron J, Woodruff TJ. Reproductive environmental health. In Praeger Handbook of Environmental Health. Friis R, ed. (in press) • Woodruff TJ, Janssen SJ, Guillette LJ, Giudice LC. Environmental Impacts on Reproductive Health and Fertility. 2010. Cambridge, New York: Cambridge University Press.
Clinical Training and Education
• Collaborative on Health and the Environment http:// www.healthandenvironment.org/ • Continuing Medical Education (free) University of Arizona http://integrativemedicine.arizona.edu/education/online_courses/enviro-med.html • Food Matters clinical education and advocacy project http://www.healthyfoodinhealthcare.org/foodmatters.overview.php
Patient-Centered Educational Materials
Nontechnical brochures filled with suggestions for avoiding toxic chemical exposure in the home, at work, in the community, at the market, and through influencing government
policy. Brochures include: Toxic Matters (English and Spanish), Work Matters, Pesticides Matter, and Food Matters.
Professional Society Statements
Professional organizations of physicians have been active in calling for regulatory and other efforts to address exposure to toxic chemicals and many other environmental threats to human health. The Professional Statements Database is a compilation of policy statements from health professional organizations related to environmental health.
Taking an Exposure History
An environmental history is an important tool for clinicians gathering information on their patients’ exposures to toxic chemicals. There are a number of useful online resources to become more familiar with environmental histories. Patrice Sutton, MPH, is a research scientist at the University of California, San Francisco, Program on Reproductive Health and the Environment. Tracey J. Woodruff, PhD, MPH, is associate professor and director, University of California, San Francisco, Program on Reproductive Health and the Environment. Jeanne C. Conry, MD, PhD, is an obstetrician and gynecologist and the assistant physician at Chief, North Valley, Kaiser Permanente. Linda C. Giudice, MD, PhD, MSc, is chair of the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco.
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Environmental Health
Scientific Evolution of Autism Trends and Patient Advice Martha Herbert, MD, PHD Recently, the CDC announced a 23 percent increase in autism prevalence, up to 1 in 88 (1 in 54 boys) as compared with 1 in 110 two years ago. While some portion of this increase is certainly due to greater awareness, few continue to deny the possibility that some of this increase is real and driven by the environment. These figures have alarmed many parents and represent a public health crisis. On the heels of this news came a study suggesting that mothers with common environmentally influenced metabolic derangements such as obesity and diabetes had greater risk of having a child with autism. And prior studies suggest that prenatal vitamins may lower this risk. For decades, the word autism meant an immutable brain disorder, genetically based, only marginally responsive to therapies. But it shouldn’t anymore. A growing body of research is dramatically changing the face and future of autism. In my new book, The Autism Revolution, I explain this evolution in autism science and offer practical strategies for families to help their children, today. Here are four of the most profound changes:
1. More than genes. No one has found anything close to
a genetic smoking gun when it comes to autism. Hundreds of genes have been associated with autism, but all of them together account for less than 15 to 20 percent of diagnoses—and many have only mild impact. Decades-old research suggests that identical twins almost always share identical autism diagnoses, but recent research shows that’s not true. Scientists are also learning more about possible environmental contributors to autism. We’ve long known that certain toxins were associated with autism, but a 2011 study showed that women who took prenatal vitamins before conceiving and in early pregnancy were less likely to have a child on the autism spectrum. Further links have been found to exposure to air pollution and pesticides during pregnancy. Another study found a link between antidepressant use during pregnancy and a child’s autism. Though there is reasonable debate about how much is genes and how much is the environment, today it is the rare expert who argues that genes are solely responsible for autism. And even beyond autism, genetics has evolved from a hunt for “the gene for” a disease to a study of more subtle influence, complex networks, and environmental influences on gene expression.
2. Beyond the brain. We’re appreciating that autism is not just a brain disorder but a whole-body condition. Roughly 70 percent of kids with autism have gut problems. Children on the autism spectrum often have sleep problems and imwww.sfms.org
mune system problems. Seizures are also common. Whatever autism “is,” it doesn’t just affect the brain. And more broadly, science is showing many new ways that brain and body deeply influence each other. Traditionally, parents have been encouraged to pursue only the therapies directed at their child’s brain and behavior issues. The family stories presented in The Autism Revolution suggest that treating these “ancillary” symptoms can make a profound difference in the family’s life, and even in the autism itself.
3. Kids can improve. A lot. Autism may not necessarily be fixed for life. We simply cannot ignore the many stories of recovery. Maybe some types of autism naturally improve with age, or maybe interventions can, in at least some cases, beat back many or most of autism’s symptoms. A study published earlier this year found that fully one-third of teenagers who had once been diagnosed on the spectrum no longer fit the diagnosis. It’s not clear how many of those teens were originally misdiagnosed and how many had outgrown or been treated out of their autism—however, those with the most physical challenges were least likely to get off the spectrum. Plus, many children on the spectrum show a significant improvement in their language and social skills when they run a fever—hinting at the possibility of change and the presence of a capable child “inside” the autism. Even genetic syndromes may be reversible—at least five major studies report reversal of symptoms in mouse models of autism-associated genetic syndromes such as Rett’s and Fragile X. These studies and others suggest that autism may be a “brain state” rather than a form of permanent damage. Continued on the following page . . .
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Scientific Evolution of Autism Continued from previous page . . .
4. Autism does not equal intellectual deficits. It
used to be thought that at least three-quarters of people with autism also had significant cognitive impairment. But research demonstrates that people on the spectrum very often have typical or even extraordinary intelligence and domains with superior perceptual abilities. Many struggle in showing what they know to the rest of us. A growing body of science and clinical experience is telling us that we have badly misjudged autism. But it is also pointing us in new and promising directions. The new vision of autism illustrated above offers great hope for scientifically based paradigm shifts in how we approach this condition. Case studies of people with autism who have improved greatly set the stage for a readable yet systematic walk through the biological foundations of autism in gene, environment, and cellular problems and how these perturb the functions of the body’s organs, particularly gut, immune system, and brain. On this basis, the reader is prepared to understand how a medically irritated brain with these kinds of problems to deal with might produce the behaviors we call autism— and how this irritation might be reduced. Each chapter also contains abundant self-help material organized around the themes of “food, toxins, bugs, and stress,” focusing on optimizing health promotion and daily environment and avoiding things that may cause harm or deplete resilience. At a time like this we need not only more research but also things we can do right now. The Autism Revolution offers people rational, science-based wellness practices that they can implement now to reduce risk and improve function. On a larger scale, it also represents a public health program we can implement immediately, based on what we already know, that could lead not only to less autism but also to healthier families and communities. Dr. Martha Herbert is an assistant professor of neurology at Harvard Medical School, a pediatric neurologist at the Massachusetts General Hospital in Boston, and an affiliate of the Harvard-MIT-MGH Martinos Center for Biomedical Imaging. She is director of the TRANSCEND Research Program (Treatment Research and Neuroscience Evaluation of Neurodevelopmental Disorders). The Autism Revolution: Whole-Body Strategies for Making Life All It Can Be (www.autismrevolution. org), published by Ballantine Books and Harvard Health Publications, by Martha Herbert PhD, MD, with Karen Weintraub. A shorter version of this article appeared on the Harvard Health Publications website at www.health.harvard.edu.
