November 2014 by San Francisco Marin Medical Society

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

HUMAN HEALTH AND THE ENVIRONMENT Early Childhood Exposures

Cancers and Chemicals Climate Change and Your Health

Agriculture and the Microbiome

SFMS & CMA Lead Successful Campaigns to Defeat Props 45 & 46!

Plus: SFMS Career Fair

VOL.87 NO.9 November 2014

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IN THIS ISSUE

SAN FRANCISCO MEDICINE

November 2014 Volume 87, Number 9

Human Health and the Environment FEATURE ARTICLES

MONTHLY COLUMNS

10 The First 1,000 Days: A Healthy Return on Investment Elise Miller, MEd, and Ted Schettler, MD, MPH

Membership Matters

President’s Message Lawrence Cheung, MD, FAAD, FASDS

Exposure to Toxic Chemicals: Reproductive Health Professionals Speak about the First 1,000 Days Patrice Sutton, MPH; Tracey J. Woodruff, PhD, MPH; Jeanne A. Conry, MD, PhD; Linda C. Giudice, MD, PhD, MSc

15 Our Mixed Environment: Chemical Soup and Breast Cancer William Goodson III, MD 17 Herbicides Linked to Cancer: A Very Mixed Blessing from Modern Agriculture Jeff Ritterman, MD 20 A New Era: Climate Change and Human Health Ross Bowling, PhD; Nyron Rouse; John Balbus, MD, MPH

22 Climate Action and Health: The New Deal for Our Health and Our Children’s Health Génon K. Jensen and Peter van den Hazel, MD, MPH, PhD 24 Fukushima and Fish: Responding to Concerns Regarding Radiation in California Steve Heilig, MPH 25 Meat and the Microbiome: From Farm to Fork to Gut David Wallinga, MD

27 A New Era for Environmental Health: 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 Web: www.sfms.org

Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH

29 Medical Community News 34 Classified Ad

OF INTEREST 31 Letter to the Editor: an Optimal Response to Ebola Phillip R. Lee, MD 32 SFMS Career Fair

Election: We did it!

SFMS and CMA have successfully led the campaign to defeat 2 onerous measures that would have negatively impacted health care. As of press time on election day, both Propositions 45 and 46 were going down to decisive defeats. Regarding Proposition 46, focus of the biggest political battle by organized medicine in our state in many years, the CMA noted “The secret weapon of this effort was the size and diversity of our coalition, one of the largest coalitions ever assembled to oppose a ballot measure. Labor, business, local government, health providers, community clinics, Planned Parenthood, ACLU, NAACP, taxpayers, teachers, firefighters—the list goes on and on. It underscores just how important an affordable, accessible health system is to every Californian.” This has truly been an example of how much stronger we are when we speak together with one voice to ensure that our patients continue to have access to quality patient care. On behalf of the SFMS and our board of directors, thank you for making these victories possible through your advocacy, contributions, and support through membership in organized medicine! Happy Holidays from the SFMS Board of Directors!

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

Pledge Your Commitment to Medicine and Renew Your Membership

SFDPH Ebola Health Advisory and Physician Resource Center

SFMS would like to thank our 1,600-plus members for your support of your local medical society this year. Because of your support and participation in organized medicine, SFMS continues to be the preeminent physician organization championing the cause of physicians and their patients as we face the many challenges of these changing times. Please take a moment to renew your support of SFMS by remitting payment for your 2015 dues today. There are three easy ways to renew your dues this year: • Mail/fax in your completed renewal form. • Renew online at sfms.org using your credit card. • Enroll in the Easy Pay (quarterly installments) Automatic Dues Renewal Plan by contacting SFMS at (415) 561-0850 or membership@sfms.org.

The Centers for Disease Control and Prevention (CDC) confirmed the first U.S. case of Ebola in September, and developments associated with the virus continue to unfold. The San Francisco Department of Public Health released an updated health advisory for clinicians on October 3, and the information can be found at http://bit.ly/1vFjeu0. The American Medical Association (AMA) has set up a resource center with resources developed by Ebola experts for patients and physicians. Tools include information about how to talk to patients about Ebola, screening and diagnosing guidelines, and preparing the hospital/physician practice for Ebola. Visit http://bit.ly/1w8Xs15 for additional details.

Soda Tax Press Conference Hosted by SFMS Spurs Media Coverage The proponents of the San Francisco and Berkeley proposed soda taxes—Propositions E and D respectively—hosted a joint press conference at the SFMS headquarters in early October. Facilitated by SFMS board member John Maa, MD, the event called attention to the $7.7 million the American beverage industry has spent in San Francisco to defeat Prop E. Other health professionals, community advocates, and elected representatives, including Supervisors Scott Wiener and Eric Mar, similarly denounced the enormous amount of money being spent to fight the measures, which will generate an estimated $54 million annually to fund local health programs. The event prompted media coverage from the New York Times, KQED, KTVU, KCBS, KGO, and several Chinese networks. A second press conference, featuring SFMS President Lawrence Cheung, MD, was held in Chinatown to highlight the negative health effects of sugary beverages on San Francisco’s Asian community as well as the public education programs to be funded to address these negative health effects. Proposition E has been endorsed by the San Francisco Medical Society and the California Medical Association to reduce the incidence of diabetes, obesity, and tooth decay. 4

SFDPH Health Advisory: Enterovirus-D68

Enterovirus D-68 has been confirmed in three San Francisco residents as of October 8, 2014. The San Francisco Department of Public Health released an updated health advisory for clinicians on October 27, and the information can be found at http://bit. ly/1tOTXzl. All the affected individuals were children under the age of 18. Two of them were admitted to hospitals for respiratory illness in mid-September and discharged in good condition. The third was hospitalized with limb paralysis and discharged in late September. The San Francisco Department of Public Health has not received reports of outbreaks or clusters of severe respiratory disease in children in San Francisco. Physicians are asked to follow the SFDPH health advisory on enterovirus-D68 and testing eligibility at http://bit.ly/1yrk4yY.

Save the Date: SFMS Annual Gala, January 30, 2015

Attend the biggest SFMS event of the year! Join the San Francisco Medical Society for our Annual Gala on January 30, 2015. Come together with many of San Francisco’s most influential stakeholders in the medical community to celebrate SFMS’s 147 years of physician advocacy and camaraderie. The 2015 Annual Gala will be held at the iconic Asian Art Museum of San Francisco. Guests will be treated to an exquisite reception with elegant hors d’oeuvres and libations. Roger Eng, MD, will be installed as the SFMS President. The event will kick off with a special lion dance performance by the internationally renowned Leung’s White Crane Martial Arts School. Invitations will be mailed out to all SFMS members in December. For more information, please contact Posi Lyon at (415) 561-0850 extension 260 or visit http://www.sfms.org/ Events/annualgala.aspx.

UCSF Soda Tax Panel

SFMS President Lawrence Cheung, MD, participated in a UCSF panel alongside Robert

SAN FRANCISCO MEDICINE NOVEMBER 2014 WWW.SFMS.ORG

Lustig, MD; Laura Schmidt, PhD, MSW, MPH; and Supervisor Scott Wiener to discuss public health advocacy. Panelists discussed Proposition E, from the research evidence on the health effects of sugar to the process of drafting the legislation to building support through advocacy. The event was well attended by UCSF medical students as well as the at-large community, including students from Mercy High.

CMS Extends Meaningful Use Hardship Exemption Application Deadline

CMS has reopened the application window for those who wish to avoid 2015 payment adjustments. Medicare providers who are noncompliant in attaining meaningful use and would like to request an exemption from planned Medicare payment adjustments in 2015 must complete and submit an application form by 11:59 p.m. EST November 30, 2014. In 2009, Congress mandated that payment adjustments be applied to Medicare-eligible professionals who are not meaningful users of Certified Electronic Health Record (EHR) Technology under the Medicare EHR Incentive Programs. These payment adjustments are set to be implemented on January 1, 2015, for Medicare-eligible professionals. Medicaid-eligible professionals who can only participate in the Medicaid EHR Incentive Program and do not bill Medicare are not subject to these payment adjustments. For more details about hardship exceptions and the corresponding application, please visit http://bit.ly/1q6rcH5.

SFMS Members Meet with Supervisor David Chiu

November 2014 Volume 87, Number 9 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD John Maa, MD Chunbo Cai, MD Payal Bhandari, MD David Pating, MD SFMS OFFICERS President Lawrence Cheung, MD President-Elect Roger S. Eng, MD Secretary Richard A. Podolin, MD Treasurer Man-Kit Leung, MD Immediate Past President Shannon UdovicConstant, MD

Local physicians joined SFMS President Lawrence Cheung, MD, and the Hospital Council of Northern and Central California for a reception benefiting San Francisco Supervisor David Chiu. Chiu is committed to protecting access to care for the patients of California and ensuring that our landmark Medical Injury Compensation Reform Act (MICRA) is not undermined through the legislative process. He has been an advocate of medicine, collaborating with the medical society on a variety of issues including the soda tax, e-cigarette regulation, and preserving access to care and health safety nets in San Francisco. Sponsored by the SFMS Political Action Committee, the event raised funds for Chiu’s candidacy for the California State Legislature to represent San Francisco’s 17th Assembly District.

SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Ariel Young

Covered California is expected to open its second enrollment period from November 15, 2014, to February 15, 2015. Officials are aiming to increase enrollment from 1.2 million to 1.7 million residents during this period. SFMS has developed a resource center at http://www.sfms.org/ForPhysicians/CoveredCalifornia.aspx to help educate physicians and practice managers on the exchange and to ensure that they are aware of important issues related to exchange plan contracting.

Term: Jan 2012-Dec 2014 Andrew F. Calman, MD Steven H. Fugaro, MD Brian Grady, MD John Maa, MD Todd A. May, MD Kimberly L. Newell, MD William T. Prey, MD

Covered California Launches Second Enrollment Period

BOARD OF DIRECTORS Term: Jan 2014-Dec 2016 William J. Black, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD

Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD

CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD

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NOVEMBER 2014 SAN FRANCISCO MEDICINE

THE SAN FRANCISCO MEDICAL SOCIETY REQUESTS

Gala THE PLEASURE OF YOUR COMPANY

SPECIAL LION DANCE PERFORMANCE BY THE INTERNATIONALLY RENOWNED LEUNG'S WHITE CRANE MARTIAL ARTS SCHOOL

Janua ry 30, 2015 • 6:30 PM - 9:00 PM Asia n Art Muse um of San Francisco Celebrate SFMS ’ 147 years of physician advocacy and camaraderie, as well as the installation of Roger Eng, MD as the 2015 SFMS President.

$90 per person with Early Bird registration (RSVP by 12/31/2014) $100 per person regular admission

Guests are treated to an exquisite reception with elegant hors d ’oeuvres, libations, and exclusive access to the Asian Art Museum’s second floor galleries.

200 Larkin St, San Francisco, CA 94102

For more information, go to www.sfms.org/Events/AnnualGala.aspx or contact SFMS at (415) 561-0850 x260

