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Visionary Science, Ethics, Law and Action in the Public Interest

Ecological Medicine – Essays

Ecological Medicine

Testimony on the EPA’s Efforts to Protect Children’s Health
Presented to the Senate Committee on Environment and Public Works
Ted Schettler MD MPH, March 2010

“Hearing on the Government Accountability Office’s Investigation of EPA’s Efforts to Protect Children’s Health”

In 1997 President Clinton issued executive order 13045, establishing an interagency Task Force on Environmental Health Risks and Safety Risks to Children and requiring every agency proposing regulatory action to consider its impacts on children. A 2010 report from the Government Accounting Office contained recommendations intended to reinvigorate EPA’s early emphasis on children. Ted was asked to comment on the US Environmental Protection Agency’s efforts to protect children’s health.

His testimony was featured in a blog by CNN chief medical correspondent Dr. Sanjay Gupta and in an article in USA Today.
Designing the 21st Century Hospital: Healing from the Inside Out
Environmental Leadership for Healthier Patients, Facilities, and Communities
September, 2006

On average, Americans spend 90 percent of their time indoors, and too often in buildings where the construction materials, cleaning solutions, machinery and other products emit toxic chemicals. Over time, these substances can concentrate in the human body and contribute to poorer health and disease outcomes.

In September, the Center for Health Design, together with Health Care Without Harm convened 40 influential health care leaders, for an invitation only symposium on Designing the 21st Century Hospital: Environmental Leadership for Healthier Patients and Facilities. This event, supported by a grant from the Robert Wood Johnson Foundation, challenged participants to advance strategies for encouraging the production and use of more cost-effective, environmentally sustainable design approaches and products. Participants also proposed ideas on how to expand the green design movement among more health and health care facilities.

The nation’s health care system is anticipating a hospital construction boom worth $200 billion over the next decade. This building boom presents a rare opportunity to incorporate green design and construction principles into new facilities. “Hospital leaders can no longer ignore the evidence that building green is better for their patients, better for their staff, and better for their bottom line,” said attendee Rosalyn Cama, chair of The Center for Health Design’s board of directors and president of CAMA, Inc.

Judith Waterson, president & CEO of Spaulding Rehabilitation Hospital in Boston, a proponent of green design principles, said, “The most compelling and resonant benefit of green building, other than constructing a building that works, is to promote environmental sustainability and, by doing so, become a leader in the industry. As a community resource, a hospital has to be taking a lead role in that.”

Download Ted Schettler’s MD, MPH (SEHN’s Science Director) white paper Toward an Ecological View of Health: An Imperative for the 21st Century presented by the Center for Health Design and Health Care Without Harm at a conference sponsored by the Robert Wood Johnson Foundation, September 2006.

Guest Perspective: Phthalate Safety Concerns Merit Substitute Products
By Ted Schettler, M.D., MPH, Science and Environmental Health Network.
February 28, 2006

As evidence of the hazards of di-2-ethylhexyl phthalate (DEHP) Continues to mount, the inevitable question arises, “When do we know enough to act to protect people from unnecessary and potentially harmful exposures?” Concerns about the safety of DEHP, a PVC plasticizer, have intensified since it became apparent that developing organisms are far more susceptible to DEHP exposures than adults. Hundreds of animal studies confirm the particular vulnerability of the developing male Reproductive system and have begun to define mechanisms of toxicity, including impaired testosterone synthesis. Birth defects, pathologic testicular changes, decreased sperm production, and altered hormone levels are caused by developmental exposures to DEHP. Lowest adverse effect levels in developing organisms are orders of magnitude lower than doses necessary to cause reproductive system impacts in adults. (excerpt)

Toward an ecological view: Complex systems, health, and disease 
By Ted Schettler, M.D., MPH, Science and Environmental Health Network.
February, 2006

Complex relationships among genetic, biologic, toxicologic, nutritional, geologic, economic, political, social, cultural, and historical phenomena are major determinants of health or disease. The dominant scientific approach to understanding this complexity involves taking it apart in order to examine more manageable pieces. That approach emphasizes the role of parts and de-emphasizes relationships. Then, in an attempt to understand some larger whole, scientists often construct models built of selected individual variables from the ground up, referring to “independent” variables that combine to determine the “dependent” outcome of interest. (excerpt)

Ted’s article was orginally published by San Francisco Medicine: Journal of the San Francisco Medical Society (January/February 2006 Volume 79, No 1). The article appears on pages 12-15 in this PDF document; however, other articles within this volume may be of interest to SEHN readers.

Dr. Ted Schettler’s speech at the first FoodMed conference in November 2005, sponsored by Kaiser Permanente and HealthCare Without Harm.
November, 2005
By Ted Schettler, M.D., MPH, Science and Environmental Health Network.

“I was asked to address the basis for making decisions across the spectrum of clinical medicine, public health, and ecological health. Understanding just how things work is limited by increasing data gaps and uncertainty across that spectrum. One question that was posed is whether or not there are, or should be, different standards of evidence for making decisions about how to act in clinical medicine and public environmental health.”(excerpt)
N.B. The link initiates an MS Word download.