“Top Ten Toxic Chemicals” The Mount Sinai Children’s Environmental Health Center (CEHC) publishes a list of the top ten toxic chemicals suspected to cause autism and learning disabilities. The CDC has reported that autism spectrum disorder (ASD) now affects 1 of every 88 American children—a 23 percent increase from 2006 and a 78 percent increase from 2002. The CDC also reported that ADHD now affects 14 percent of American children. As these disorders continue to affect more children across the U.S., researchers are asking what is causing these dramatic increases. Some of the explanation is greater awareness and more accurate diagnosis. But, clearly, there is more to the story than simply genetics, as the increases are far too rapid to be of purely genetic origin. The National Academy of Sciences reports that 3 percent of all neurobehavioral disorders in children are caused by toxic exposures in the environment and that another 25 percent are caused by interactions between environmental factors and genetics. But the precise environmental causes are not yet known. To guide a research strategy to discover potentially preventable environmental causes, the Children’s Environmental Health Center (CEHC) has developed a list of ten chemicals found in consumer products that are suspected to contribute to autism and learning disabilities. This list was published in Environmental Health Perspectives in an editorial written by Dr. Philip J. Landrigan, director of the CEHC; Dr. Linda Birnbaum, director of the National Institute for Environmental Health Sciences (NIEHS); and Dr. Luca Lambertini, also of the CEHC. The top ten chemicals are:
• Lead • Methylmercury • PCBs • Organophosphate pesticides • Organochlorine pesticides • Endocrine disruptors • Automotive exhaust • Polycyclic aromatic hydrocarbons • Brominated flame retardants • Perfluorinated compounds
The editorial was published alongside four other papers, each suggesting a link between toxic chemicals and autism. All five papers call for increased research to identify the possible environmental causes of autism in America’s children.
Reference Landrigan P, Lambertini L, Birnbaum I. A Research Strategy to Discover the Environmental Causes of Autism and Neurodevelopmental Disabilities. Environ Health Perspect. 25 April 2012. http://ehp03. niehs.nih.gov/article/info%3Adoi%2189%2Fehp.1104285.
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Environmental Health
fukushima’s lessons The Dangers of Nuclear Power Robert M. Gould, MD Since the multiple meltdowns at the Fukushima Daiichi site in March 2011, massive amounts of radioactive water have flushed into the seas bordering Japan, with unknown ramifications for sea life and
the food chain.1,2 Extensive contamination of land and food has been reported throughout Japan. Approximately 150,000 people have evacuated their homes and farmlands, with inadequate compensation for their losses.2 With growing opposition to nuclear power, all fifty-four nuclear plants are currently shut down in Japan,3 which has halted plans to expand its domestic program. However, Japan has continued to push to reopen and/or extend the lifetime of currently sidelined plants3 and to aggressively promote the export of Japanese nuclear technology to other nations in the region, such as Vietnam.4 The triple meltdown at Fukushima demonstrates the faulty nature of the nuclear industry’s “probabilistic risk assessment” that predicted that an accident such as that at Fukushima would only occur once every 250 years. Since 1957 there have been a dozen nuclear accidents with reactor core damage, including the major disasters at Three Mile Island in 1979 and Chernobyl in 1986.5 With Fukushima’s three meltdowns, this amounts to one major accident every seven years.2 Great concern remains about spent fuel pools that remain open to the atmosphere since the explosions. Located about 100 feet above the ground, they could topple or collapse from further strong quakes that are endemic to the Pacific “Ring of Fire” upon which Japanese nuclear facilities have been built.6 According to former U.S. Department of Energy official Dr. Robert Alvarez, the Fukushima complex contains 10,833 spent fuel assemblies, including an amount of cesium-137 that is approximately eighty-five times the amount estimated to have been released at Chernobyl. The structurally damaged pool No. 4 is especially vulnerable given intense seismic activity recorded in northeast Japan in mid-April 2012.6 Dr. Alvarez has warned for years about the vulnerability of the spent fuel pools, which contain far more radioactivity than reactor cores, to accidents and terrorist attacks. For example, a 1997 report by Brookhaven National Laboratory found that a severe pool fire could render about 188 square miles uninhabitable, cause as many as 28,000 cancer fatalities, and cost $59 billion in damage.7 Events at Fukushima have thus underscored central fallacies inherent in the promotion of nuclear power as a “safe” alternative energy suitable for addressing our current combined global warming and energy crises. Nuclear power is not carbon-neutral, as significant fossil-fuel inputs are needed to produce nuclear fuel and to construct hundreds of planned www.sfms.org
reactors. A life-cycle analysis would include the profound environmental and public health impacts of worldwide uranium mining, fuel fabrication and waste storage, etc., on workers and communities and on land, air, and water quality. It would also include a full accounting of the risks of nuclear weapons proliferation and terrorism that have been historically connected with nuclear power programs.8,9
With more than 100 million Americans living within a fifty-mile radius of a nuclear power plant, our health system remains unprepared for a Fukushima-like nuclear disaster.10,11,12 Twenty-three U.S. reactors are of the same design as those that failed in Fukushima, and in some locations, including California, plants sit astride dangerous earthquake faults.13 With the true economic costs of nuclear power obscured by extensive financial subsidies and historic liability relief for the nuclear industry,14 it behooves our country to heed the example of countries such as Germany and Switzerland, who have announced they will end their nuclear power programs in the face of strong public opposition.15,16 In California, an antinuclear coalition is working on blocking the relicensing of the Diablo Canyon facility and stopping the operations of the San Onofre plant, which was recently closed because of severe erosion of hundreds of steam generator tubes.17 The highly promoted nuclear renaissance would at best increase global energy capacity only marginally, at a cost that would effectively starve the capital needs for alternative, sustainable technologies that would, in combination with increased energy efficiency and conservation, provide a better way forward.18 With the final costs of Fukushima far from being accounted for, it is noteworthy that John Rowe, ex-CEO of the Exelon Corporation, which runs twenty-two U.S. nuclear power plants, recently remarked that nuclear power is not an economically viable source of new energy in the U.S., adding, “Let me also state unequivocally that new ones don’t make any sense right now.”19 This is a lesson for all of us to embrace in developing an energy strategy befitting the challenges posed by global warming. Dr. Gould, a pathologist, is president of the SF-Bay Area chapter of Physicians for Social Responsibility and a member of the Santa Clara County Medical Society. A full list of references is available online at http://bit.ly/JfSTIS.
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Environmental Health
assessing toxin risk Improvements Needed to Protect Human Health from Chemicals Ted Schettler, MD, MPH; Sarah Janssen, MD, PhD, MPH; Jennifer Sass, PhD; Gina Solomon, MD, MPH; and Tracey Woodruff, PhD
Companies in the United States produce or import more than forty billion pounds of chemicals daily.1 Thousands of these chemicals are used to produce materials and products in commerce. Studies show that chemical exposures in the workplace and general population are common and, in some cases, increase the risk of various diseases and disorders.2 Unfortunately, under current law, most industrial chemicals, with the exception of pesticides, are not adequately evaluated for their toxicity or exposure potential and no formal assessment of their health risk is ever done. They are simply presumed safe. The few chemicals that have been assessed usually come to regulatory attention because of incidental observations of adverse health effects in wildlife, laboratory animals, or people. In 1983, the National Academy of Sciences (NAS) considered the need to standardize the assessment of risks associated with exposure to chemicals and recommended this four-step process, which has been widely adopted in the context of human health.3 Risk assessment consists of: (1) hazard identification—a determination if a chemical is linked to a health effect; (2) doseresponse assessment—a determination of the relationship between magnitude of exposure and the likelihood of a health effect; (3) exposure assessment—the determination of the extent and magnitude of exposure in human populations; and (4) risk characterization—a numerical description of the nature and the magnitude of human risk, based on the information gathered during the preceding three steps. Regulatory agencies, businesses, and other organizations use the results of this process to establish “acceptable” levels of exposure to a chemical. In turn, these levels determine concentrations allowable in the air, water, and food supply; allowable exposures from consumer products and in the workplace; and cleanup levels for hazardous waste sites. Although this process has theoretical merits, in practice it has been plagued by chronic delays, and many risk assessments take years or decades to complete. In 2009, at the request of the Environmental Protection Agency (EPA), a committee of the NAS reviewed the process and its nearly thirty-year history of implementation, in light of these long delays and recent scientific advances.4 The committee concluded that the process was “bogged down,” flawed, and needed significant overhaul to incorporate more contemporary science. Here we summarize several of the committee’s key recommendations. Unfortunately, these recommended changes to the process are not widely known and most have not yet been implemented by regulatory agencies or others.