PRESIDENT’S MESSAGE Lawrence Cheung, MD, FAAD, FASDS

Ebola in the United States The first case of Ebola virus disease diagnosed in the United States occurred on September 28, 2014, in Dallas. This patient died on October 8, 2014, marking this as the first Ebola virus disease death on United States soil. Like many of you, I have been following the Ebola pandemic intently for the past several months. I knew that due to our increasingly global community, the appearance of Ebola in the United States was only a matter of time. Frankly, I am surprised that with our high volume of international travel, San Francisco was not the first place that Ebola touched down and that the first index case had not occurred any earlier in the United States. Fortunately the United States is not like Liberia, Sierra Leone, or Guinea. It is unlikely that we will experience a pandemic of Ebola because we have very strict infection disease control protocols and we have the resources to provide protective gear for health care workers, isolate suspected patients, and provide supportive care. Because Ebola is currently believed to be infectious only when a patient exhibits EVD symptoms, isolating suspected patients should effectively stem the spread of the disease. That being said, we now have confirmed spread of the disease to the patient’s two nurses in Dallas, and there has also been a confirmed spread of the disease to a nurse in Spain who also took care of an Ebola patient. There is also a case of a physician in New York City who was exposed and contracted the disease while working in West Africa. I hope that the spread of the disease in the U.S. and Spain will end with those heroic health care providers. We must all be vigilant in practicing universal precaution and be ready if and when Ebola arrives in San Francisco. The San Francisco Department of Public Health (SFDPH) Division of Communicable Disease Control and Prevention (CDCP) has an excellent website with information and resources on this topic at http://www.sfcdcp.com. I was informed by my SFDPH colleague that the Centers for Disease Control and Prevention (CDC) will be releasing outpatient guidance very shortly, and it will be available on their website: http://www.cdc.gov/vhf/ebola/index.html. In contrast, my concern about enterovirus-D68 (EV-D68) causing significant morbidity in San Francisco is much higher than my concern about Ebola. EV-D68 is classified as a nonpolio enterovirus, a family of virus that can cause respiratory, gastrointestinal, cutaneous, and, very rarely, neurologic diseases. Already there have been many cases of severe respiratory disease resulting in deaths caused by EV-D68. Most alarming to me, as a father of young children, are the number of cases in Colorado in which children with acute focal limb weakness have tested positive for EV-D68. These cases of paralysis have correlating lesions on MRI of the spinal cord and brain stem; the concern, of course, is that this paralysis could be permanent, WWW.SFMS.ORG

like that seen with polio virus. Unlike Ebola, EV-D68 has been confirmed to be here in San Francisco, so we must be prepared for it. There is a double irony in this situation. First, I am always humbled by nature in that, as physicians, we are in a perpetual arms race against virulent diseases. As soon as we develop a stronger antibiotic, the virulent organism develops resistance to it and we are back to square one. The only chance that we have would be eradication, and that brings me to my second point. Eradication is possible only with vaccination, and we are admittedly victims of our own success. Vaccinations against other life-threatening diseases, such as small pox, have been so successful that we are now officially eradicated of these diseases. As a society, we have succumbed to our cozy assurances that we will no longer be afflicted by these scourges. In California, the rate of vaccine refusal has been increasing because people feel that these diseases are no longer a threat. Diseases that I have only read about and seen old Kodachrome images of, such as measles, are making a comeback in California because of pockets of population with high rates of vaccine refusals. With every challenge, I see an opportunity, and in the cases of Ebola and EV-D68 this is no different. As physicians, we must use these hot topics to educate our patients about the nature of infectious diseases and the role of infection control in modern medicine. We need to promote concepts of general hygiene, such as appropriate hand washing, guidelines for the use of antibiotics, and the effective role of vaccinations as means of eradicating dangerous diseases from our society.

EBOLA HOTLINE

The California Department of Public Health has established an Ebola hotline call center to respond to public inquiries related to Ebola announced by Dr. Ron Chapman, CDPH director and state health officer. “This hotline has been set up and staffed to answer questions from those concerned about the possibility of Ebola in California,” said Chapman. The hotline, (855) 421-5921 will be in operation from 8:00 a.m. to 5:00 p.m. Monday through Friday.

NOVEMBER 2014 SAN FRANCISCO MEDICINE

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EDITORIAL Gordon Fung, MD, PhD, and Steve Heilig, MPH

Our Environment Is Us The “environmental movement” first arose mostly out of concern for things other than ourselves—animals, fish, air, water, land, forests, and so forth. Even Rachel Carson’s landmark 1962 book Silent Spring focused on the impact of pesticides on nonhuman creatures. Gradually, however, concerns about the effects of pollution, crowding, and more on humans became important topics of research and debate. After all, we all depend on clean water, food, and air, and most of us want to have some contact with unspoiled natural settings when we can. A dozen years ago, a notable event occurred at the SFMS: a national conference on human environmental health, wherein a new network called the Collaborative on Health and the Environment (CHE) was launched. Arising from the conviction that many professionals and patients have growing concerns about environmental degradation and human health but did not often communicate about their work, the CHE brings together clinicians, researchers, policymakers, patients, environmental advocates, and others to learn about and work together on important projects and issues. Beginning with a couple of large conferences at UCSF, CHE now has well over 4,000 partners, linked via an active online presence. CHE partners endorse a consensus statement—printed in this issue—and then choose how much they wish to be involved together. Every two years, San Francisco Medicine presents updates from the CHE partnership, and this is our sixth such edition. Our authors show a sample of what the many CHE partners are doing in research, clinical work, public health advocacy, and much more. For this edition, we decided to focus at least partly on early exposure, in utero and in early childhood, to environmental influences—especially the industrial chemicals that, research has confirmed, are in all of us at varying levels and to varying degrees of concern. The introductory piece by Elise Miller and Ted Schettler, two of CHE’s founding figures, sets the scene, noting that much of what happens in our earliest months has lasting influence on our health. Following logically on that note, leading reproductive health figures from UCSF and beyond explore groundbreaking work by specialty groups such as ACOG and the American Society of Reproductive Medicine to address environmental concerns. SFMS Past President and prominent breast cancer specialist and researcher William Goodson explores environmental connections in his specialty. Jeff Ritterman outlines an impassioned plea for less harmful use of the agricultural chemicals that have become so widespread in modern food production. Two articles then address the sweeping issue of climate change and how it impacts our health, from American and European perspectives. David Wallinga, touching on the microbiome theme of our SepWWW.SFMS.ORG

tember issue, links the modern mass production of meat with untoward influences on our flora and health.  One recent meta-analysis of case studies of a specific industrial chemical revealed an average fourteen-year period between concern and action—action as in regulation or other means of lessening human exposure and known or potential harm. This of course means that people are exposed for extended periods, including throughout some entire lifetimes. Tens of thousands of chemicals are in use; many have been shown to have demonstrable negative impact on health, and many more are reasonably suspected. But given the sheer number of industrial chemicals now in use in our modern economy, with more added daily, it is unlikely that all or even most will ever be fully evaluated and regulated. The piecemeal research and regulation of chemicals continues, like an uphill, endless race. In the meantime, the struggle to institute some more rational “do no harm” approach, often called a “precautionary” one analogous to that of the Food and Drug Administration’s role with pharmaceuticals, continues. Unfortunately, this effort is often as political as it is scientific. We thus salute those scientists, researchers, and others who lend their expertise and credibility to ongoing efforts to institute sane, health-supporting environmental policies. And in that respect, we cannot close here without mention of and tribute to two veteran physicians who have led in this realm: UCSF Chancellor Emeritus Philip Lee, MD, (pictured right) who chaired the first meeting of CHE at the SFMS and then CHE itself; and the late Edgar Wayburn, MD, (pictured left, at a young age) a president of both the SFMS and the Sierra Club, whose legacy one can witness any time from the Golden Gate Bridge—miles of unspoiled, beautiful coast. Now there’s some proof that precaution can work very well.

NOVEMBER 2014 SAN FRANCISCO MEDICINE

Human Health and the Environment

THE FIRST 1,000 DAYS A Healthy Return on Investment Elise Miller, MEd, and Ted Schettler, MD, MPH A vital and productive society with a prosperous and sustainable future is built on a foundation of healthy child development. Health in the earliest years—beginning with the future mother’s well-being before she becomes pregnant—lays the groundwork for a lifetime of vitality. . . . Sound health also provides a foundation for the construction of sturdy brain architecture and the achievement of a broad range of skills and learning capacities. —Harvard Center for Early Childhood Development

The Significance of Early Childhood for Lifelong Health Upward trends in a number of childhood diseases and disabilities are featured almost daily in the media. As many as one in six children in the U.S. has a neurodevelopmental disability, including autism, ADHD, and speech or cognitive delays. The number of children needing special education has increased by 200 percent from a quarter century ago. The incidence of childhood leukemia and brain cancer is also on the rise, and asthma is still the number-one reason for school absenteeism among children. Meanwhile, we have been learning a great deal more about how children’s earliest experiences, beginning in utero, can significantly influence their lifelong health. Many studies show that “toxic stress”—intense, sustained adverse experiences—in childhood increases the risk of many health and behavioral problems in the short and long term, including intellectual delays, obesity, diabetes, and heart disease. This evidence has in turn prompted a surge of programs that provide support for new mothers and improved childcare, such as Zero to Three and Early Head Start. Other environmental influences on fetal development, starting even before conception, can of course be critical for lifelong health as well. Initiatives like the Program for Women, Infants, and Children (WIC) take this into consideration with their emphasis on healthy nutrition before, after, and during pregnancy. Efforts to address other social stressors, such as poverty and violence, are also included in some maternal health programs in different health care systems as well as at local, county, and state levels across the country. Various biologic mechanisms mediate the influence of environmental variables on child development, including genetic and epigenetic changes, altered molecular signaling patterns, and influences on hormonal and metabolic set points, which can lead to disturbances of organ structure and function over varying time frames. 10

Another Highly Influential Factor: Chemical Exposures in Early Life In addition to excessive stress and inadequate nutrition, a large and growing body of research shows that the developmental effects of pre- and postnatal exposures to toxic chemicals— now ubiquitous in air, water, food, soil, and consumer products—must also be considered. Most chemicals circulating in maternal blood can and do pass through the placenta and can adversely impact the developing fetus. Lead, alcohol, mercury, some pesticides, and flame retardants are among the best known, but in its Proposition 65 program, California lists 652 chemicals as reproductive/developmental toxicants. Biomonitoring programs, such as the CDC’s NHANES, show how commonly the general population is exposed to chemicals that can interfere with normal development, with lifelong health consequences. Chemicals that can adversely affect human development may also act additively or synergistically with “toxic stress” or inadequate nutrition to magnify adverse effects. In fact, emerging evidence suggests that, on a physiological level, some biomarkers—the molecular or cellular events that link a specific environmental exposure to a health outcome— for social stressors are similar to those for toxic chemicals. (A forthcoming e-Book, A Story of Health, uses narrative case studies on specific health endpoints to examine the complexity of interacting contributors to chronic disease and disability. See insert in this issue.) This means that in addition to supporting programs that address social determinants of health, nutrition, and exercise, we also need significant investment in further research on other environmental agents that may impair normal child development, as well as efforts to reduce exposures to harmful contaminants, beginning before conception and continuing throughout pregnancy, infancy, and childhood.

Chemical Exposures and Brain Development: The Emerging Science

One of the most robust and rapidly developing areas of research probes the impact of environmental chemicals and contaminants on brain development. Given that deficits in IQ and other neurological functions can undermine the ability of a person to learn, be employed, and contribute to society generally, healthy brain development is of utmost importance for a healthy society and a competitive economy. Exposures to certain chemicals during critical phases of rapid brain growth, starting not long after conception and continuing through early childhood, can interfere with how the brain forms and functions later in life.1 For example, lead and mercury

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have been well studied and are strongly associated with adverse neurological outcomes, such as ADHD, learning and intellectual disabilities, loss of IQ, and behavioral problems. Some pesticides, flame retardants, and arsenic are consistently linked to adverse impacts on brain development as well and, like lead and mercury, meet the scientific criteria for a causal relationship for even the most conservative analysts.2 Newer studies find similar associations with air pollutants and other chemicals to which we are commonly exposed.3

What Are the Economic Implications?

With so much national attention on the exorbitant costs of health care, anything that we can do to stem the upward trend in various childhood disabilities and diseases should warrant concerted effort and investment. Nobel Prize-winning economist James Heckman has been recognized for his seminal research showing that the quality of early childhood development has strong correlations with the health, economic, and social outcomes for both individuals and society as a whole. Particularly noting the significance of IQ, Heckman emphasizes that investing in early childhood is well worth every dollar, given the economic gains to be realized later in life.4 Yet we often fail to include this observation even in decision making based on costbenefit analyses, and we rarely consider the adverse impacts of environmental chemical exposures. Individuals, families, and communities are left to deal with them. By conservative estimates, the environmentally attributable fraction of annual costs related to a range of pediatric diseases and disabilities in the U.S., including lead poisoning, intellectual disability, asthma, and cancer, is approximately $76.6 billion in direct and indirect expenses. Notably, loss of IQ from exposure to neurotoxic chemicals, like lead, reduces lifetime economic productivity and accounts for a significant proportion of these costs.5 In another study, the annual cost to the U.S. economy of children with ADHD alone was estimated at $21–$44 billion. Some portion of this is attributable to environmental factors, including neurotoxic chemicals that increase the risk of ADHD.6 Since most harmful environmental exposures are preventable—and arguably easier to mitigate than some particularly pervasive, complex social problems like poverty—we have the potential to significantly reduce health care costs as well as mitigate lost wages and productivity associated with lifelong neurological deficits. Coupled with the social and emotional burdens that these disabilities and diseases often place on individuals, their families, and their communities, we clearly have a great deal to gain by including and prioritizing environmental health in our collective efforts to promote healthy child development.

Tipping the Scale toward Health and Resiliency

The good news is that although many interacting factors influence child development, starting even before conception, anything we can do to tip the scale toward health and resiliency will only improve the capacity of children to reach their fullest potential. Exposures to harmful environmental chemicals and contaminants are preventable, as are reductions in toxic stress and poor nutrition. Broad and diversified efforts addressing each of these areas will help confront the systemic nature of the challenge. None is exempt. Strategic interventions at key leverage points within this complex mix of variables during the WWW.SFMS.ORG

earliest days of child development can shift the prospects for lifetime health for the entire population or groups of people at particular risk. With concerted investment and strategic action, we can improve our children’s prospects of achieving the bright futures they deserve—and the future we would be proud to call our legacy. Elise Miller, MEd, is director of the Collaborative on Health and the Environment (CHE) and has more than twenty years of experience working with researchers and health professionals to address environmental health issues. Ted Schettler, MD, is science director at CHE and of the Science and Environmental Health Network. A full list of references is available online at www.sfms.org.