Key Recommendations from the NAS
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Addressing an overarching concern, the NAS recommended San Francisco Medicine June 2012
that, in order to avoid delays and unnecessary analytic detail, the agency should first identify the decision that needs to be made and then focus the risk assessment on answering the specific questions that would most significantly inform the decision. For example, in the initial evaluation of a chemical, if significant hazardous properties and exposures are identified, the committee recommended efforts to reduce the hazard or exposure at the earliest stages of decision making.5 This could be accomplished by switching to a safer alternative, such as an inherently less hazardous chemical or process. Furthermore, the NAS recommended that simplified guidelines and methods be developed to allow risk assessments to be done in a timely fashion and to facilitate community participation.
The committee specifically recommended that:
(1) Risk assessments should identify and incorporate variability in both human exposure and vulnerability so that all people are better protected.3 Under current practice, the U.S. EPA generally assumes that exposures and vulnerability do not differ by more than tenfold among individuals and can be addressed with a single tenfold “safety” factor.3 The NAS recommended that the types, sources, extent, and magnitude of variability be explained for each step in the risk assessment process, and it advised that special attention should be directed to vulnerable individuals and populations that may be particularly susceptible and/or more highly exposed. (2) Risk assessments of single chemicals should incorporate information about the potential influence of exposure to multiple chemicals. In addition, risk assessors should consider the extent to which other factors, such as exposure to biological and radiological agents and social conditions, influence the effect of chemical exposures.2,3 Here the committee explicitly recognizes that people are regularly exposed to multiple environmental agents and other stressors, and that this context should be considered. Today, with a few notable exceptions, most chemicals are evaluated individually, with the unrealistic underlying presumption that there are no other concurrent exposures and that nothing else in people’s environment interacts with the chemical to alter the risk of adverse effects. Health care professionals will be familiar with this concern, since the potential for drug interactions and other circumstances regularly influence prescribing practices for individual pharmaceuticals. (3) Since people are exposed to multiple chemicals, with varying susceptibilities, it cannot be presumed that even lowlevel exposures are risk free. It should therefore be assumed that low levels of exposures are associated with some level of risk, unless data are sufficient to reject this assumption.3 www.sfms.org
Currently, the EPA, FDA, and other agencies have very different approaches to dose-response assessments for cancer and noncancer health effects. For most carcinogens, the current assumption is that any exposure is associated with some cancer risk and increasing exposure levels proportionately increase risks. This linear dose-response model is assumed to apply to all carcinogens unless data show otherwise. In contrast, for noncancer health effects, the current assumption is that there is a dose threshold below which exposures do not contribute to increased risk. The NAS committee recommended that agencies use the same approach for addressing risks related to both cancer and noncancer health effects.6 The committee also pointed to multiple differences across the population with respect to age, disease status, nutrition, and other factors. Because of these differences, as well as concurrent exposures to multiple chemicals, science supports using a model that does not have an assumption of a “threshold” below which exposures cause zero risk in the population. Thus, the NAS recommended using a “no-threshold” model unless data are sufficient to reject low-dose linearity.7 Neither the EPA nor any other federal or state agency has begun to follow this recommendation. (4) The committee also made specific recommendations with respect to underlying default assumptions used throughout the risk assessment process. In 1983, the NAS defined a default assumption as the “option chosen on the basis of risk assessment policy that appears to be the best choice in the absence of data to the contrary.” For example, if a risk assessment relies on extrapolating data from laboratory animal studies to humans, assumptions about differences in species sensitivities are required if empirical data are missing. The committee recommended using scientifically-based default assumptions that will protect health, rather than waiting for more data, in order to improve the timeliness of the chemical assessment and decisionmaking process.3
Conclusion
The NAS has recommended improvements in the chemical risk assessment process to reflect current science, to make the process more responsive to policy needs, and to better protect people from adverse health effects resulting from chemical exposures. Unfortunately, since the publication of the NAS report in 2009, federal agencies have undertaken few measures to incorporate these recommendations and update risk assessments of chemicals in consumer products, workplaces, and the general environment. As a result, the medical community should not assume that legal levels of contaminants in our air, water, food, or consumer products are truly safe for humans, especially for people with underlying disease, age-related vulnerabilities, or people who are vulnerable because of exposure to multiple www.sfms.org
stressors, including violence, poor nutrition, or lower socioeconomic status. Moreover, the medical community should be aware that many chemicals in commerce have undergone little or no evaluation at all. Health care professionals should advocate for prudent exposure and risk reduction among their patients and in their communities. They should also support efforts to reform state and federal policies so that chemicals in commerce are adequately evaluated for their safety.
Ted Schettler, MD, MPH, is science director, Science and Environmental Health Network. Gina Solomon, MD, MPH, is clinical professor of medicine at UCSF and deputy secretary, California Environmental Protection Agency. Jennifer Sass, PhD, is senior scientist, Natural Resources Defense Council. Sarah Janssen, MD, PhD, MPH, is senior scientist, Natural Resources Defense Council. Tracey Woodruff, PhD, is professor and director, Program on Reproductive Health and the Environment, UCSF.
References 1. Wilson M, Schwartzman M. Toward a new U.S. chemicals policy: Rebuilding the foundation to advance new science, green chemistry, and environmental health. Environ Health Perspect. 2009; 117(8):1202-1209. 2. CHE toxicant and disease database. Available at http:// www.healthandenvironment.org/tddb/. 3. NRC (National Research Council) 1983. Risk Assessment in the Federal Government: Managing the Process. Washington, D.C. National Academy Press. 4. NRC (National Research Council) 2009. Science and Decisions: Advancing Risk Assessment. Committee on Improving Risk Analysis Approaches Used by the U.S. EPA, National Research Council. Washington, D.C. National Academies Press. 5. Science and Decisions, pp. 10-12. 6. Science and Decisions, p. 9. 7. Science and Decisions, p. 144. See also: Janssen S, Sass J, Schettler T, Solomon G. Strengthening risk assessments to protect public health. An issue paper. Available at http://www.nrdc.org/health/strengthening-toxicchemical-risk-assessments.asp. June 2012 San Francisco Medicine
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Environmental Health
The european Example What Have We Learned about Health and the Environment? Genon K. Jensen and Lisette van Vliet Over the past decade, an important new debate on health protection through environmental action has been created and several significant reforms in
European law introduced. Although changes have not necessarily been commensurate with the urgency of the problem, or fully responsive to the scale of the emerging research on the impacts to our health, progress has nevertheless been made. The health community, including medical professionals, health-affected groups, and researchers, has proved vital in shaping the strategic and legislative developments and in engaging the public on how pollution is intrinsically linked to human health. The energy of these groups coalesced into a new network in 2003, which is now known as the Health and Environment Alliance (HEAL). HEAL has been inspired by and collaborates with the U.S.-based Collaborative on Health and the Environment and its extensive evidence-based resources on diseases and environmental risk factors.
Health and Environment Strategies
Ten years ago, policy makers, doctors, and scientists were increasingly concerned about the special vulnerability of children to environmental hazards. The World Health Organization in Europe, which brings together fifty-three countries, had been running an environment and health process for more than ten years. But 2002 marked a turning point, with a landmark publication reviewing the scientific basis for linking environmental causes to key children’s health problems. Its findings had wide appeal and it quickly led to the groundbreaking Children’s Environmental and Health Action Plan for Europe (CEHAPE). This political attention also spread to the European Union, led by the E.U. Commissioner for the Environment at the time, Margot Wallstrom, who helped articulate a new rationale for precautionary interventions to protect human health. The E.U. formulated a health and environment strategy in 2003, and an associated Action Plan put a special focus on vulnerable groups and on identifying emerging environmental health threats, such as endocrine disrupters and priority diseases.
Chemicals and Pesticides Legislation
The framing of the debate and heightened awareness were reflected in several key pieces of E.U. law, including REACH, which established the registration, evaluation, authorization, and restriction of chemical substances. Medical experts and the health community played a key role in bringing the health arguments in favour of REACH to the policy makers 28 29
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and in highlighting the public health benefits of the new legislation. In 2004, hundreds of individuals and networks, including the Standing Committee of Medical Doctors (CPME), representing more than two million doctors across Europe, signed the Paris Appeal on the role of chemical pollutants in damaging public health. The new law radically changed chemicals governance, establishing new principles of mandatory registration, health and environmental data submission, and company responsibility for chemical safety. Certain hazardous chemicals must now obtain authorization to remain on the market. Although inadequate in its implementation and weak on endocrine-disrupting chemicals (EDCs), REACH aims to eventually phase out the most harmful chemicals on the European market and has set a high benchmark for chemicals legislation reform around the world. At the national level, medical and health groups are continuing to raise awareness of the shortcomings in E.U. legislation on EDCs. Doctors in Denmark and France have been important in achieving national bans on the EDC bisphenol A in certain products, which catalyzed an E.U.-wide ban in baby bottles. A second important reform involved updating the existing pesticides law to reflect the science on health and environment risks. Again, the health community’s role in bringing forward the evidence to E.U. and national decision makers proved crucial, for example through scientific consensus statements. The new law represents a significant step forward for public health protection because the basis on which pesticides are now judged has been changed: from a risk approach to one based on “hazard” (or intrinsic properties). This means certain harmful pesticides—specificially those that are cancerogenic, mutagenic, and toxic to reproduction, as well as endocrine disruptors—will now be banned.
Putting Health into the Climate Debate
The voice of medical professionals and health groups has changed the policy debate on climate change, not only in the E.U. but also at global level. While climate change is relatively well accepted in Europe, the necessary political measures are not. The health community has therefore worked with scientists and economists to find strategic arguments. For example, HEAL has highlighted how moving to a 30 percent reduction target on carbon emissions in the E.U. (to mitigate climate change) would bring up to 30 billion Euros per year by 2020 in public health benefits. These benefits occur because policies to reduce carbon emissions also reduce pollutants in outdoor air. A growing understanding of these so-called “health www.sfms.org
co-benefits” has contributed to the climate debate by bringing arguments in terms of economic savings and also in how climate action can directly improve the lives of people suffering from asthma and other respiratory diseases. Clearly, in the past ten years in Europe, the environmental health movement has successfully advanced the debates and legislative changes. This has been achieved because scientists, doctors, and health-affected and community groups have taken a scientific dialogue to politicians in a format that works for them. Genon K. Jensen is executive director and Lisette van Vliet is toxics policy advisor at the European Health and Environment Alliance (HEAL).
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Children’s Health and Environment. A review of evidence by the European Environment Agency and the WHO Regional Office for Europe. 2002. http:// www.euro.who.int/__data/assets/pdf_ file/0007/98251/E75518.pdf. HEAL (on behalf of the Belgian Federal Minister for Environment). The E.U. environment and health action plan EHAP: Assessment and outlook for future action (2004–2010). 2010.http://www.health.belgium.be/internet2Prd/groups/ public/@public/@nehap/documents/ie2form/19063534.pdf.
REACH, E.U. Chemicals Policy
ARTAC. The Paris Appeal 2004: International declaration on diseases due to chemical pollution. 2004. http://www.artac.info/fr/ appel-de-paris/texte-en-six-langues/english_000082.html. HEAL, ChemTrust and ISDE. What will new E.U. chemicals legislation deliver for public health? 2007. http://www.env-health. org/IMG/pdf/21-_What_will_new_EU_chemicals_legislation_deliver_ for_public_health_-_REACH_briefing_EN.pdf. CHEM Trust and HEAL. Challenges and solutions in the regulation of chemicals with endocrine-disrupting properties. 2012. http://www.env-health.org/IMG/pdf/36-_HEAL_CT_EDC_Criteria_ Briefing_Paper.pdf. Standing Committee for European Doctors (CPME). REACH letter from the CPME to the College of Commissioners. 2006. http:// www.cpme.be/news_press.php?id=59.
Pesticides
CHEM Trust. Report: A review of the role pesticides play in some cancers: Children, farmers, and pesticide users at risk? 2010. http:// www.chemtrust.org.uk/Pesticidesandcancer.php. Collegium Ramazzini Statement. The control of pesticides in the European Union—A call for action to protect human www.sfms.org
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tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m
health. 2008.http://www.collegiumramazzini.org/download/13_ ThirteenthCRStatement(2008).pdf. HEAL and PAN-Europe. Cut back on pesticides for healthier lives: New scientific understanding of health impacts of pesticides demands precautionary policy making. 2007. http://www.env-health.org/ IMG/pdf/2-_Cut_back_on_Pesticides_for_healthier_lives.pdf Prague Declaration on endocrine disruptors. 2005. http://www.ourstolenfuture.org/Consensus/20050620praguedeclaration.htm.
Climate Change
European Respiratory Society (ERS). Climate change and respiratory disease. 2010. http://dev.ersnet.org/uploads/Document/ cc/WEB_CHEMIN_5568_1260432234.pdf. HEAL and HCWH. Acting NOW for better health: A 30% reduction San target for E.U.Fran climateMed policy.Mag 2010. http://www.env-health.org/spip. php?rubrique97. 01-29-09 The Lancet and University College London, U.K. Managing the health effects of climate change. 2009. http://www.thelancet.com/ climate-change. The World Health Organization. Protecting health from climate change: World Health Day 2008. 2008. http://www.who.int/worldhealth-day/previous/2008/en/index.html. World Medical Association (WMA). WMA Declaration of Delhi on health and climate change. 2009. http://www.wma.net/ en/30publications/10policies/c5/index.html. June 2012 San Francisco Medicine
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Environmental Health
electromagnetic fields The Effect on Human Health David. O. Carpenter, MD We are all bathed in electromagnetic fields (EMFs) constantly, and indeed life on earth would not be possible
without sunlight, the form of EMFs familiar to most. But too much sunlight can result in skin cancer and a suppressed immune system. The infrared portion of the electromagnetic spectrum is essential for life on earth, because this is what warms the planet. But too much infrared causes excessive heat, which kills crops and people. The high end of the electromagnetic spectrum includes the ionizing EMFs, X-rays, cosmic rays, and gamma rays. These EMFs contain sufficient energy to directly damage DNA and kill cells, but even these have medical uses for diagnosis and treatment. So for all of these forms of EMFs, there are important benefits to humankind but also serious injury if exposure is excessive. EMFs consist of waves of energy that do not have any mass. The EMFs mentioned above are all at the higher-frequency portions of the electromagnetic spectrum, but what about those EMFs that have lower frequencies? These EMFs are usually considered in two broad groups: the extra-low frequency EMF (ELFs) coming from powerline and electricity and the radiofrequency (RF) EMFs that mediate AM and FM radio, television, radar, cell phone, WiFi, and all of the other wireless devices that open your garage door or turn on your TV from your easy chair. Could these forms of EMFs, so much a part of our daily lives, cause harm? In 1979 the first publication appeared showing that children who lived in homes where there was excessive exposure to EMFs coming from powerlines in the street were at elevated risk of developing cancer. This observation has been replicated many times for childhood leukemia, and the conclusion that powerline EMFs are associated with elevated rates of childhood leukemia have been confirmed in at least three meta-analyses. While childhood leukemia is relatively rare and treatable, it is a terrible disease for a child. Adults exposed to high ELFs by occupation also have elevated rates of leukemia. A major concern is that the exposure level associated with elevated rates of childhood leukemia are not much higher than those many of us are exposed to on a daily basis. In fact, we do not know a threshold below which there is no increase in risk, in part because no one is unexposed. So we are always investigating rates of leukemia in groups more highly exposed as compared to those less exposed. If ELFs can cause cancer, what about RF fields? Exposure to RFs has increased enormously in the wireless age. The strongest evidence for harm from RF comes from studies of long-term cell phone use and brain cancer, evidence that, in spite of denials from industry and some government organizations, is strong and consistent. Like other environmental exposures, the evidence indicates that risk increases with aggregate use. The clear30 San 31 SanFrancisco FranciscoMedicine Medicine June June2012 2012
est relationships are seen in adults who have used cell phones for ten years or more and for many hours, but there is some evidence that cell phone use by children is even more hazardous than for adults. There are still many uncertainties about the relationships between exposure to EMFs of all frequencies and human disease. We don’t know any one single mechanism whereby EMFs cause cancer, although we have many biological effects that could lead to cancer, but this is the case for many known human carcinogens. We don’t know with certainty what other diseases are associated with EMF exposures, although there is now evidence for associations with Alzheimer’s disease and neurologic abnormalities. Why, in the face of all this evidence, has government not taken steps to reduce human exposure? In great part it is because we, the public, like our EMFs. We depend on electricity, we like our wireless devices, and we don’t want to acknowledge that they may pose dangers. Federal regulations are not based at all on known human health effects. Without public outcry, certainly the industry is not going to worry. There needs to be federal regulation, but in the meantime there are steps individuals can take to reduce exposure. The first step is to acknowledge the danger. Keep your distance from sources of EMF exposure. Stand back from electric appliances while in use. Use a wired ear piece for your cell phone. Wired computer labs and wired smart meters do not generate RF. This is the concept of “prudent avoidance,” which is the practice of taking steps to reduce exposure that are neither outrageously expensive nor difficult. We need more research, but we have enough information now to know that there are real hazards from exposure to EMFs. David Carpenter, MD, is with the Institute for Health and the Environment at the University at Albany, State University of New York, in Rensselaer, New York.