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Calls to Ban Toxic Chemicals Fall on Deaf Ears Around the World Endocrine-disrupting chemicals are everywhere, found in cosmetics, preservatives, medicines and countless household products such as shampoos and toothpaste, which are used every day by billions of people across the world. Some, such as the pesticide DDT and the “anti-miscarriage” medication DES, were banned years ago, leaving a legacy of health and environmental problems in their wake. Many others are still in use, though exactly how many no one knows. The full story is here: http:// www.newsweek.com/2014/11/07/calls-ban-toxic-chemicalsfall-deaf-ears-worldwide-280697.html

S.F. Medicine 02-20-14

NOVEMBER 2014 SAN FRANCISCO MEDICINE

Human Health and the Environment

EXPOSURE TO TOXIC CHEMICALS Reproductive Health Professionals Speak about the First 1,000 Days Patrice Sutton, MPH; Tracey J. Woodruff, PhD, MPH; Jeanne A. Conry, MD, PhD; Linda C. Giudice, MD, PhD, MSc Human exposure to toxic environmental chemicals during the first 1,000 days after conception is ubiquitous. In 2012, there were 9.5 trillion pounds of in-

dustrial chemicals domestically manufactured and imported in the U.S.—equal to more than 30,000 pounds for every person. Every day, pregnant women and children are exposed to toxic chemicals in our air, water, food, and consumer products. Virtually every pregnant woman in the U.S. has at least forty-three toxic chemicals in her body. While the size of this chemical mixture in pregnant women is daunting, this number is likely the tip of the iceberg. We have the technical capacity to measure only about 10 percent of the 3,000 high-production-volume chemicals in the U.S. Exposure to toxic environmental chemicals before and during pregnancy can have harmful health impacts on the infant, child, adult, and future generations. For example, many of the chemicals in pregnant women and children disrupt the endocrine system. A 2013 report by the World Health Organization documented that many endocrine-related diseases and disorders are on the rise, such as low semen quality, genital malformations, preterm birth and low birth weight, neurobehavioral disorders associated with thyroid disruption, endocrine-related cancers, early onset of breast development in young girls, and type II diabetes.1 The time frame in which these adverse health trends have occurred is inconsistent with the time it takes for changes in the human genome and points to the environment as the primary culprit. Thus, modifying our environment in support of human health could generate significant health benefits for the pregnancy, the child, the adult, and future generations.

Reproductive Health Professional Societies Respond to the Science

In recognition of this opportunity to advance health, in 2013, the American Congress of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM) issued a groundbreaking Joint Committee Opinion on Toxic Environmental Agents.2,3 The ACOG/ASRM Opinion describes how toxic chemicals in the environment harm our ability to reproduce, negatively affect pregnancies, and are associated with numerous other long-term health problems. The Opinion speaks to the impact of first 1,000 days on health across the lifespan of individuals, stating, “An important outcome of pregnancy is no longer just a healthy newborn but a human being optimally programmed for health from infancy through old age.” While all patient populations are exposed to toxic environmental chemicals, the ACOG/ASRM Committee Opinion underscores the fact that some groups are more vulnerable than others. For example, minority populations not only tend to live 12

where toxic exposures are higher but they also often live in poverty and are subject to racism, psychosocial stress, poor nutrition, and other factors that exacerbate the impacts of their exposures. Women and men exposed to chemicals at work are also at increased risk of harm. The ACOG/ASRM Opinion has made the prevention of patient exposure to toxic environmental chemicals a legitimate area of practice for reproductive health professionals in the clinical setting and in policy arenas. Specifically, ACOG and ASRM recommend that physicians do the following:

Learn about toxic environmental agents common in the community. Educate patients on how to avoid toxic environmental agents.

Record environmental exposure histories during preconception and first prenatal visits.

Report identified environmental hazards to appropriate agencies. Encourage pregnant and breastfeeding women and women in

the preconception period to eat carefully washed fresh fruits and vegetables and avoid fish containing high levels of methyl-mercury (shark, swordfish, king mackerel, tilefish).

Advance policies and practices that support a healthy food system.

Advocate for government policy changes to identify and reduce exposure to toxic environmental agents.

Many resources to support these recommendations, such as links to environmental health history forms, patient educational materials, journal articles, and other reference materials are available at the UCSF Program on Reproductive Health and the Environment website: http://prhe.ucsf.edu/prhe/clinical_ practice.html. What is happening on the ground? A recent survey about what practicing U.S. obstetricians think, know, say, and do about toxic chemicals found that while most obstetricians are concerned about the impacts of the environment on pregnant women, most do not routinely discuss environmental exposures as part of prenatal care.4 The study identified many systemic impediments to obstetricians and patients acting on their own to address environmental exposures, including but not limited to the affordability, availability, and reliability of safer alternatives to toxic environmental chemicals; the inadequacy of workplace protections to prevent harmful exposures and protect against discrimination; and the ubiquitous nature of environmental

SAN FRANCISCO MEDICINE NOVEMBER 2014 WWW.SFMS.ORG

chemicals. The study authors recommend medical education and training, evidence-based guidelines, and tools for communicating risks to patients to support the clinical role in preventing harmful environmental exposures. The research also underscores the fundamental need for societal-wide solutions in support of the first 1,000 days.

Prevention for All

The ACOG/ASRM Opinion promotes an all-encompassing view of prevention, noting that “recognition of environmental disparities is essential for developing and implementing successful and efficient strategies for prevention.” This means looking upstream for societal-wide prevention strategies that will not simply reduce exposures in one population by pushing them onto another population—or future generations. As many environmental exposures are not actionable by individuals alone, i.e., air and water pollution, ACOG and ASRM recommend that health professionals also advocate for government policy changes to identify and reduce exposure to toxic environmental agents. A foundational societal-wide need is chemical policy reform. In the U.S., due to deficiencies in our current regulatory framework governing manufactured chemicals, population exposure to exogenous chemicals typically occurs before regulatory scrutiny of a compound and in the absence of risk-benefit analysis. In her article “When Environmental Chemicals Act Like Uncontrolled Medicine,” Dr. Linda Birnbaum, director of the National Institute of Environmental Health Sciences, described the quandary this policy gap presents for health providers: “Physicians who disregard medicines delivered to a patient may be disciplined for inadequately obtaining a sufficiently detailed patient history, but there is no consequence for medical professionals who ignore the delivery of endocrine-disrupting chemicals into the environment, other than a shocking increase in disease. Unlike medicines, which must undergo strict scrutiny by the U.S. Food and Drug Administration, where health benefits are weighed against side effects, environmental chemicals are not required to be tested for side effects and potential hazards prior to their commercial use.5” Efforts are now underway to reform the Toxic Substances Control Act (TSCA), the law that governs the regulation of manufactured chemicals in the United States. ACOG and ASRM, along with the American Academy of Pediatrics and the Society for Maternal and Fetal Medicine, have expressed their views on the need for chemical policy reform to Congress. One of the most important reforms needed is to shift the burden of proof about a chemical’s safety or toxicity to the manufacturers before a chemical can be released into the environment, comparable to the burden of proof that pharmaceutical manufacturers shoulder. Reform must also specifically protect vulnerable and underserved populations, including pregnant women, infants, and children, from aggregate exposure to harmful chemicals, and it must adopt a safety standard based on health considerations only. Effective reform will require deadlines and timetables to ensure implementation.

Evidence-Based Decision Making

Acting on the science linking environmental chemicals to adverse health outcomes requires a road map to transparently and efficiently assess the strength of the evidence about a chemiWWW.SFMS.ORG

cal’s toxicity—or lack of toxicity. Clinicians need to be able to respond to their patients’ questions and industry needs to know whether replacement chemicals are truly less toxic. In the clinical sciences, i.e., the Cochrane Collaboration and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group, methods of research synthesis have been developed over the past decades and serve as an underpinning to evidence-based medicine. Until recently, similar systematic and transparent approaches to evidence integration in environmental health sciences have been lacking. Beginning in 2009, UCSF scientists addressed this gap by undertaking a collaborative process that developed the Navigation Guide systematic review method, a robust method to synthesize existing knowledge on the environmental drivers of health to make the science actionable. Just this month, proof of concept of the Navigation Guide method was published in four papers in Environmental Health Perspectives6-9. In this first case study, the researchers found that developmental exposure to perfluorinated ocatanoic acid (PFOA)—a chemical that confers grease- and water-resistance to consumer goods and food packaging and is found in virtually everyone in the U.S.—reduces fetal growth; the researchers concluded that “developmental exposure to PFOA adversely affects human health.” The provision of a clear, concise, and transparently derived conclusion about a chemical’s toxicity by government agencies and guidelines developers will provide health professionals with an evidence-based bottom line for their decision making. While this is a crucial first step, ultimately, practicing clinicians need guidance on what to say to and share with their patients. To this end, in 2015 researchers at UCSF hope to begin development of step 4 of the Navigation Guide method, grading recommendations for prevention. Such evidence-based guidelines will incorporate patient values and preferences, the availability of safer alternatives, and other relevant issues into grading the final recommendation.

Summary

Reproductive health professionals are uniquely poised to play a critical role in the first 1,000 days after conception by serving as trusted sources of scientific information for their patients and health care institutions and by lending their authoritative voices to efforts to improve policy. Engagement by reproductive and other health professionals in preventing exposure to toxic environmental chemicals is a fruitful pathway to securing a healthy 1,000 days and thus reaping the intergenerational benefits of a healthy start in life.

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 professor and director, University of California, San Francisco, Program on Reproductive Health and the Environment. Jeanne A. Conry, MD, PhD, is immediate past president, American College of Obstetricians and Gynecologists. Linda C. Giudice, MD, PhD, MSc, is immediate past president, American Society for Reproductive Medicine. A full list of references is available online at www.sfms.org.

NOVEMBER 2014 SAN FRANCISCO MEDICINE

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Human Health and the Environment

OUR MIXED ENVIRONMENT Chemical Soup and Breast Cancer William Goodson III, MD Breast cancer takes a great toll in stress, medical care, and human life, so there is a great need to determine why there is more breast cancer now than when most of us were born. The answer to this question

involves many issues: 1. Is there really more cancer? 2. Is the cancer caused by changes in our environment? 3. What is the definition of the environment? 4. Are chemicals a functional part of our environment? 5. How are we actually exposed to environmental factors? The answers to these questions are the basis to plan for the future of each of us, our children, and our grandchildren.

Is There More Breast Cancer?

The age-adjusted number of invasive breast cancers per year in the United States has hovered at an average of 127 cases/100,000 women per year for the last six years (with 129/100,000 in 2011 being the last number for which data is available). This is a drop from the peak 141/100,000 in 1999, but significantly higher than 105/100,000 in 1975, the baseline for most SEER data. After the publication of the Women’s Health Initiative studies of breast cancer with hormone replacement, there was a little drop as use of HRT dropped, but levels quickly stabilized. Some argue that the increase is actually an artifact of increased screening, but they overlook the fact that breast cancer increased from 62/100,000 in 1937 to 70/100,000 in 1950 and 90/100,000 in 1973, and the increase from 1950 to 1980 was also attributed to increased diagnosis of cancers that would have been clinically irrelevant if simply left alone. Either one of these major increases might be partially attributable to increased attention, but it challenges the imagination to think that the age-adjusted incidence of invasive breast cancer could double in sixty years simply by being overdiagnosed.

Is Increased Breast Cancer Caused by the Environment?

Male breast cancer, though much less common than female breast cancer, has also doubled over the same time. Importantly, the shape of the curve for male breast cancer is the same for men as for women, with a peak just before the millenium, a slight drop, and a stable—and increased—level for the last ten years. More male breast cancer can scarcely be attributed in increased attention through a misguided screening program. Men don’t get screening mammograms, men are not taught to do self-examination, and men generally ignore breast changes unless they are painful—a situation like that of women a century ago. Therefore, whatever explanation is offered for the increase, it must apply to both men and women. Since men do WWW.SFMS.ORG

not delay childbirth, breast-feed babies, take birth control pills, or take hormone replacements, it seems we must look to what we breathe, eat, and put on our skin—our environment—to find factors common to both sexes.

What Is the Definition of the Environment?