References Carpenter DO, Sage C. Setting prudent public health policy for electromagnetic field exposures. Rev Environ Health. 2008; 23:91-117. Greenland S, Sheppard AR, Kaune WR, Poole C, Kelsh MA, the Childhood Leukemia-EMF Study Group. A pooled analysis of magnetic fields, wire codes, and childhood leukemia. Epidemiology. 2000; 11:624-634. Hardell L, Carlberg M. Mobile phones, cordless phones, and the risk for brain tumors. Internat J Oncology. 2009; 35:5-17. Wertheimer N, Leeper E. Electrical wiring configurations and childhood cancer. Am J Epidemiol. 1979; 109:273-284. www.sfms.org
Environmental Health
biomonitoring update Measuring Exposures to Chemicals Davis Baltz and Sharyle Patton Biomonitoring—short for biological monitoring—is defined by the CDC as “the assessment of human exposure to
chemicals by measuring the chemicals or their metabolites in such human specimens as blood or urine. A metabolite is a chemical alteration of the original compound produced by body tissues.” While blood and urine are the tissues most commonly analyzed by directly measuring chemicals in the body, exposure can also be measured in hair, fat, nail clippings, saliva, bone, semen, amniotic fluid, cord blood, meconium, and breast milk. In February 2012, the CDC’s national biomonitoring program posted updated tables that provide new data since the release of the Fourth National Report on Human Exposure to Environmental Chemicals in 2009. Tables are provided for thirty-four new chemicals, as well as updated tables for sixty-six chemicals that were included in the Fourth Report. The new chemicals include the anions thiocyanate and nitrate; seventeen sulfonyl urea herbicides (compounds that interfere with a key enzyme required for weed cell growth); and the pesticides acephate, methamidophos, dimethoate, omethoate, ethylene thiourea, and propylene thiourea. The blood and urine samples reported in these publications were collected from participants in CDC’s National Health and Nutrition Examination Survey (NHANES, http://www.cdc.gov/exposurereport/), which obtains and releases health-related data from a nationally representative sample in two-year cycles. A March 2012 Boston University study that used the CDC’s NHANES biomonitoring database discovered that chemical exposures vary with social disparities for perfluorinated compounds (PFCs) and bisphenol A (BPA). Analysis of urine samples showed that socioeconomic status and reliance on food assistance programs were correlated with chemical body burdens. Levels of BPA were higher in people who were poor, especially among children aged six to eleven with low food security who needed emergency food aid. For PFCs, measurements in urine were higher among the more affluent. The overwhelming majority of food cans have a BPA-based lining, and food banks receive many donations of canned food. Other known exposure pathways for BPA include leaching from polycarbonate plastic bottles, other food containers and packaging, soda cans, and carbonless receipt paper commonly used in retail stores. PFCs, which are extremely persistent and long-lasting in the environment, are used widely as grease, stain, and water repellents, including in outdoor wear, fast-food packaging, carpets, textiles, computer chips, some kinds of fire-fighting foam, and antistick cookware like Teflon. California’s state biomonitoring program—the California Environmental Contaminant Biomonitoring Program or “Biomonitoring California”—is poised to publish two studies. The Maternal www.sfms.org
and Infant Environmental Exposure Project looked at exposures to pregnant mothers and their newborns recruited through UCSF. The mothers’ urine was collected during the third trimester of pregnancy and compared with cord blood collected during delivery. The second study, the Firefighter Occupational Exposures (FOX) Project, biomonitored firefighters in Orange County: http:// www.cdph.ca.gov/programs/Biomonitoring/Pages/default.aspx. The European Union pilot human biomonitoring project, tasked with developing harmonized monitoring protocols for use by E.U. members, is testing 120 mother/child pairs in each of seventeen participating countries. All countries in the project are testing for levels of lead, mercury, phthalates, and cotinine, with some countries opting to test additionally for triclosan, bisphenol A, and parabens. Like Biomonitoring California, the E.U. is required by law to share individual results with biomonitoring study participants upon request. Conveying individual results is challenging, given that within both California and E.U. borders, people speak many languages with different levels of science literacy. Some want to know only their personal results, while others prefer a fuller context for understanding results, as well as detailed information about health effects and avoiding further exposures. Draft materials for explaining individual results for Biomonitoring California’s FOX study can be found at http://oehha.ca.gov/multimedia/biomon/sgp031612.html. Unlike the U.S. Centers for Disease Control and the Biomonitoring California programs, the E.U. human biomonitoring program is designed to link data to regulatory work within the E.U., including pesticide and biocide regulations and the implementation of REACH, the legislative framework in Europe for chemicals and their safer use (REACH: Registration, Evaluation, Authorization and Restriction of Chemical substances, http://ec.europa.eu/ environment/chemicals/reach/reach_intro.htm). Current plans include integrating biomonitoring data into thematic work concerning endocrine-disrupting chemicals and mercury exposures, and European action plans concerning human health and the environment. The EU’s human biomonitoring pilot project is described in more detail at www.eu-hbm.info. Davis Baltz is special projects advisor, Collaborative on Health and the Environment; Sharyle Patton is director, Commonweal Biomonitoring Resource Center.