The definition of the environment is a contentious issue. In 2011, the Institute of Medicine issued a report on breast cancer and the environment. The report, funded by Komen for the Cure (and problematic, as discussed below), defined environment to mean factors that could readily be altered by individual actions. It suggested that it was an individual responsibility of each woman to change her “environment” by exercising, limiting alcohol, keeping her weight down, not smoking, and not using exogenous hormones such as menopausal HRT. The report glossed over exposure to chemicals, stating there was not enough information on which to base recommendations. This attitude closely mirrors a report on cancer and the environment published in 1981 by Richard Doll and Richard Peto. That paper also glossed over unintended exposure to chemicals through daily life, stating that there was not enough evidence to comment. It was not known for a decade that the lead author, Richard Doll, was a paid consultant for chemical manufacturers. Similarly, it is interesting to note the overlap between the IOM report and the Komen board, and then to look on the streets of San Francisco for another possible conflict of interest: Most Alhambra Water trucks have a sign, “Proud Sponsor of Komen for the Cure.” This is laudable, but the signs do not mention that all Alhambra water is distributed in reused polycarbonate jugs—a source of dietary bisphenol-A (BAP).

At all times we are all exposed to a chemical soup that is poorly defined and poorly understood.

BPA and other chemicals are part of the environment where we all live. BPA is in canned foods, but we also absorb it transcutaneously when we touch thermal paper credit card receipts and the like. More than 90 percent of Americans and Canadians test positive for BPA in random urine samples (meaning that most of us are exposed every day, since BPA has a half-life of about eighteen hours and clears very quickly). In addition, we are exposed to DDT through fish including wild salmon, PCBs through house dust, various parabens from personal care products, terephthalic acid from #1 plastic bottles, etc. It may, indeed be easier to encourage women to change their lifestyle than to eliminate our

Continued on the following page . . .

NOVEMBER 2014 SAN FRANCISCO MEDICINE

Our Mixed Environment Continued from the previous page . . . daily exposure to these chemicals, but that does not take even a baby step toward removing them from our personal environment.

Are Chemicals a Functional Part of Our Environment?

Doll and Peto asserted that since there was no data to prove that chemicals affected cancer, there was no basis to worry that they might have a functional effect on human health. If one read selectively, they might have reached that conclusion in 1981. In 2014, however, there are several studies demonstrating that environmental chemicals increase breast cancer. The best studies are of DDT and diethylstilbestrol (DES), and—although neither chemical is in use in the United States today—they are important because we still ingest residual DDT forty years after it was banned; and because DES is a congener of BPA, based on research with BPA, and thus it provides insight into what we should expect from BPA. We have data on DDT and DES because we can define exposed and unexposed groups of women, whereas for most chemicals there is no unexposed group to compare to the rest of us who, without consent, have been enrolled in the great environmental chemical experiment. Initial studies of DDT and breast cancer did not find different levels of DDT in cases and comparison controls. These studies did not, however, take into account the age of women at the time they were exposed. When researchers looked at women who had reached puberty before 1945, when DDT was widely applied on civilians, levels of DDT were not associated with subsequent breast cancer. However, when they looked at women who were exposed to DDT before reaching puberty, women with highest serum DDT had five times the breast cancer compared with women with the lowest levels. Clearly exposure at a young age had a persistent effect. Exposure at an even younger age has revealed the carcinogenic effects of DES. Through misguided assumptions, many women in the 1940s through the early 1970s received DES during pregnancy. In the early 1970s, it was found that teenage daughters who had been exposed in utero had increased clearcell carcinoma of the vagina, and that almost all the girls exposed in utero during the first trimester had abnormal vaginal epithelial proliferation. As the mothers aged, they were found to have double the rate of breast cancer, after even short exposure for just the duration of a pregnancy. And in 2011 it was conclusively shown that the daughters had nearly double the rate of early breast cancer. Although DES is used little today, as the designer drug developed from BPA, the effects of DES give some hint of what we should expect from BPA if we were ever able to find an unexposed control population for comparison. This effect of age at exposure is also shown in the incidence of breast cancer in women with BRCA mutations, which allow cancer by failing to effect repair of DNA double-strand breaks. Mary Claire King observed that women with the same BRCA mutations developed more and earlier breast cancer if they were born after 1940. Confirmation of this came from a Texas study where the younger generations in the same families with BRCA mutations developed breast cancer an average of eight years 16

earlier. Recently, when the new breast cancer associate gene PALB2 was described, the authors also noted that compared to women born before 1940, women born between 1940 and 1959 had three times the risk of breast cancer, and women born after 1959 had six times the risk. This rapid shift toward earlier development of disease corresponds with the rapid increase in environmental exposure to man-made chemicals, most of which have never been tested for their carcinogenic and/or teratogenic effects.

How Are We Actually Exposed to Environmental Factors?

The challenge for most studies of environmental chemicals is to discern the effects of one chemical when we all live in a soup of other—usually similarly poorly defined—other chemicals. This fact is largely ignored by what limited safety testing has been performed on some chemicals. Typically chemicals are tested one at a time, using traditional toxicology methods, to determine the NOEL (no observed effect level) for the chemical. This testing assumes that if a chemical does not have an effect by itself at a low level, it does not have an effect at all. This is a dangerous assumption. In fact, there is nothing about identifying one chemical in a person even to suggest that one or dozens of other relevant, biologically active chemicals are not also present in the same person. Or that the chemicals would not act synergistically. The best demonstration of the principle of synergy in mixtures comes from Philippa Darbre in the (still) United Kingdom. Her team measured parabens in mastectomy specimens done for cancer. As expected, there were a variety of parabens present in various amounts, and often the levels of the individual parabens were too low to stimulate MCF7 cancer cells to grow when used one at a time. However, when she reproduced the mixture of chemicals found in individual patients, and exposed MCF7 cells to the mixture—when the levels of individual parabens were too low to have an effect individually—the mixture stimulated cancer cell growth. This is evidence of our worst nightmare. However, just as not all mixtures cause cancer cells to grow, not all cancer cells grow in response to either individual chemicals or mixtures. An important principle is that what we know about cancer shifts risk higher—or lower—but no factor causes cancer in 100 percent of people. Not every obese woman gets breast cancer, and many women take HRT for years and do not get cancer. There must be other factors in play. Since cancer is a multifactorial disease, we are unwise if we restrict our concept of the environment to the narrow definition of things that an individual can change for herself. There are many alternative possibilities, and we should not shift the burden to persons (ourselves included) who may not—who usually do not—have the ability to change the chemicals they are exposed to in the course of their daily lives. William Goodson III, MD, is a senior scientist at the California Pacific Medical Center Research Institute and member of a team studying the mechanisms of how xenoestrogens induce hallmarks of cancer in non-malignant human breast cells. He is a breast cancer surgeon and past president of the San Francisco Medical Society.

SAN FRANCISCO MEDICINE NOVEMBER 2014 WWW.SFMS.ORG

Human Health and the Environment

HERBICIDES LINKED TO CANCER A Very Mixed Blessing from Modern Agriculture Jeff Ritterman, MD A brilliant and celebrated inventor, John Franz, gave us an herbicide, Roundup, that has changed the face of agriculture. This herbicide has become the foundation for

an entirely novel approach to farming—biotech agriculture— that has expanded rapidly throughout the globe. Monsanto makes seeds for soy, corn, canola, cotton, alfalfa, and sugar beets that are genetically engineered to be tolerant to Roundup. The seeds are marketed in 120 countries. Throughout the world, Roundup is sprayed heavily as a weed killer without fear of damaging the cash crops, which have been engineered to survive the herbicide’s effects. Roundup seemed, at first, to be the perfect herbicide. It blocks the EPSP synthase enzyme, which prevents the synthesis of amino acids that plants need for growth. Since animals don’t have this enzyme, it was initially hypothesized that they would be safe from Roundup’s effects. Unfortunately, Roundup has now been shown to affect much more than the EPSP synthase enzyme. The herbicide has been proven to cause birth defects in vertebrates, including in humans, and it may also be the cause of a fatal kidney disease epidemic.

Roundup Linked to Increased Cancer in “Soy Republic”

Roundup is now heavily sprayed in what is known as the “Soy Republic,” an area of Latin America larger than the state of California. Doctors serving these areas have documented an alarming increase in cancers. A group of dedicated physicians formed an organization, Doctors of Fumigated Towns. They held a national conference in August of 2010 in Córdoba, the center of Argentina’s soy region. The Department of Medical Sciences of the National University at Córdoba sponsored the conference. An estimated 160 doctors from throughout the country attended. It was the health of the population that concerned Dr. Damian Verzeñassi, professor of social and environmental health from the National University at Rosario. In 2010, he began a house-to-house epidemiological study of 65,000 people in Santa Fe, also in Argentina’s soy region. He found cancer rates two to four times higher than the national average, with increases in breast, prostate, and lung cancers. Dr. Verzeñassi commented on his findings, “Cancer has skyrocketed in the last fifteen years.”

Roundup Linked to Lymphoma

Research has also been done in the United States, Canada, Europe, Australia, and New Zealand to investigate possible links between glyphosate, Roundup’s active ingredient, and cancer. A large number of studies have focused on glyphosate’s possible association with non-Hodgkin’s lymphoma. WWW.SFMS.ORG

Scientists from the International Agency for Research on Cancer (IARC) have analyzed studies spanning almost three decades. The IARC is the branch of the World Health Organization that promotes cancer research. Scientists throughout the world with skills in epidemiology, laboratory sciences, and biostatistics are brought together to identify the causes of cancer so that preventive measures may be instituted. The agency views cancers as linked, directly or indirectly, to environmental factors. In April of 2014, scientists at the IARC published their review of twenty-five years of research on the relationship between pesticide exposure and non-Hodgkin’s lymphoma. They found a positive association between organo-phosphorus herbicides, such as glyphosate, and this cancer. The B-cell lymphoma subtype, in particular, was strongly associated with glyphosate exposure.

Roundup Linked to Brain Cancer

The linkage to lymphoma is the most recent research raising concerns about glyphosate’s connection to cancer. Scientists from the Agency for Toxic Substances and Disease Registry, a branch of the U.S. Department of Health and Human Services, specialize in illnesses caused by toxic substances. They published the results of the U.S. Atlantic Coast Childhood Brain Cancer Study in 2009. Children with brain cancer from Florida, New Jersey, New York, and Pennsylvania were compared to agematched controls. The researchers found that if either parent had been exposed to Roundup during the two years before the child’s birth, the chances of the child developing brain cancer doubled.

Roundup and Cancer: Human Observations Summarized

The research shows that Roundup is linked to a host of cancers in those living in the heavily sprayed regions of Latin America. It has also been linked to B-cell lymphoma and to brain cancer. While the epidemiological studies show close correlation, they cannot prove causality. The gold standard for scientific proof is a randomized controlled trial, which would be unethical in this instance. You cannot ethically expose humans to an herbicide. Scientists therefore use a variety of experimental models to assess cancer risk.

Roundup Causes DNA Damage, Errors During Cell Division

Cancer risk can be evaluated by experiments that measure Roundup’s ability to induce DNA damage. Often, one of the initial steps in the development of cancers is damage to our DNA.

Continued on page 19 . . .

NOVEMBER 2014 SAN FRANCISCO MEDICINE

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Herbicides Linked to Cancer Continued from page 17 . . . Each of our cells gets its operating instructions from its DNA. If the DNA is damaged, the faulty operating instructions can reprogram cells to divide rapidly and chaotically. When this happens, cells become transformed into cancers. A number of experiments have been done using various animal models, all showing the same results: After exposure to Roundup, cells exhibited DNA damage. This was true in fruit fly larvae, in mice, in the blood cells of the European eel, and in the lymphocytes of cows. Another experimental model that has been used to judge glyphosate’s cancer risk focuses on the herbicide’s impact on cell division. Cells are vulnerable to being turned into cancers if an error is made during this delicate process. In the process of cell division, the DNA must be copied precisely. Each daughter cell must receive from its parent cell an identical copy of the DNA. If a mistake is made, the daughter cells will receive faulty DNA copies. Cells with damaged DNA can turn into cancers.

Roundup Damages Human DNA

The most worrisome of the DNA studies are the ones that show DNA damage in humans. Dr. Fernando Manas, a biologist at the National University of Rio Cuarto in Argentina, has been investigating the effects of pesticides for years. He believes that glyphosate spraying is causing cancer by inducing DNA damage. His research has documented genetic damage in those exposed. When Dr. Manas studied pesticide sprayers working in the soy industry in Córdoba, he found significantly more DNA damage in their lymphocytes than in those of an unexposed group of controls. Roundup was one of the most commonly used pesticides. Interestingly, scientists have known since 1998 that when normal human lymphocytes were exposed to Roundup in a test tube, the lymphocytes developed DNA damage. The pesticide sprayers in Córdoba, the Ecuadorians living in Sucumbíos, and the normal volunteers all developed Roundup-induced DNA damage in their lymphocytes. A cancer of the lymphocytes is known as a lymphoma, the very same type of cancer that the International Agency for Research on Cancer showed to be strongly associated with glyphosate exposure.