References Nelson, JW, MK Scammell, EE Hatch, TF Webster. 2012. Social disparities in exposures to bisphenol A and polyfluoroalkyl chemicals: A cross-sectional study within NHANES 2003–2006. Environmental Health. 2012; 11:10 doi:10.1186/1476-069X-11-10. June 2012 San Francisco Medicine
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Environmental Health
new online data tool Local Environmental Health Data Now Available Online Paul English, PhD, MPH
Health professionals recognize the growing impact of the physical environment on health; many
chronic diseases, such as asthma, cancer, and heart disease, have links to the environment. Now clinicians can access an exciting online tool, located at http://www.ehib.org, to obtain information on environmental disease and hazards in their patients’ neighborhoods. Developed by the California Environmental Health Tracking Program (CEHTP), the tool provides data and information on environmentally related conditions and exposures. Below are some examples of the types of information available: Traffic-related pollution has been linked to poor respiratory health, adverse birth outcomes, heart attacks, and cancer. San Francisco County has the highest proportion of its population living near busy roads in California. Using the CEHTP traffic tool, clinicians can enter a patient’s address and view the amount of traffic nearby, which is a good proxy for exposure to traffic pollutants. Preterm birth, which is related to many factors including maternal smoking and lack of prenatal care, has also been found to be associated with exposure to traffic pollutants. CEHTP creates maps of preterm birth rates that identify neighborhoods where interventions, such as increasing access to prenatal care, should be directed. Asthma-related health care utilization is heavily influenced by access to care and income. Maps of asthma-related emergency department visits can be used to identify areas with poor access to primary care and an increased need for preventative efforts, such as promoting asthma self-management in the community. Heat waves will increase in the future. During the 2006 32 33
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heat wave, which resulted in more than 16,000 excess emergency room visits, areas in California with cooler climates had the highest risk for emergency room visits for heat illness, possibly due to a lack of acclimatization and air conditioning. Clinicians must prepare for the health impacts of climate extremes and educate their patients on how to protect themselves—for example, recommending increased hydration during heat waves. The Web tool provides information and resources on the health effects of climate change. Other topics on the CEHTP web tool include birth defects, cancer, drinking water, lead poisoning, and heart attacks. Paul English, PhD, MPH, is branch science advisor, Environmental Health Investigations Branch, California Department of Public Health.
For more information, go to www.CEHTP.org.
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Environmental Health
Ecological Health Complex Science, New Models, and Public Health Ted Schettler, MD, MPH Many different pathways lead to complex diseases, such as diabetes, cancer, dementia, and cardiovascular disorders. Diverse combinations of risk factors from
multiple levels—cellular, individual, neighborhood, community, ecosystem, and society—determine disease risks in individuals and disease patterns in populations. Dynamic interactions within and across levels are the rule, influenced by time, scale, and proportion. Scientists from many disciplines have long studied this complexity by simplifying it, looking for an effect when selected variables change while others are constant. They have focused mostly on proximal causes of effects rather than causes of causes. This has yielded important insights but has limited predictive and explanatory power. The real world is more complex, and interest in new, system-wide models is growing.
New Models
New models for understanding disease mechanisms are rapidly developing in the field of systems biology. Similarly, epidemiologists see the need for more systems-based models to help clarify causes of disease patterns in populations.1,2 They recognize the importance of a life-course perspective, since early life exposures to environmental chemicals, air pollution, poor nutrition, or chronic stress uniquely influence health status not only in childhood but also decades later. This also sets a context for risks from exposures later in life. Beyond that, relationships among variables in a dynamic, systems-based model can change over time. For example, lack of exercise increases the risk of obesity, but obesity can then influence activity levels. Dynamic complex systems feature feedback loops and nonlinear, emergent behavior, challenging epidemiologists and public health practitioners whose interest is in identifying interventions that will make a difference in health outcomes.
Complexity Science
Some attempts to develop system-wide models draw on complexity science, chaos, and self-organizing system theories.3 These models interpret biologic systems as adaptive and open, relying on a continual flux of matter and energy from the environment in order to stay alive. Interactions within and across levels of organization are richly complex, as in ecologic systems. Nonlinear system behavior is the rule, with changes in the dynamics of feedback loops, the abrupt appearance of thresholds, and newly emergent properties. Chaos theory is sometimes invoked to help explain the behavior of complex systems. In 1961, Edward Lorenz, a meteorologist, used computer modeling to predict weather patterns. He discovered that rounding 0.506127 to 0.506 during a comwww.sfms.org
puter run resulted in large changes in the long-term outcome prediction.4 He showed that small changes in initial conditions can profoundly affect the trajectory of a dynamic, highly-complex system—a consequence that has subsequently been extensively validated. Complex, chaotic systems also exhibit fractal structure— that is, they show self-similarity at progressively smaller scales, such as in the branching of a tree or the respiratory tract. Thus, with close inspection within what appears to be chaotic activity, one can often find repetitive patterns, suggesting behavior on the edge of chaos—far from equilibrium yet not wildly random. Chaos theory leads to the conclusion that the behavior of an open adaptive system will be difficult to quantify, although over time it will lie within what ecologists call a basin of attraction or what Lorenz called an attractor. Here, while dynamic and far from equilibrium, system behavior lies somewhere within a set of boundaries and has certain qualities. In short, although the behavior of a system on the edge of chaos is difficult to predict precisely, it is subject to a probabilistic set of outcomes. Chaos and complexity theories are increasingly used in the natural sciences, business-cycle analysis, and economics. Applications in medicine and public health are in their early stages but are sparked by the need to develop models that reflect a more integrated, dynamic, multilevel understanding of human biology and population health.
Applications of System-Wide Models in Medicine and Public Health
Complex dynamic models have been used primarily in understanding infectious disease processes and patterns. Some analysts have applied chaos theory to the interpretation of electroencephalograms5 and heart function, where heart rate variability often shows fractal patterns, and loss of variability may predict the progression of cardiovascular disease.6,7,8 Obesity: The emergence of obesity as a major public health threat has led to the development of many models intended to explain why this has happened and help prioritize among possible interventions. Most people agree that the trends reflect combined effects of the interaction of multiple factors at many levels—genetic, metabolic, behavioral, psychological, social network-related, built environment-related, institutional, food system-related, and food policy-related. Environmental chemicals, called obesogens, are a relatively recent and potentially important addition to the list.9 The Foresight project in the U.K. developed a causal loop model that incorporates input and interactions among these multilevel factors.10 Although the graphic depiction of the com-
Continued on page 36 . . .
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The Black Plague was a major pestilence in the 14th century.
kill
Communication Failures more then 50,000 patients each year in the 21st century. *
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eVigils™ is compliant with HIPAA and the Joint Commission ruling on texting. * Institute of Medicine. “To err is human: building a safer health system.” Washington, DC: National Academy Press; 2000
© MITEM 2012 35 Corporation, San Francisco Medicine June 2012
Artwork copyright © 2012 Dan Harding www.sfms.org
Environmental Health
The Collaborative on Health and the Environment Consensus Statement Background The Collaborative on Health and the Environment (CHE) is a nationwide network of concerned people and organizations working together toward the shared goal of improving public and individual health. CHE partners include representatives of patient organizations, health professional and scientific societies, community organizations, environmental health advocates, funders, and indeed all those interested in working together to improve public and individual health. To that end, we begin with a statement on environmental hazards and human disease and disabilities, followed by the consensus statement that identifies the facts and principles upon which CHE partners agree.
The Problem: Human Diseases and Disabilities and Environmental Hazards
Chronic diseases and disabilities have reached epidemic proportions in the United States, affecting more than 100 million men, women, and children, which is more than one-third of our population. Asthma, autism, birth defects, cancers, developmental disabilities, diabetes, endometriosis, infertility, Parkinson’s disease, and other diseases and disabilities are causing increased suffering and concern. The human cost for families and communities is immeasurable, particularly those already disadvantaged by persistent economic disparities. The economic cost of these diseases exceeds $325 billion yearly in health care and lost productivity. Scientific evidence increasingly indicates a relationship between a range of environmental factors and these diseases and conditions. One important contributor may be increased exposure to the wide array of chemical substances that are used in modern industrial society, including diverse synthetic chemicals, compounds, metals, and related elements such as lead, mercury, and arsenic, as well as other pollutants in food, water, and air. Since World War II, more than 85,000 synthetic chemicals have been registered for use in the United States and another 2,000 are added each year, and few are adequately tested for their potential impacts on health. Other forms of pollution are increasing as well. These pollutants have become widespread in our air, water, soil, food, homes, schools, and workplaces, and thus also in our bodies. The sources of these exposures are manifold. They include pesticides, industrial chemicals, chemicals found in the home and workplace, personal care products, and pharmaceuticals to which people are widely exposed. Recognizing these links between chemicals and human effects, the Institute of Medicine emphasizes the importance to health of minimizing environmental exposures to “chemical and physical hazards in homes, communities, and workplaces through media such as contaminated water, soil, and air.” Low-income communities and communities of color ofwww.sfms.org
ten bear a disproportionate burden of health risks from such environmental contamination. In developing an inclusive network of people concerned with environmental health, we seek to address the need for more and better science, cooperation, and ultimately, health and equality.
Consensus Statement
1. The State of the Science The public believes what scientists have long known: that environmental factors are important contributors to disease and developmental disabilities. The understanding of risk varies widely among individual toxicants and diseases. The developing human fetus appears to be uniquely at risk of harm from environmental toxicants, and such damage can be profound and permanent. Although some linkages are well established and knowledge about others is emerging, more research is needed regarding the mechanisms, levels, and types of exposures that can adversely affect health. Research must include the study of interactions among chemicals and longitudinal studies examining links between early developmental exposures and health challenges much later in life, in order to determine what might be making us sick and how to prevent future illnesses.
2. The Need for a Heightened Public Health Response
Many cases of some diseases and developmental disabilities could likely be prevented if exposure to contributory environmental factors before and after birth were lessened or eliminated. Some strategies for prevention are well known, but more resources need to be devoted to prevention research and practice than is currently the case. Better epidemiological tracking of chronic diseases and developmental disabilities is needed. More detailed and widespread monitoring of human exposure to toxicants is vital. This should include health tracking of conditions, including disease surveillance, biomonitoring to inform individuals and health care professionals regarding the extent of actual “body burdens” of known and suspected toxicants, and rapid response epidemiology where indicated. Innovative, scientifically reliable methods are needed to study communities with clusters of diseases versus unaffected populations. Where the weight of plausible scientific evidence shows that contaminants are likely to contribute to increased disease, exposures should be reduced or eliminated. Good, uncompromised science must be the underpinning of all such efforts.
Continued on the following page . . . June 2012 San Francisco Medicine
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Consensus Statement Continued from previous page . . .
3. The Importance of a Precautionary Approach The precautionary principle should become a guiding factor in public health and environmental policy. The precautionary principle indicates that, when there is plausible scientific evidence of significant harm from a proposed or ongoing activity, preventive or corrective action should be taken to reduce or eliminate that risk of harm, despite residual scientific uncertainty about cause and effect relationships. Implementing the precautionary principle requires assessment of how to accomplish desired goals, looking for the safest alternatives, democratic participation, and reversal of the burden of proof. That is, the proponent of an activity bears the burden of assessing its safety and of showing that it is both necessary and the least harmful alternative. Decisions affecting public and environmental health should be fully participatory.
4. The Need for New Models of Collaboration in Environmental Health
Efforts in environmental health have too often been fragmented. Medical, patient, public health, and environmental groups and others sharing some convictions too often have not worked together toward common goals. Our emerging realization of the scale of the problem, and the growing body of scientific information linking plausible cause with effect, encourages a commensurate response. A new emphasis on a diverse and inclusive collaboration is essential to successfully reducing public exposure to environmental toxicants and helping to implement preventive strategies. Established researchers and health-affected (or patient/client) groups can collaborate in conducting important new research. Medical organizations can also work with health-affected groups toward better approaches to treatment, services, or interventions. Organizations that are engaged in the issues of environmental justice, poverty, civil rights, and human rights must be represented and work together as equal partners. Everyone concerned—health-affected groups, scientists, health professionals, and environmental organizations—can serve as resources for each other in collaborations such as these that will help reduce public exposure to environmental toxicants and contribute significantly toward creating a healthier society. This original consensus statement was drafted and approved when CHE was founded in 2002. While we might update some items therein, since over 4,000 CHE partners have signed on to this version, we reprint it here. This and a vast array of other related material may be found on CHE’s homepage, http://www.healthandenvironment.org.
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Ecological Health Continued from page 33. . . plete model appears at first glance to be so complex as to be nearly uninterpretable, closer study suggests a number of practical applications.11 Once the general architecture of the model is grasped, the universe of relevant variables becomes more apparent. The model helps to communicate the systemic nature of the problem and highlights the need for changing the general dynamics of the system to achieve population-wide benefits. This kind of model can also help in prioritizing where to intervene most effectively—for example, in feedback loops, at leverage points, and upstream in causal cascades—and help guide research strategies. The model can also be refined as new data become available. Cancer: Early applications of chaos theory in cancer biology are intriguing.12 One model proposes that malignant transformation and loss of control of cellular proliferation occurs just beyond the edge of chaos, where a biological system escapes from self-organization and orderly complexity to conditions of disorderly complexity.13,14 A recently developed causal-web model for post-menopausal breast cancer incorporates physical/chemical, biologic, behavioral, societal, and cultural dimensions.15 When fully functional, the model will help to prioritize research strategies, including cross-disciplinary collaboration, and may help in predicting the outcome of proposed interventions.
Summary
New models, influenced by recent developments in systems science, can help clarify the origins of complex diseases, guide research, and prioritize interventions. These models recognize that interaction is fundamental to processes involving multiple events, and the nature of interactions may change over a life course. Although there will always be the temptation to apply these models to individuals, they are based largely on data from populations and are most applicable to population health. The complexity of these models makes clear that disease prevention will require acting with less than certainty about the magnitude of impacts of particular interventions. Nonetheless, basic principles can guide efforts to change system dynamics favorably. For example: (1) intervene early and upstream in causal cascades, (2) design interventions to interrupt detrimental feedback loops and reinforce those that are beneficial, (3) look for leverage points, where interventions are likely to have multiple benefits, (4) recognize the potential for combined interventions to change the dynamics of the entire system. Biologist René Dubos famously said, “It is seldom recognized . . . that each type of society has diseases peculiar to itself— indeed, that each civilization creates its own diseases.”16 New complexity models can help illuminate the ways we do that and choices among the paths ahead. Ted Schettler, MD, MPH, is science director at the Science and Environmental Health Network. A full list of references is available online at http://bit.ly/JfSTIS.
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HOSPITAL NEWS KAISER
Veteran’s
CPMC
Robert Mithun, MD
Diana Nicoll, MD, PhD, MPA
Michael Rokeach, MD
In 1963, author and environmental crusader Rachel Carson spoke to Kaiser Permanente physicians at the San Francisco Medical Center in one of her last public speeches. Author of the seminal environmental book Silent Spring, Carson warned the physicians about the dangers of a compromised environment and its deleterious effects on human health. The physicians, and Kaiser Permanente as an organization, took note. Today, Kaiser Permanente emphasizes the importance of a healthy environment in maintaining the overall health of its patients and the larger community. For example, the organization has stringent purchasing policies regarding chemicals and construction materials, as well as institutional recycling and composting programs. Through our waste-minimization program, Kaiser Permanente San Francisco diverted 42 percent of its waste from landfills in 2011 alone. Other green programs include weekly farmers’ market at every Kaiser Permanente facility in the Bay Area and locally sourced food from regional farms for hospital meals. In 2011, Kaiser Permanente San Francisco earned the U.S. Environmental Protection Agency’s Energy Star certification, which signifies high standards of energy efficiency in hospitals. In San Francisco, our local Green Team is active in promoting sustainable practices throughout the medical center and in coordinating awareness events, such as Earth Day celebrations and recycling campaigns. Additionally, the team and volunteers have planted mature trees around the campus and surrounding neighborhoods. Understanding the crucial link between a healthy environment and total health is essential to maintaining well-being, now and in the future. Working through a national initiative with dozens of local efforts, Kaiser Permanente is making a significant environmental impact by leaving as small a footprint as possible.