Rounding up the Evidence

Epidemiological studies in humans, in the soy regions of Argentina and in Europe, the United States, Canada, Australia, and New Zealand, have shown Roundup to be linked to an increase in cancer risk. There is a strong association between Roundup and B-cell lymphoma, brain cancer, and a variety of other cancers in those living in heavily sprayed areas. In addition to these epidemiological observations, laboratory studies have shown that Roundup causes DNA damage, disturbs cell division, increases cancer growth in tissue culture, and induces cancer when fed to test animals.

Proving Causality

Does the evidence linking Roundup to cancer prove causality? In the 1964 landmark Surgeon General’s Report, which for the very first time linked tobacco to cancer, Surgeon General Dr. Luther Terry presented criteria for the establishment of a causeWWW.SFMS.ORG

and-effect relationship in a scientific study. To meet Dr. Terry’s criteria, an association must be strong, specific, and consistent. Cause must precede effect. And the association must be biologically plausible. How well does the association between Roundup and cancer fit these criteria? Roundup exposure is consistently and specifically associated with precancerous abnormalities in a wide variety of experimental settings. Epidemiological observations show a tight linkage between glyphosate and cancer. In laboratory research, as well as in the epidemiological studies in the field, exposure to the herbicide precedes the development of the abnormalities. There are plausible biological mechanisms that explain how glyphosate can transform cells into cancers. In citing the Surgeon General’s report, Drs. Wild and Seber, in their highly regarded statistics textbook Chance Encounters, provide an example of a strong association. If an “illness is four times as likely among people exposed to a possible cause as it is for those who are not exposed,” the association is considered strong. Most of the glyphosate exposure experiments and epidemiological observations show a doubling of cancer risk. This leaves some room for doubt. But who, given the science, would want to expose their loved ones to Roundup?

Cancer’s Lessons

Roundup has now been conclusively proven to cause birth defects and to be closely linked to cancer. If we do not want this herbicide to accumulate in our water, land, and food, we need to stop using it. There is a disturbing parallel between the exponential growth of biotech agriculture and the spread of a cancer in the human body. Cancers are cells that reproduce rapidly and haphazardly with no regard for the greater good of the organism. Cancer cells consume valuable energy, starving out normal cells. They grow so wildly and so quickly that they crowd out their neighbors. They send off emissaries to start new cancer colonies. They make harmful substances that damage healthy cells. They spread relentlessly. In the final sad irony, when the cancer cells reach their growth peak, they kill their host and die in the process. Like a cancer, biotech agriculture has crowded out its neighbors and is spreading relentlessly. Also like a cancer, it makes harmful substances. Roundup is one of them. As more acreage comes under GM cultivation, we can expect Roundup use to continue to increase. Roundup kills plants, causes birth defects in vertebrates, and is linked to cancer. Can a living planet withstand the continuous assault from this poison any more than the human body can withstand the attack from an aggressive cancer? Do we need to fight biotech agriculture with the same persistence, commitment, and force that we bring to bear in battling cancers? Jeff Ritterman, MD, is vice president of the board of directors of the San Francisco Bay Chapter of Physicians for Social Responsibility. He is the retired chief of cardiology at Kaiser Richmond and a former Richmond, California, city councilman. This is an authorized version of an article that originally appeared at Truthout.org at http://www.truth-out.org/news/item/26614monsanto-s-roundup-linked-to-cancer. NOVEMBER 2014 SAN FRANCISCO MEDICINE

Human Health and the Environment

A NEW ERA Climate Change and Human Health Ross Bowling, PhD; Nyron Rouse; John Balbus, MD, MPH For many years, policy discussions about climate change rarely considered the issue from a public health perspective. Scientists and public health profession-

als concerned about the health consequences of climate change focused on “getting a seat at the climate table”—in other words, finding a way to get considerations of health effects into the larger discourse on climate change. Over this past year, health has become a much more significant aspect of climate change dialogue in the U.S. and around the world. Moreover, just as climate scientists have become increasingly interested in health impacts, climate change has become a bigger topic in public health events. Health now has a seat at the climate table, and climate has found its way to the health table. This increased interaction marks a new phase in the efforts to address the many health implications of climate change, and it is promoting a much fuller discussion of the potential health benefits of actions to reduce greenhouse gases. The growing collaboration has also increased recognition of synergies between mainstream health promotion goals and sustainable, “green” community goals. The global health and development communities are beginning to identify opportunities for low-income countries to receive assistance in enhancing the resilience and robustness of their public health systems. At the same time, this new phase raises questions and some challenges. Health officials want to know the current and future burden of ill health attributable to climate change. For many of these health implications, the knowledge base has not been sufficiently developed by research to allow such questions to be answered with certainty. There is sufficient understanding to identify pathways and demonstrate impacts, but not enough to confidently quantify the contribution of climate variability or climate change relative to other drivers. Similarly, the ability to quantify some of the health benefits of greenhouse gas reduction measures is limited. In order to deliver useful decision support tools, the health and climate communities must ensure that current and future scientific studies of climate and health are asking the right questions and focusing on the most important issues. Addressing the special vulnerability of children to the impacts of climate change illustrates some of the challenges mentioned previously. While researchers have developed a considerable knowledge base about climate change’s effects on children’s health,1 there are still gaps in understanding differential effects across life stages. Projections of climate change effects and existing studies on children’s health indicate that in some ways children will be disproportionately affected by climate change. For example, because their bodies are less effective at adapting to heat,2 young children and infants are 20

particularly vulnerable to heat-related illness and death.3 Climate change may also significantly affect children’s respiratory health. Children’s body weight, the size of their airways, their still-developing lungs, and their level of physical activity make them particularly susceptible to air pollution, and climate change is anticipated to increase the concentration of ozone and particulate matter in the air. Ozone exposure in young children is significantly associated with risk for asthma.4 Similarly, a recent study showed that young children are exposed to twice as much particulate matter indoors as outdoors,5 and extreme heat and other climate effects might be expected to increase the amount of time children spend indoors. These and other recent studies point to children’s vulnerability but are not sufficient to quantify their risks in many cases. Just as climate effects are increasingly prevalent in public health analysis, public health considerations have become a more important element in climate change policy. For example, children’s respiratory health provided a key framing device for the EPA’s release of power plant guidelines in the summer of 2014. While these guidelines are intended primarily to mitigate the severity of climate change itself, the White House supported the announcement by releasing a report that highlighted the public health benefits that would result from following the guidelines.6 As the report argued, measures to reduce carbon dioxide emissions would also decrease emissions of more conventional pollutants, such as nitrogen oxides, mercury, and sulfur dioxide. This would translate into near-term health benefits, such as reducing the risk of asthma attacks and other respiratory illnesses. The EPA quantified the benefits of the guidelines in terms of the prevention of asthma attacks and premature deaths, and the White House paper argued that expenses incurred from the emissions reduction would be more than offset by savings from health benefits. Meanwhile, the public health community has begun to build climate change considerations into its own events. To return to the example of children’s health, the interagency Presidential Task Force on Environmental Health and Safety Risks to Children recently formed a subcommittee on climate change. In July 2014, that subcommittee convened an expert consultation to address climate change and children’s health. In addition to discussing child health risks related to heat and respiration, the workshop highlighted potential PTSD and other mental health concerns for children. Although understanding of climate change’s effects on mental health is still developing, the workshop considered how children might be affected by increased exposure to traumatic, extreme weather events (fires, tornadoes, floods, hurricanes) and their aftermaths (injury, loss of loved ones, displacement from homes and schools).

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The workshop discussed another emerging area of research interest in climate changeâ&#x20AC;&#x2122;s health effects: how fetal development and adverse birth outcomes might be affected by climaterelated exposures, such as extreme heat, increased air pollution, and floods. Recent studies have associated extreme heat events with adverse birth outcomes, such as low birth weight and preterm birth.7 As discussed above, climate change is expected to increase concentrations of air pollutants such as particulate matter and ozone in some areas, and these pollutants have been associated with negative birth outcomes.8 Climate change is also projected to increase the severity and frequency of floods, which may lead to increased risk of maternal exposure to environmental toxins and resulting health outcomes. One recent product of the partnership between the public health and climate change communities in the U.S. was the human health chapter of the 2014 National Climate Assessment.9 The chapter revealed four key findings: that climate change will have varied and multiple effects on health, some of which are currently occurring (e.g., health effects associated with impaired air quality, increasing allergens, temperature and precipitation extremes); that climate amplifies existing health stressors and will thus disproportionately affect already-vulnerable populations; that taking adaptive measures early will avoid later costs; and that responses to climate change may have multiple benefits for health.

The dynamics at play between the public health and climate change communities in the U.S. are also occurring at the international level.

In September 2014, the United Nations Summit on Climate Change included, for the first time, a thematic session devoted to health. This session emphasized the health and economic co-benefits of climate change mitigation and resilience. For instance, discussants noted that a shift toward renewable energy would decrease concentrations of black carbon and ozone. Similarly, in August 2014, the World Health Organization brought climate to the health table by convening its first-ever Conference on Health and Climate. The three-day conference included health ministers from around the world and experts in sustainable development. Primary topics included how to strengthen health system resilience against climate risks and how to promote health while mitigating climate change. The health ministers at the conference were especially interested in guidance for conducting health adaptation and vulnerability assessments. However, particularly in less developed countries, there is currently little capacity for such assessments. A clear priority for the climate and health communities, then, is determining the most effective ways to help health systems prepare for climate change effects. Recently the Department of Health and Human Services has made significant strides toward developing such assessment tools for health facilities. In addition to holding a briefing on the potential health effects of climate change,10 HHS is preparing to release its Sustainable and Climate Resilient Health Care Facilities Initiative tool kit. This tool kit, developed with input from a variety of private health sector stakeholders, provides case studies of climate resilience efforts from hospitals across the U.S. It WWW.SFMS.ORG

also features a set of tools to assist hospitals in assessing the particular risks they face from climate change, based on facility location and characteristics. This tool kit is a part of a larger government initiative, the Presidentâ&#x20AC;&#x2122;s Climate Action Plan, and will eventually form part of an online Climate Data and Tools Initiative. The Climate and Health Program at the Centers for Disease Control and Prevention has also recently released detailed guidance for health departments on how to conduct climate vulnerability assessments.11 The climate change and public health communities have begun a useful dialogue that will be vital in preparing health systems for the effects of climate change. Now the talk must turn to appropriate action to protect public health and prevent the worst manifestations of climate change.

Ross Bowling, PhD, is a presidential management fellow at the Department of Health and Human Services. Nyron Rouse is a member of the Management Intern Program at the National Institutes of Health and currently works in the office of the Assistant Director for Policy Development at the National Library of Medicine. John M. Balbus, MD, MPH, of the National Institute of Environmental Health Sciences, is senior advisor to the Director on public health issues and leads efforts on climate change and human health. Dr. Balbus received his BA degree in Biochemistry from Harvard University, his MD from the University of Pennsylvania, and his MPH from the Johns Hopkins School of Public Health. A full list of references is available online at www.sfms.org.

NOVEMBER 2014 SAN FRANCISCO MEDICINE

Human Health and the Environment

CLIMATE ACTION AND HEALTH The New Deal for Our Health and Our Children’s Health Génon K. Jensen and Peter van den Hazel, MD, MPH, PhD Although the news is currently dominated by Ebola, many health advocacy organizations, including ours, believe that the real, enduring health crisis is the menace of climate change. We’re in good company.

Joining others in a recent British Medical Journal article on climate change, World Health Organization (WHO) Director General Dr. Margaret Chan called for urgent action to protect health. “Climate change, and all of its dire consequences for health, should be at center stage . . . whenever talk turns to the future of human civilizations. After all, that’s what’s at stake.” The last few months have seen a boom in activity by doctors and nurses and other health professionals on climate and health. They have taken part in huge, worldwide demonstrations for climate justice. Many have provided evidence for the first U.N. Climate Summit called by Secretary General Ban Ki-Moon in New York in September 2014, and more than 400 health representatives from 96 countries took part in the first-ever WHO Climate and Health Summit in Geneva in August 2014. The civil society network, Global Climate and Health Alliance, in which HEAL is a founding member, released a call to action urging WHO DG Dr. Chan to declare climate change as a global public health emergency and to take urgent measures to address it. This article aims to show why this boom in the involvement of the health community in climate and health must maintain its force and grow. Full engagement of medical professionals and the health community is an imperative for our climate and for our health. We describe the health impacts of climate change and show why, if advocacy by health professionals helps clinch a legally binding and properly resourced agreement on climate, it could be the best public health deal ever achieved.

The Facts

At a global level, the latest figures from the World Health Organization show that climate change is expected to cause approximately 250,000 additional deaths annually from 2030 to 2050. Of those deaths, 38,000 are due to heat exposure in elderly people, 48,000 result from diarrhea, 60,000 are caused by malaria, and 95,000 are due to childhood malnutrition. But climate change is already impacting public and community health in far greater ways, as evidenced by the U.S. National Climate Assessment, the IPPC assessment published earlier this year, and other recent studies. Most at risk are the most vulnerable, such as children. According to WHO, more than 80 percent of the current health burden due to the changing climate occurs in children younger than five years old. This is primarily because of physiological and developmental factors. They will disproportionately suffer from the effects of heat waves, air pollution, infectious illness, and trauma resulting from extreme weather events. 22

Allergy and asthma are special concerns for children’s health in the U.S. and Europe. More frost-free days and warmer seasonal air temperatures can contribute to shifts in flowering time and pollen initiation from allergenic plant species, and increased CO2 by itself can elevate production of plant-based allergens. Higher pollen concentrations and longer pollen seasons can increase allergic sensitizations and asthma episodes and diminish productive work and school days. Air pollution has also been linked to other health conditions affecting children and is increasingly recognized as a source of behavioral problems in children. An article published in Pediatrics in October 2014 shows that prenatal exposure to air pollution and maternal psychological distress affects child behavior. The study in Krakow, Poland, and New York City shows the greatest effects among children with high levels of prenatal exposure to air pollutants, such as polycyclic aromatic hydrocarbons (PAH) resulting from combustion sources including motor vehicles, coal-fired power plants, residential heating, and tobacco smoke.

The Good News

Fortunately, strong action to address the climate challenge will be a positive force for health. This is why success at the international UNFCCC climate talks in Paris in December 2015 would mean revolutionary changes in the promotion of good health. A growing body of scientific work shows that many of the policies that will reduce greenhouse gas emissions will also benefit health. For example, a fall in greenhouse gases is associated with a rise in air quality. As levels of harmful gases and pollutants in the air fall, major improvements in cardiopulmonary health, including asthma, bronchitis, and stroke, take place. City policies that encourage “active transport” highlight how extending opportunities to walk and cycle can produce significant physical and mental health benefits, as well as reducing air pollution. Evidence is now available to show that ending our dependency on fossil fuels, the cause of climate change, can help tackle both climate change and the rise in noncommunicable diseases such as diabetes, obesity, cancer, heart disease, stroke, and asthma. Europe was one of the first regions of the world to promote the so-called “co-benefits” of climate action in policy discussions. In 2010, HEAL published its first major report on climate and health, Acting NOW for Better Health, showing the health benefits that Europeans could expect from stronger climate action by the European Union. The estimates of health costs avoided covered both respiratory and heart problems. The report also showed that the sooner action was taken, the sooner the benefits for health. Recognition of health co-benefits has helped reshape thinking on climate policy. Once economic assessment of the health

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benefits became available, it provided European policy makers with a persuasive new argument in favor of climate action. Today, research shows that the short- and long-term benefits for health can offset—partly or sometimes wholly—the costs of climate policies. The most recent example is New Climate Economy’s groundbreaking report Better Growth, Better Climate, which includes figures on the potential health gains, and their associated cost savings, resulting from climate action. In September 2014, at the U.N. Climate Summit, the positive message on climate action and health came over loud and clear. The health community spoke about the concrete examples of a range of investments that would mitigate climate change and benefit health. One of the main approaches is to support a move away from coal to help avoid millions of early deaths through improved air quality. Coal is the dirtiest of all fossil fuels, and burning it is a major contributor to climate change worldwide. HEAL’s coal report published last year shows that in the European Union, emissions from coal power plants are responsible for more than 18,200 premature deaths, 8,500 new cases of bronchitis, and more than 4 million lost working days. The associated costs of up to €43 billion per year fall on individuals, families, health services, and governments in Europe and represent what HEAL calls an “unpaid health bill.” The impact of the findings has not only reverberated in Brussels, home of the European Union institutions, but also in many European countries, including Poland, Germany, Romania, and the U.K. The U.S. and Chinese governments have already embraced the message of better health in their support of recent actions against pollution from coal power plants. But we believe that with the help of health professionals, the health co-benefits model can be used more extensively to drive up national climate targets in all regions of the world.

Health Community Voice in Climate Matters

Physicians, health care professionals, and other health advocates can make a powerful and compelling case for a strong agreement on climate action on public health grounds. They have already proved their strength in relation to the international tobacco convention. This climate change agreement offers much higher stakes and arguably the best-ever new deal for global and national health. In Europe, HEAL has worked with the U.K. Climate and Health Alliance to help formulate a public health warning message that “Climate change may be hazardous to your health,” and a second message, that climate action could actually promote health; a third message, “What’s good for the climate is good for health and the economy,” emphasizes creating substantial fiscal savings. The European Respiratory Society, the European Lung Foundation, and the Standing Committee of European doctors, as well as national asthma groups from the European Federation of Allergy and Airways Diseases Patients’ Association, have used this positive frame in their communications while speaking to the media to multiply and extend the impact of these messages to their communities. The health community voice matters because health professionals can speak with experience and authority; many are already on the front line and witnessing the impact of climate change on health outcomes. Some European networks are already involved WWW.SFMS.ORG

in sharing information with their patients and associations. For example, tens of thousands of fact sheets for children on climate change and health in different languages have been distributed in respiratory and asthma clinics in Europe.

“Climate and Health” Road to Paris

In just over a year, leaders will meet in Paris at the COP21 international climate talks. There are a few things that we all can do to bring the health message and the health messenger to the climate table. We can become ambassadors for a move away from fossil fuels and toward a clean, sustainable energy pathway. These investment choices benefit public health. What this requires is the removal of subsidies for certain types of agriculture and for coal and all other fossil fuels while supporting investment in renewable energy sources, including reinforcing health services. These and other recommendations are spelled out by the Global Climate and Health Alliance call to action. We can respond positively to the plea of Christiana Figueres, chair of the U.N. Framework Convention on Climate Change, who is urging health ministries and the wider public health and advocacy community to gear up for climate discussions in 2015, be ready to provide expertise to their national climate negotiators, and make the case for a strong global agreement. The health community can lead by example and turn this climate problem, identified as the greatest public health challenge of the twenty-first century, into a massive public health opportunity. A strong and well-resourced agreement will be a great asset for public health. It can help create resilient, low-carbon, healthpromoting cities, economies, and communities, in which everyone has access to clean air and water and healthy food.

Génon K. Jensen is executive director, Health and Environment Alliance (HEAL), and coordinator for the CHE Climate Change and Health Working Group. Peter van den Hazel, MD, MPH, PhD, is president of both HEAL and the International Network on Children’s Health, Environment, and Safety (INCHES). A full list of references is available at www.sfms.org.

NOVEMBER 2014 SAN FRANCISCO MEDICINE

Human Health and the Environment

FUKUSHIMA AND FISH Responding to Concerns Regarding Radiation in California Steve Heilig, MPH It’s now more than three and a half years since the nuclear disaster in Japan, and concerns regarding the impacts continue. In Japan itself, the impacts have

been huge and disastrous indeed, depending on location—and upon one’s source of information. Allegations of mismanagement, secrecy, and long-term impacts ranging up to the apocalyptic continue. Beyond the more than 15,000 deaths tied to the earthquake, tsunami, and related destruction, the World Health Organization has estimated minimal actual radiation exposure, morbidity, and mortality. However, it is expected that people in the area most impacted may have a slightly higher risk of leukemia and thyroid and breast cancers. Here in California, worries persist, especially among those with excess Internet access. Public reports have noted detectable radiation in tuna caught off the West Coast; in October, the esteemed Woods Hole Oceanographic Institution reported Fukushima radiation—mainly cesium—was nearing the West Coast, but also that the radiation is at very low levels that aren’t expected to harm human health or the environment. “I’m not concerned,” said the chemical oceanographer measuring the radiation. In March, the Food and Drug Administration stated that there is “no evidence that radionuclides from the Fukushima incident are present in the U.S. food supply at levels that would pose a public health concern.” In June the FDA stated that fish from Alaska—closer to Japan—are “safe from radiation.” Physicians for Social Responsibility, the leading antinuclear organization with a focus on health, has stated that risks here are not a real cause of worry, although further disasters at Fukushima could alter that opinion. In a webinar on Fukushima’s impacts presented by the SFMS and the Collaborative on Health and the Environment last year, a leading nuclear physicist, the PSR president, and a Marin physician all concurred that residents on California’s coast did not have reason to worry. The clinician said she feels that the benefits of eating fish outweigh any suspected risk. However, one physician with much expertise in environmental health has recently noted, “I’d avoid eating fish caught in Japan . . . especially sushi.” Of course, the other important and ongoing debate about fish safety concerns mercury. The FDA this month issued draft guidelines for pregnant women and young children stating “Eat 8 to 12 ounces of a variety of fish (or shellfish) each week from choices that are lower in mercury. The nutritional value of fish is important during growth and development before birth, in early infancy for breastfed infants, and in childhood.” Some experts immediately questioned this increased “dosage” as being potentially hazardous, and the final recommendations are in flux. 24

RESOURCES • The Wikipedia page on Fukushima is quite extensive: http://en.wikipedia.org/wiki/Fukushima_Daiichi_nuclear_disaster • The FDA: www.fda.gov/newsevents/publichealthfocus/ucm247403.htm • Woods Hole Institute’s ocean radiation measurements: www.ourradioactiveocean.org/results.html •Physicians for Social Responsibility’s Advisory: www.psr.org/resources/health-risks-releases-radioactivityfukushima-daiichi-nuclear-reactors.html

Podcast: Radiation and Human Health: After The Japan Disaster

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Human Health and the Environment

MEAT AND THE MICROBIOME From Farm to Fork to Gut David Wallinga, MD There’s no mistaking a medical fad. Suddenly, “it” appears to be everywhere—as the special theme for conferences, in abounding journal articles, etc. Such is the status of the microbiome. With repetition, the statistics become familiar: Your body carries 3 to 5 pounds of bacteria, ten times more single-cell bacteria—around 100 trillion in total—than there are human cells. Bacterial genes outumber, 100 to 1, their human counterparts in your body. What’s typically lacking from treatment of the microbiome in the popular or medical press is that this fundamentally is a story about how our broader environment shapes us, and shapes our health. If that’s not obvious, try turning the standard narrative on its head. Rather than talk about a person’s microbiome as their own internal environment, consider instead that humans are just a small part of the much bigger, more complex microbial ecosystem. Bugs beat humans hands down in both numbers and genetic diversity. With that perspective, we turn in this essay to the question of exactly how our microbiome might intersect with the enormous U.S. consumption and production of meat. The meat industry may be one of the biggest drivers there is of our physical environment. Meat and Manure

In 2012, the U.S. produced 92.9 billion pounds of chicken, turkey, pork, beef, and other meat. The meat comes from nearly 9 billion food animals raised and slaughtered in the U.S. each year, including 8.6 billion chickens, 113 million hogs, and 32 million cattle. Over a year, these animals produce about 100 times more manure than the amount of human sewage processed in municipal wastewater treatment plants. One mega-dairy, with 2,500 cows, creates as much waste as a city of 400,000 residents. Laws for treating that manure waste are often nonexistent, inadequate, or unenforced. One way or another, much of that untreated or undertreated manure ends up being applied to food-producing land as fertilizer—again, potentially affecting the microbial flora that might normally be found there.

We Are What They Eat

From space, the most visible feature of middle America may be yellowish-looking corn. Over half the entire U.S. land base, including Alaska, is agricultural. Just two crops—corn and soybeans—dominate; together, they are the chief ingredients we feed to livestock. Around 97 million corn acres were planted last year, somewhat less in soybeans. Planted corn is nearly inedible. The vast bulk is fed instead to livestock, either directly, or after its sugars are first fermented into fuel as corn ethanol. Only a tiny fraction of the corn crop is turned into corn starches or corn syrups to be added to sodas or processed foods—foods, of WWW.SFMS.ORG

course, that we acknowledge typically are high in added sugars and carbohydrates. What once was a rural ecosystem in most of the “corn belt” has been replaced by a broken corn and soy “monoculture.” It is largely because of corn that the American meat industry is such a huge consumer of precious natural resources. The varieties of corn and soy that are nearly universally planted have been specifically designed to tolerate heavy applications of the chemical pesticide glyphosate. Over 5.6 million tons of nitrogen are applied to U.S. corn each year via chemical fertilizers, while corn drinks up an estimated 5.6 cubic miles per year of irrigation water from America’s rivers and aquifers. Much of the nitrogen fertilizer ends up downstream, polluting our lakes and rivers. The dead zone in the Gulf of Mexico is the iconic poster child. From the Midwest to the Gulf, the ecosystem impact of the corn and soybean monoculture is huge. It’s not only the waters of the Gulf that die. Much of the native microbial diversity of the soils growing these crops is robbed as well. Heavy chemical fertilizer use is, in part, a reflection of how dead and infertile that soil has become. Feeding corn to cattle, whose rumens were evolved to digest cellulose, affects the acidity of the gut and therefore its hospitableness to various microbial flora. Although equivocal, some studies have pointed to the changes in diet and rumen acidity as contributing factors to a heightened risk of E. coli O157:H7 in cattle. Of course, that was the pathogen behind the infamous 1993 outbreak that sickened 732 people and killed four children after they ate undercooked beef from seventy-three Jack-in-the-Box restaurants.