San Francisco VA Medical Center (SFVAMC) is one of five centers in the United States selected as a Center of Excellence in Primary Care Education to engage trainees in a new model of care called patient-aligned care teams (PACT). The SFVAMC has created an educational program called EdPACT (Education in Patient-Aligned Care Teams). Highly motivated primary care residents, internal medicine residents, nurse practitioner students, and associated health trainees work collaboratively to provide care for veterans. The purpose of EdPACT is to transform clinical education by preparing graduates of health professional programs to work in and lead patient-centered, interprofessional teams that provide coordinated care. Another EdPACT goal is to reverse a trend toward future primary care provider shortages. In the past ten years, there has been a notable decline in the number of medical students choosing primary care as a career path. Reasons cited were job overload and less compensation than specialists receive. It is hoped that teaching this teambased approach will result in a more successful, satisfying experience such that trainees can imagine themselves choosing primary care for a career. EdPACT is supported by a five-year, $1 million/year grant from the VA. We hope that at the end of these five years, residency programs nationwide will teach the PACT model of patient care. So far the SFVAMC, which partners with the Schools of Medicine and Nursing and the Graduate Medical Education Office at the University of California San Francisco, is experiencing positive results from the PACT approach. Staff have reported numerous positive comments from patients indicating that they’re amenable to having a team of medical professionals assigned to their care. SFVAMC’s EdPact program codirectors are Rebecca Shunk, MD, and Susan Janson, RN, ANP, DNSc.
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Surgeons at the renowned Buncke Clinic at California Pacific Medical Center have successfully reattached the forehead and scalp of a twenty-two-year-old Stockton woman whose hair was caught in machinery at her workplace. This type of surgery is extremely rare and has been successfully performed only a handful of times worldwide. The woman was flown by helicopter to CPMC, where Buncke Clinic surgeons performed the seven-hour surgery using special microsurgery techniques. Microsurgery is a surgical technique that allows the surgeon to repair small nerves and blood vessels with sutures thinner than human hair. “By repairing six blood vessels with the microscope as an aid, we were able to successfully restore the blood supply and replant the completely amputated forehead and scalp,” said Drs. Brian Parrett and Bauback Safa, lead surgeons on the procedure. “The patient’s scalp hair began to grow back within days after the surgery, and she was able to go home after just one week.” The procedure performed is one of very few known surgeries of its kind. Dr. Eric Denys, associate clinical professor at UCSF, is the 2011 winner of the Charlotte Baer Memorial Award for Excellence in Teaching. The award recognizes clinical faculty contributions to the School of Medicine and is named for UCSF clinical faculty member Dr. Charlotte Baer, who died in 1973. Dr. Denys is an outstanding educator who has taught residents and students for more than twenty years. Students have given him high marks for the clarity of his teaching and the utility of time spent under his preceptorship. Dr. Denys has worked in a variety of capacities at CPMC, including director of Education and Training in the Department of Neurosciences, director of the EMG Laboratory, and director of the Institute for Neurological Sciences at the Medical Research Institute.
June 2012 San Francisco Medicine
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HOSPITAL NEWS St. Mary’s
Saint Francis
Francis Charlton, MD
Patricia Galamba, MD
Health care delivery systems of the future (ACOs, or Accountable Care Organizations) will probably look nothing like what we have today. Financial as well as quality-ofcare issues demand that we restructure both our facilities and our relationships with them. Outpatient care is certain to become the standard for more and more of the conditions we currently treat in the acute hospital setting. Inpatient lengths of stay have decreased almost beyond belief for many conditions and procedures. Medical device design and designer antiplatelet drugs are responsible for much of this. When Dr. Richard Myler performed the first percutaneous coronary balloon angioplasty in the U.S. at St. Mary’s more than thirty years ago, who knew how many patients would today have their coronary arteries stented as outpatients? Total joint replacements (hip, knee, and shoulder) can be performed with prostheses and techniques developed by our own St. Mary’s-trained orthopedic surgeons, enabling patients to go home on post-op day one or two. Spinal decompression surgery for spinal stenosis is now treated worldwide with the X-Stop, likewise a creation of our spine surgeons, as an outpatient procedure. Laparoscopic techniques are being used for an ever-expanding array of surgical conditions. In fact, endoscopies into myriad body compartments open up a whole new world of less-invasive ways to perform surgery and have the patient go home the same day. Our challenge will lie in how well we are able to take care of all of these outpatients with medical and surgical conditions once they’re no longer under our watchful eye in the hospital. Oral antibiotics and anticoagulants may take the place of IV forms, but nothing can take the place of a face-to-face patient encounter. Again, I envision house calls or, for the tech-savvy and gifted, video conferences.
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There’s no better day to tackle this column than by acknowledging April 22, Earth Day. Earlier this week Saint Francis hosted a “Get Green with Earth Day” event for employees, physicians, and visitors. The hospital has taken a progressive stance on recycling and composting. Saint Francis is doing its part in saving the planet, reducing landfill and keeping costs down at the same time. Our cafe has been recycling and composting for years, and we have now implemented similar initiatives in the kitchen. All oil is recycled; all the paper plates, soup cups, and so on are compostable. And all leftover food is picked up by Food Runners and delivered to soup kitchens such as St. Vincent de Paul and St. Anthony’s. We have contracted with Medline, a vendor that produces non-dye recyclable plastic containers for patient use, including emesis basins, water pitchers, etc. We no longer serve water in bottles but in pitchers. We use cleaning fluids that are the most environmentally friendly products on the market. We print only on recycled paper and we use only recycled toner cartridges. All cardboard boxes and containers are recycled. Patients leave our hospital with their belongings in reusable bags. Our new Surgical Department reprocesses OR items such as burs, bites, blades, and pulse oximeters, allowing us to reuse them multiple times. Our employees are encouraged to use public transportation and to carpool, and we provide an informal match service. If you bicycle to work, you get free parking in a secure area and there are showers and lockers for staff who need them. A recent mandate from the City and County of San Francisco requires us to benchmark our energy use. We hired a licensed engineer to review the last ten years of our energy use and air quality. The results showed that the hospital has reduced its energy use by 25 percent and that air quality and thermal loss are rated “very good.” Saint Francis won an Energy Star distinction!
San Francisco Medicine June 2012
UCSF Michael Gropper, MD
Over the past several years, we have seen a scientific revolution linking the environment to human health. Of course, all of us who work in health care have a mission-based interest in understanding the science linking environmental exposure to patient, employee, and community health. After all, the epidemic of diseases in which environmental factors play a role—obesity, cancer, asthma, diabetes, and others—continues to grow, as do the costs related to treating these conditions. But we in health care also have a special responsibility to address these issues because our environmental footprint has traditionally been so large. Representing nearly 20 percent of the economy, health care is among the largest users of toxic chemicals in the economy and is the second-most energy-intensive commercial building sector. U.S. hospitals also generate nearly six million tons of waste each year. In addition to having a negative effect on the general population, health care workers and patients are also affected. For example, nurses, who experience a variety of chemical exposures while on the job, have one of the highest adult asthma rates. For patients and health care workers alike, other environmental exposures occur through cleaning products, electronic emissions, radiological equipment, and many other sources. With the science linking low-dose exposure to a variety of conditions growing stronger each year, steps are being taken on an unprecedented scale to minimize the risks for everyone. A few examples of this effort at UCSF Medical Center include the goal of achieving year-2000 emission levels by 2014, and 1990 levels by 2020. We are also nearing our goal of 75 percent waste diversion this year, with zero waste by 2020. Also, while at 12 percent today, we plan for 20 percent of food at the medical center to be from sustainable sources by the end of the decade. We are also designing our new hospitals at Mission Bay—and continually redesigning our current facilities—to reduce energy costs, improve environmental health, and contribute to better patient outcomes and fewer medical errors. To learn more about our commitment to a healthy environment and a sustainable future, visit http://sustainability.ucsf.edu. www.sfms.org
A former employee sued me for wrongful termination.
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We Celebrate Excellence – Corey S. Maas, MD, FACS CAP Member and founder of “Books for Botox®” community outreach program, benefitting the libraries of local underfunded public schools
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