Linking Human and Animal Microbiomes

There are more insidious ways, however, that the upstream practices of the meat industry may change our microbial environment, and therefore our microbiome. In Missing Microbes, Dr. Martin Blaser talks about changes he’s seen after nearly four decades of medical practice and research. Blaser, an internist and infectious disease specialist, is now director of the Human Microbiome Program at New York University, which looks at how antibiotics affect resident microbes and their hosts, both animal and human. A key finding of the program, writes Blaser, is that early life is a key window of vulnerability. Using mouse models, his lab has shown how early-life exposure to antibiotics, and the loss of friendly gut bacteria, drives later-life obesity. This has been widely reported. But Blaser goes on to talk about the need to focus on strategies for restoring these “missing microbes,” starting with reductions in the overuse of antibiotics that helps drive their loss in the first place. Much of our antibiotic use is simply unneces-

Continued on the following page . . .

NOVEMBER 2014 SAN FRANCISCO MEDICINE

Meat and the Microbiome Continued from the previous page . . . sary—as much as half of all human use and likely much, much more of the use in livestock. The latest data from the Food and Drug Administration underscore the point. These data show a 16 percent rise in antibiotics sold for use in livestock from 2009 to 2012, 70 percent of which are drugs of importance to human medicine. Many of the latter have risen much faster over that time period: Animal sales of penicillins are up 40 percent, cephalosporins are up 37 percent, and aminoglycosides are up 23 percent. In contrast, the Netherlands, Europe’s largest livestock producer, reduced its use of livestock antibiotics by 50 percent over the same time frame. FDA data also make clear that 80 percent of the more than 30 million pounds of antimicrobials sold in the U.S. each year are given to animals, and 97 percent of those have been sold over the counter. Though he’s not the first to make these connections, Blaser revisits the two chief human health implications to our children and families of the huge and prevalent use of human drugs in the nation’s food supply. Antibiotic use, we know, helps to drive the evolution and spread of genes making bacteria resistant to antibiotics. Experts on the antibiotic resistance epidemic ranging from the WHO and CDC to the President’s Council of Advisors on Science and Technology now acknowledge the extensive evidence base that connects this human epidemic in part to the extensive use of antibiotics in livestock. One way that reservoirs of resistance fostered in intensive livestock settings can be transferred back to the human population is through a meat supply contaminated with bacteria carrying that resistance—often resistance to multiple antibiotics. Last week, the National Antimicrobial Resistance Monitoring System (NARMS) announced a Web-based tool that lets users visualize the percent resistance among Salmonella and Campylobacter bacteria isolated from humans, food animals, and retail meats, by year. The latest data incorporated is from 2011. But Blaser raises another, less investigated issue. With such an enormous use of human antibiotics in food animals, including penicillins, tetracyclines, cephalosporins, and the like, what might be impacts on children and others ingesting the lingering residues of so many drugs? Both federal and international bodies set residue limits for individual drugs in individual foods. But for those who are more vulnerable to these exposures, either by dint of their developmental age or because they already have a drug allergy, the level of exposure to any one food or drug may be less than salient. “The point,” Blaser says, “is that it all adds up.” Legal limits for any one particular drug in a particular food don’t reflect the fact that people likely ingest a far higher cumulative level of exposure to multiple different antibiotics across the multitude of meats, fish, orchard fruits, and dairy products that make up their diet. There’s additional residue in tap water and other drinking water sources as well. What is the total impact on our microbiome? We really have no idea. We are only beginning to ask those questions. And our experience with a host of other environmental health issues of the last half century, from dioxins to pesticides to air pollution, should remind us that answers are often slower in coming than questions. In the interim, however, one thing seems clear. 26

Our children deserve to live in environments where the use of antibiotics is avoided wherever possible. And make no mistake, that should include the meat supply. David Wallinga, MD, is the founder/director of Healthy Food Action, a national network of health professionals who advocate for making health the future of farm and food policy. Register for the network’s Meat Matters webinars, including one featuring Dr. Blaser in January 2015, at http://healthyfoodaction.org/webinarseries-industrial-meat-health-of-the-system/. A full list of references is available online at www.sfms.org.

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Human Health and the Environment

A NEW ERA FOR ENVIRONMENTAL HEALTH The Collaborative on Health and the Environment Consensus Statement

This statement was developed when CHE was founded at the SFMS in 2012, at a meeting chaired by Philip R. Lee, MD,

chancellor emeritus of UCSF and former United States Assistant Secretary of Health. While we might wish to update some aspects of the statement, more than 4,000 CHE partners have signed onto the statement and we still feel it is valid. For much more information, see CHE’s website at www.healthandenvironment.org.

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 (below).

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 WWW.SFMS.ORG

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 often 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, ex-

Continued on the following page . . .

NOVEMBER 2014 SAN FRANCISCO MEDICINE

A New Era for Environmental Health Continued from the previous page . . . posures should be reduced or eliminated. Good, uncompromised science must be the underpinning of all such efforts.

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-andeffect 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 oth-

Coming Soon! The first installment of a new eBook on how to promote health and prevent disease

ers 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. The Collaborative on Health and the Environment (CHE) has been established to address this need and to take environmental health efforts into a new era of improved scientific understanding, cooperation among diverse interests sharing similar goals, and better policies and preventive efforts.

A Story of Health

A Story of Health begins with

a family reunion that brings you into the lives of fictional people with some of the chronic illnesses that are a serious problem for the health of our nation – asthma, developmental disabilities, cancer, infertility, diabetes, and cognitive decline. Through their stories, you’ll learn the potential causes of these diseases and conditions, and explore prevention strategies.

The stories highlight the

many ways our health is affected by the environments where we live, eat, work, play, pray, volunteer, gather and socialize. These stories also illustrate how we can prevent disease and promote health.

This interactive eBook

includes colorful illustrations and graphics, videos from health and policy experts, links to numerous resources, and more, to help readers navigate the complex world of health.

A Story of Health is written by health experts, with content relevant to a wide audience, from clinicians, to health advocates, to policy makers.

They are stories about our health as individuals, families and communities.

A Story of Health is a collaboration among the Agency for Toxic Substances and Disease Registry (ATSDR), the Collaborative on Health and the Environment (CHE), the Office of Environmental Health Hazard Assessment,

Finally, a resource that clearly explains the multiple factors that influence our health across the lifespan – the natural, built, chemical, food, economic, and social environments – and how they interact with genetics and each other.

California Environmental Protection Agency (OEHHA), the Science and Environmental Health Network (SEHN), and the University of California, San Francisco, Pediatric Environmental Health Specialty Unit (UCSF PEHSU).

A Story of Health will be available as an eBook with free Continuing Education credits available for health professionals.

Download flyer

For more information contact Maria Valenti, mvalenti@igc.org or Brian Tencza, bht1@cdc.gov

SAN FRANCISCO MEDICINE NOVEMBER 2014 WWW.SFMS.ORG

MEDICAL COMMUNITY NEWS CPMC

Edward Eisler, MD

CPMC honors the late Ray Dolby, founder of Dolby Laboratories, by naming the Ray Dolby Brain Health Center in San Francisco. The family of Ray Dolby provided a founding gift of $21 million in 2011 to establish the Brain Health Center, which provides services to patients and families suffering from Alzheimer’s, dementia, or other memory disorders. More than 2,000 people have been treated at the center since its opening in 2012. The Ray Dolby Brain Health Center was the first program of its kind in the U.S. to be developed in collaboration with the Alzheimer’s Association. The Center offers workshops on brain health, coping with memory loss and caregiving, and support groups for newly diagnosed individuals and their families. Results from 40 percent of clinical trials for migraine on the world’s registries are not readily available more than two years after study completion, according to an analysis and scorecard for public availability of results. To capture a snapshot of registered clinical trials related to migraine and a scorecard of the availability of trial results, Dr. Michael Rowbotham, scientific director of the CPMC Research Institute (CPMCRI) and senior study author, and his colleagues created RReMiT. Global findings from the Repository of Registered Migraine Trials (RReMiT) database were published in the September 5, 2014, issue of Neurology, the medical journal of the American Academy of Neurology. An unprecedented collaboration between CPMC and Lucile Packard Children’s Hospital Stanford is anticipated to significantly improve the detection and management of primary ciliary dyskinesia (PCD), a genetic lung disorder without cure affecting thousands of children worldwide. A conference was held at CPMC’s Research Institute (CPMCRI) and cohosted by Lucile Packard Children’s Hospital and the PCD Foundation. The meeting highlighted new perspectives on research into PCD, with international experts presenting their latest findings. PCD is a poorly understood genetic disorder characterized by chronic infections of the respiratory tract, progressive deterioration of lung function, and acute respiratory failure. WWW.SFMS.ORG

St. Luke’s

Barbara Bishop, MD

On Friday, September 26, the groundbreaking ceremony for St. Luke’s took place. I was pleased to witness this historic moment, which many of us have worked for nine years to bring to fruition. St. Luke’s Hospital was founded in 1871 by Dr. Thomas Brotherton, a physician and Episcopal priest; it was the first hospital on the West Coast. As Brotherton described the mission of St. Luke’s Hospital, “St. Luke’s doors as a charitable hospital are open wide to our community for the reception of all colors, nationalities, and creeds. Its benefits, refused to none, will be limited only by its means.” This is the mission that has attracted many of us to work these many years at St. Luke’s Hospital and has kept the medical staff committed to providing high-quality medical care to our community. St. Luke’s Hospital became part of Sutter Health in 2001 and of CPMC in 2005. The association with CPMC and Sutter has brought increased services and improved quality of care to our patients, and we support the increased integration into the Sutter system. At the same time, we recognize the unique mission that we have served and intend to continue our commitment to community service. We look forward to a new hospital facility where we can expand and grow our services for all of the growing and expanding sectors of San Francisco. We have many new physicians joining our medical staff in both primary and specialty care, and we look forward to the medical staff expanding as we prepare for this larger state-of-the art facility in the next five years. The physicians of CPMC, including the physicians at the St. Luke’s campus, are poised to bring groundbreaking approaches to health care in San Francisco as we face the challenges of the changing health care landscape.

Kaiser Permanente Maria Ansari, MD

Environmental health is central to the overall well-being of our patients. The air we breathe, food and water we ingest, and substances we come into contact with during our daily activities can all affect our health. Many health conditions are linked to environmental exposures, especially those occurring early in development. Conditions such as cancer, neurological and neurobehavioral problems, respiratory illness, and reproductive issues have been linked to environmental causes. Kaiser Permanente has been a leader in addressing environmental health issues. As a health care organization, Kaiser Permanente has eliminated use of toxic chemicals such as mercury and phthalates from our medical devices and triclosan from hand soaps, installed low-VOC carpets and other building materials, eliminated the use of flame retardants from upholstered furniture, introduced healthy food free from antibiotics and pesticides, and decreased our carbon footprint through building energy efficiency and encouraging staff to use public transit and carpools. In addition, at the San Francisco Medical Center we have started an environmental medicine consult service. This is a unique service for our members with questions or concerns about exposures outside of work that may be impacting their health or the health of their children. Our primary care team identifies patients’ concerns and refers to our specialty clinic for in-depth evaluations to assess exposures, risks, needs for further testing, and recommendations. In our specialty clinic, we can evaluate varied environmental exposures, such as chemical exposures, drinking water or air contaminants, and exposures during pregnancy or early childhood. We work in collaboration with our colleagues in the KP Toxicology Department and with our colleagues at UCSF, the San Francisco Department of Public Health, and the California EPA for further support and informational assistance. Kaiser Permanente knows that environmental health is critical to the overall health of individuals and our community.

NOVEMBER 2014 SAN FRANCISCO MEDICINE

MEDICAL COMMUNITY NEWS Saint Francis Robert Harvey, MD

The Bothin Burn Center at Saint Francis has been caring for burn victims since 1967, when it was the first burn unit to open west of the Rockies. As a regional center covering nine counties in the greater Bay Area, we have outgrown our current space in the hospital. Delivering top-quality care to our patients in a compassionate, healing environment is of the upmost importance and plans are in place to build a new $16 million Burn Center occupying the entire fifth floor of the main hospital. Our bed count will increase from ten to sixteen and the Center will feature the latest medical technology and equipment, including state-of-the-art life support, monitoring equipment, and ultrasonic hydrotherapy for bathing wounds. We understand that treating a burn goes far beyond wound care, and our dedicated team delivers a holistic approach that treats mind, body, and spirit. Our new Burn Center will feature more spacious, accommodating treatment rooms for patient comfort and care and will include a gym and an operating room. Since we treat approximately seventy children per year, great planning has gone into the pediatric features of the new Burn Center, including a family center equipped with a sound system, media outlets, and a relaxation area. Dedicated pediatric treatment rooms will include a play area compatible with Wii consoles and iPads, all designed to be appealing and comforting to children. Currently the Bothin Burn Center, under the directorship of Medical Director Jeffrey DeWeese, MD, in association with Richard Grossman, MD, treats more than 500 patients per year. We are proud to be the first burn unit in the Bay Area to be verified by the American Burn Association and the American College of Surgeons, Trauma Division. When construction of the new Bothin Burn Center is complete in fall 2015, it will be the largest burn unit in Northern California. We look forward to continuing our legacy of excellent care for burn victims. 30

St. Mary’s

Robert Weber, MD

St. Mary’s Medical Center President Anna Cheung is the chair of the 2014 Silver SPUR Awards Luncheon, taking place November 18 at the Moscone Center. The Awards honor distinct individuals whose goals and achievements have made San Francisco and the Bay Area a better place to live, work, and play. As San Francisco’s oldest continuously operating hospital in the city, we are proud to partner with SPUR, a member-supported nonprofit that promotes good planning and good government to lead the way to a better future for the Bay Area. As the event chair, Anna hosted a smaller, more intimate event for SPUR members, comprised of business and community leaders, at the Sister Diane Grassilli Women’s Health Center at St. Mary’s on October 28. Since we opened the Center in 2012, we’ve been designated as a Center of Excellence by the American College of Radiology, and we are one of only two hospitals in San Francisco to receive the prestigious Healthgrades Women’s Health Excellence Award. We are also eagerly anticipating the implementation of a new tomosynthesis (3D mammography) machine. Coupled with the whole breast ultrasound (WBUS) that is already being used, this addition will give St. Mary’s the most comprehensive breast imaging services in San Francisco. This new technology will enhance our already wideranging women’s care services, which include computer-assisted digital mammography, MRI-guided biopsy, bone density testing, and bladder control diagnostics and therapeutics. With the belief that women’s health is more than just the absence of disease, we will continue to innovate and provide exceptional care for our patients.

Sutter Pacific

Bill Black, MD, PhD

Mold exposure is one of the many environmental exposures that can cause adverse health effects. It’s not surprising that in San Francisco’s mild but often damp climate, exposure to mold is a concern, says Nancy Wiese, DO, MBA, MS, Sutter Pacific Medical Foundation’s medical director of the Occupational Medicine Clinic at California Pacific Medical Center. Dr. Wiese notes, “Some people can be exposed to mold with no health effects; others may experience upper and lower respiratory health effects that can include a runny nose, red eyes, skin rashes, asthma, fever, shortness of breath, or coughing and wheezing. Mold allergy symptoms vary from person to person, and they may flare up only at certain times of the year or only when someone is in a space with a high concentration of mold. “I see a number of exposures that cause adverse health effects, but mold exposure, in particular, can be difficult to sort through,” says Dr. Wiese. Under Dr. Wiese’s direction, CPMC’s Occupational Medicine Clinic also treats workrelated exposures to noise, chemicals, cotton dust, blood-borne pathogens, and lead. A good general approach to evaluating a mold exposure, Dr. Wiese says, is to take a detailed patient history to determine whether an exposure is likely at home or at work. Determine whether the patient’s complaints are consistent with symptoms known to be related to mold exposure. If the answer to both is yes, removal from exposure is the best treatment. Advise the patient to fix plumbing leaks and water intrusion. Controlling humidity and improving ventilation can be helpful. Visible mold can be cleaned with commercial products designed for that purpose or with a bleach solution of no more than one cup of bleach in one gallon of water. The Centers for Disease Control and Prevention and the California Department of Public Health websites are reliable sources of information regarding mold exposure. Though mold exposure can be residential or occupational, Dr. Wiese’s practice is limited to workrelated exposures.

SAN FRANCISCO MEDICINE NOVEMBER 2014 WWW.SFMS.ORG

Letter to the Editor UCSF

Wade Smith, MD

Hand washing with antibacterial soap exposes hospital workers to significant and potentially unsafe levels of triclosan, a widely used chemical currently under review by the U.S. Food and Drug Administration, according to a study led by researchers from UC San Francisco. Triclosan, a synthetic antibacterial agent, is found in thousands of consumer products, including soaps, cosmetics, acne creams, and some brands of toothpaste. The FDA is reviewing its safety based on a growing body of research indicating that it can interfere with the action of hormones, potentially causing developmental problems in fetuses and newborns, among other health concerns. In the current study, published in the August issue of the Journal of Occupational and Environmental Medicine, researchers analyzed urine samples from two groups of thirty-eight doctors and nurses—three-fourths of them women—at two hospitals, identified as Hospital 1 and Hospital 2. Hospital 1 used an antibacterial soap containing 0.3 percent triclosan, while Hospital 2 used plain soap and water. Workers at Hospital 1 had significantly higher levels of triclosan in their urine than workers at Hospital 2. “Antimicrobial soaps can carry unknown risks, and triclosan is of particular concern,” said coinvestigator Paul Blanc, MD, a professor of medicine at UCSF who holds the Endowed Chair in Occupational and Environmental Medicine. “Our study shows that people absorb this chemical at work and at home, depending on the products that they use.” We at UCSF remain committed to the health of the environment, which also includes the working environment of our employees. This study is a reminder that the hospital environment can carry its own special risks, sometimes from surprising sources.

WWW.SFMS.ORG

An Optimal Response to Ebola To the Editor: I have been dismayed about the response to Ebola in our country, but not surprised, for several reasons: An optimal response requires adequate public health funding at federal, state, and local levels; it is easy to show that government can’t work if lawmakers don’t give government agencies the funds they need to do their work. Partisan politics and the reorganization of government agencies since my tenure as a federal health official have made it very difficult to confirm strong leaders in critical positions and to coordinate efforts across agencies. Health experts are driving policy without the active involvement of the front-line health care providers who need to follow those policies; many of the problems we have recently experienced could have been avoided by actively involving practicing nurses, physicians, and other hospital staff members in thinking these issues through in advance. PHILIP R. LEE, MD

This letter was published in the New York Times on Oct. 19, 2014. The writer, an internist, was assistant secretary for health in the Johnson and Clinton administrations (as well as chancellor of UCSF and a longtime SFMS member).

SAVE THE DATE T H E C A L I F O R N I A M E D I C A L A S S O C I AT I O N AND C A L I F O R N I A M E D I C A L A S S O C I AT I O N F O U N D AT I O N P R E S E N T

The 18th Annual President’s Reception & Awards Gala Saturday, December 6, 2014 The U.S. Grant Hotel • 326 Broadway • San Diego, CA 92101 6-7pm – Reception 7-10pm – Dinner, Awards Presentation, Live Auction 10pm-2am – After Party For more information or to RSVP, please visit www.cmanet.org/gala

NOVEMBER 2014 SAN FRANCISCO MEDICINE

SFMS CAREER FAIR 2015 EXHIBITORS

The SFMS fifth annual Career Fair enjoyed a great turnout. Residents and fellows from local residency programs

connected with recruiters from twenty-three exhibiting organizations representing a variety of practice types and settings based in the San Francisco Bay Area. Many residents felt this was a wonderful opportunity to become acquainted with practice position opportunities available in their specialty in the San Francisco Bay Area and a great way to highlight small clinics and groups that may have been overlooked at regional or national job search events. One event attendee commented, “Thank you for organizing an event that showcases the Bay Area’s local community clinics. This event is unlike any other because of the emphasis on San Francisco Bay Area job opportunities.” For those who missed the career fair, send a PDF version of your CV to membership@sfms.org by December 1 so that SFMS can circulate it to all of the career fair recruiters. Please name your file using the following format: PrimarySpecialty_LastName, FirstName. SFMS would like to thank the California Pacific Medical Center for providing the venue for this event. We would also like to recognize our participating exhibitors and staff at the graduate medical departments of CPMC, UCSF, St. Mary’s, and Kaiser Permanente for their generosity and support.

Asian Health Services Bay Area Hospitalist Associates Brown & Toland California Pacific Medical Center Chinese Hospital Cynthia Point, MD Dignity Health John Muir Health Kaiser Permanente/The Permanente Medical Group Laguna Honda Hospital Marin Community Clinics My Doctor Medical Group North East Medical Services One Medical Group Palo Alto Medical Foundation San Francisco Department of Public Health Saint Francisco Medical Group Sonora Regional Medical Center Sutter Gould Medical Foundation Sutter Health East Bay Region Sutter Health Sacramento Sierra Region Sutter Pacific Medical Foundation University Healthcare Alliance/Stanford Hospital

Sutter Pacific Medical Foundation (SPMF) is a non-profit medical organization affiliated with Sutter Health that provides primary and specialty medical care, research and education. Physician Foundation Medical Associates (PFMA) and Sutter Medical Group of the Redwoods (SMGR) are multi-specialty groups that are physician affiliated with SPMF and the larger Sutter Medical Network. We are rapidly growing and our foundation structure enables clinicians to work within a supportive team to provide excellent care. Our caregivers develop and share best practices, mentor new peers and contribute to clinical initiatives. The collegial environment attracts physicians and advance practice clinicians who are patient-centered, innovative, value teamwork and are committed to excellence. For consideration of any of the following physician practice opportunities, please email a cover letter and curriculum vitae to Denise Jimenez, Human Resources Manager, at jimenedj@sutterhealth.org.

Physician Foundation Medical Associates (PFMA)    

Family Medicine Internal Medicine Internal Medicine Clinician-Educator Integrative Primary Care

   

Medical Director, Internal Medicine Ambulatory Training Psychiatrist Clinician-Educator Transplant Nephrologist Maternal Fetal Medicine (OB-GYN)

 

Urology (Oncology or Female Urology) Medical Oncologist or Medical Oncologist/Hematologist

Sutter Medical Group of the Redwoods (SMGR)   

Family Medicine Internal Medicine General Surgery (Endocrine)

All positions are posted at sutterhealth.org/doctors/opportunities

Applicants will be considered regardless of race, color, creed, national origin, ancestry, sex, marital status, disability, protected veteran status, religious or political affiliation, age, sexual orientation, medical condition or pregnancy. Applicants with criminal histories will be considered for employment in a manner consistent with federal, state and local laws.

Chinese Hospital Health System is recruiting for the following positions:

 Primary Care FPs and Internal Medicine Preference for: • Bilingual (Cantonese or Mandarin) • Board Certified/Board Eligible  Urologist  Psychiatrist  General Surgeon Preference for: • Bilingual (Cantonese or Mandarin) • Board Certified/Board Eligible

For more information call or email: DocJobs@chasf.org | 415-677-2493 or visit: sfbayareacantonesespeakingfamilypracticejob.com Please visit our website at NEMS.org and look for our vacancies.

More details can be found at http://bit.ly/S5sAMYi E-mail letter and CV to: Susan M. Huang, MD, Medical Director shuang@ahschc.org 818 Webster Street, Oakland, CA 94607

CLASSIFIED AD Office Sublet 2100 Webster 5th floor â&#x20AC;&#x201C; Premier floor adjacent to hospital passageway in well-known medical office building with indoor pt. parking. Janitorial, utilities included. Office share with one physician. MD parking available. Two exam rooms, one physician office and ability to share staff if needed. All equipped, professionally decorated. 1,580 sq. ft./790 per MD. $3,759 per month. Confidential â&#x20AC;&#x201C; Contact Debra Phairas: (415) 764-4800 or dphairas@practiceconsultants.net.

Welcome New Members! The SFMS would like to welcome the following new members.

Physicians

Residents

SAN FRANCISCO MEDICINE NOVEMBER 2014 WWW.SFMS.ORG

Member Benefit News: Open enrollment for the San Francisco Medical Societysponsored dental plan has started! You and your family are eligible to enroll in the SFMS-sponsored dental plan only during open enrollment periods. Apply by December 31, 2014! To be eligible for coverage, applications must be received during the special open enrollment period ending on December 31, 2014.

For more information... Call a Client Advisor at 800-842-3761 for more information. Or visit www.CountyCMAMemberInsurance.com to download a brochure and application.