Nutrition and Food Production Systems: A Role for Health Care Institutions
July, 2004
By Ted Schettler, M.D., MPH, Science and Environmental Health Network.

Food production, distribution, and consumption in the US and throughout the world lie at the intersection of diverse interests in nutrition, clinical medicine, public health, land use, economics, ecosystem health, labor concerns, immigration policies, justice, spirituality, and national security. Few issues are as fundamental, cross-cutting, and all-encompassing. Because of the wide reach of many aspects of food systems into personal and public life, the way that such a basic human need is met is the focus of attention of a large and diverse group of organizations and institutions.

Recognizing that there are a wide variety of lenses through which to view the food system, this brief summary attempts to consider the view from the perspective of the health-care system in the US. Intersections with other perspectives are apparent and suggest opportunities as well as barriers to improving aspects of the food system in ways that benefit a variety of interests.

Since diet is a leading contributor to morbidity and mortality in the US, supporting healthy food systems in health care is an opportunity to address major causes of disease. Hospitals can play a leadership role in promoting healthy agriculture and healthy foods. This paper discusses a rationale and proposes some goals and expected benefits from moving hospitals and agriculture towards a healthier system.
N.B. The link initiates an MS Word 2000 download.

Wolves and Precaution: The Precautionary Principle and Children’s Environmental Health
May 8, 2002
By Carolyn Raffensperger, Science and Environmental Health Network.
Keynote address to the Washington State Environmental Health Association’s 57th Annual Educational Conference, Olympia, WA
N.B. The link initiates an MS Word 2000 download.

Health Implications of Snowmobile Use In Yellowstone National Park
March 2003
By Sarah Janssen, M.D., Ph.D. and Ted Schettler, M.D., MPH
(N.B. The link initiates the download of a 32-page paper in MS Word format.)

Executive Summary – The National Park Service recently announced a major change in how it plans to manage winter visitation in Yellowstone and Grand Teton National Parks. Instead of phasing out the use of snowmobiles, the agency said it intends to restrict the numbers and types of snowmobiles permitted within the parks, protecting environmental and human health through careful limits.

The agency noted that its plan to continue snowmobile use would provide less protection for air quality and human health than an earlier decision to replace snowmobile use with a transportation system of snowcoaches.

The agency also reported that its plan would reduce snowmobile emissions significantly but not enough to remove a likelihood of adverse health effects for employees and visitors susceptible to respiratory and other health problems.

These two acknowledgements seemed at odds with Yellowstone’s designation by Congress as a Class 1 airshed, a place intended to have the cleanest air in the nation.

This report grew out of a strong interest on the part of organizations concerned about public health to better understand the human health implications of this change in policy.

Specifically, the report was undertaken to assess:

  • The pollution levels predicted by the National Park Service;
  • Peer-reviewed literature on the health effects of pollutants prevalent in snowmobile emissions; and
  • Assumptions used by the National Park Service in modeling snowmobile emissions and the agency’s resulting conclusions about the effects on air quality and human health.

The assessment highlights significant omissions and discrepancies in the National Park Service’s analysis. It appears that risks to human health under the Preferred Alternative would likely be greater than the National Park Service has acknowledged, particularly for children, pregnant women, seniors, asthmatics, and people with other respiratory and cardiovascular diseases. Some of these risks are not accurately described in the National Park Service’s analysis. Others are overlooked entirely.

This report details concerns about data both used and not incorporated by the National Park Service in development of its plans to change winter use in Yellowstone. At present, the agency is using flawed analysis to make a decision, which, as a result, is unlikely to be fully protective of employee or public health:

  • The National Park Service has predicted pollution levels with a continuation of snowmobile use that would clearly pose health risks for particular populations. Individuals with asthma and other respiratory and cardiovascular diseases, pregnant women, children, and the elderly would face a higher level of risk than under a snowmobile phase-out. These groups comprise a large percentage of the general public. Yet the National Park Service did not analyze their elevated risk.
  • Many employees and visitors in Yellowstone are exposed to concentrations of snowmobile emissions that are much higher than those measurable as ambient pollution. Examples include employees working in areas of concentrated snowmobile traffic, snowmobilers trailing large groups of machines, or children riding on the backs of snowmobiles. Studies have demonstrated that in these circumstances exposure to harmful pollutants can increase dramatically. The National Park Service’s most recent analysis did not model for these circumstances. As a result there would likely be frequent discrepancies between predicted pollution levels and actual exposure to air contaminants.
  • Recent health studies have identified airborne particulate matter less than 2.5 microns in size (PM2.5) as causing many of the health effects attributed to particulate matter, including respiratory disease, lung damage, cancer, and premature death. Even modest levels of PM2.5 have been associated with adverse health effects. Virtually all particulate matter emissions from snowmobile engines are PM2.5 or smaller yet the National Park Service did not model specifically for PM2.5 in its most recent analysis. Nor did the agency discuss potential health effects of acute and chronic exposure to PM2.5 in its analysis.
  • Visitors not acclimated to Yellowstone’s high elevation are likely to be more susceptible than local residents to adverse health effects from carbon monoxide exposure. CO enters the bloodstream from the lungs, binds to hemoglobin in red blood cells, and forms carboxyhemoglobin (COHb). COHb impairs oxygen delivery throughout the body. For individuals who travel from low elevation to Yellowstone’s average elevation of more than 7,000 feet, the resultant decrease in oxygen delivery to tissues and organs could be highly significant. People who already suffer from compromised oxygen delivery are especially sensitive to changes in elevation and CO exposure. Individuals with cardiac disease are more likely to experience arrhythmia or angina when exposed to CO at high elevations than when exposed to the same concentration of CO at lower elevations. These factors are likely to apply to many of Yellowstone’s winter visitors. However, the National Park Service analysis does not discuss this potential health consequence of permitting higher levels of carbon monoxide than are achievable through a snowmobile phaseout.
  • The National Park Service has overstated benefits to air quality from its plan to cap numbers of snowmobiles and require that all machines be “Best Available Technology” (BAT). In predicting total snowmobile emissions, the agency used data from a snowmobile that is significantly less polluting than the new definition of BAT. The Park Service defines BAT as snowmobiles that emit 90 percent fewer hydrocarbons (HC) than a standard 2-stroke snowmobile and 70 percent less carbon monoxide (CO). The agency’s modeling of future air quality used emissions data from a snowmobile with 95 to 98 percent less HC and 85 percent less CO.
  • The National Park Service has stated that its plan to allow continued snowmobile use is one that assures dramatic reductions in snowmobile emissions. But the agency has failed to make clear that cutting emissions is not the same as cutting pollution. During the winter, Yellowstone frequently experiences stable air masses and/or inversions that limit dispersion of emissions. When emissions accumulate, pollution levels rise. Pollution levels can remain high hours after peak snowmobile traffic has subsided. This is a critical distinction because pollution levels, not emissions from individual snowmobiles, are the relevant factor for human health. By not making this distinction clear, the National Park Service analysis reflects a distorted view of air quality and health benefits associated with its plan to continue snowmobile use. For example, carbon monoxide emissions would be reduced by some 70 percent per snowmobile. But modeling indicates that peak carbon monoxide pollution levels would drop by just 51 percent at Old Faithful, and only 26 percent at the West Entrance where fresh air is piped into work booths and employees still experience symptoms of CO toxicity, including headaches, dizziness, and nausea.
  • The National Park Service plan for continued snowmobile use hinges upon several disputed assumptions regarding “Best Available Technology” (BAT). These include whether the agency has the authority to require emissions reduction more stringent than the Environmental Protection Agency and whether snowmobiles meeting these requirements would be readily available and affordable to the public. It is also unclear how the National Park Service would ensure that all private snowmobiles would be BAT when the machines are not clearly labeled as such by the manufacturers and can be modified, resulting in higher emissions and more noise.

In summary, the evidence presented here demonstrates that serious public health risks from pollution would remain under the National Park Service plan to continue snowmobile use in Yellowstone and Grand Teton national parks. The agency did not use the best available data in its most recent analysis. Air pollution and health effects from snowmobiles have been underestimated, poorly depicted, and, in some cases, not analyzed at all. For these reasons, actual exposure and health risks for park employees and potentially tens of thousands of winter visitors would be greater than the National Park Service has reported. The aim of this report is to convey these concerns, and the large body of peer-reviewed science upon which they are based, to the National Park Service and the public so that more informed decisions can be made. More than 60 published studies referred to throughout this report are listed on pages 26-29.

It´s Time To Address DEHP Concerns
2001
Ted Schettler MD, MPH

An environmentally sustainable and safe plastics industry is a laudable goal. Unfortunately, those who critique any aspect of the plastics’ supply chain are too often characterized as being opposed to the use of all plastics, typically with no evidence to support that claim. But let’s be clear … (excerpt)

Environmental Challenges and Visions of Sustainable Health Care
May 2001
Ted Schettler MD, MPH

As long ago as the 4th century BC, Hippocrates advocated a framework that related medical and public health practices. He urged physicians to pay attention to the environmental, social, and behavioral context in which illness occurs. The airs “peculiar to each particular region”, the “properties of the waters” that individuals drink and use, and the “mode of life” of inhabitants were, he said, essential to understanding their health. Much later, in the 19th century, Florence Nightingale promoted this same framework with her emphasis on the importance of clean water and air, along with adequate sanitation. At the same time, Rudolf Virchow, considered by many to be the founder of modern pathology, emphasized the importance of social and political factors in determining health. Virchow described medicine as a social science and politics as the practice of public health on a large scale … (excerpt)

Phthalate Esters and Endocrine Disruption
2001
Ted Schettler MD, MPH

The toxicity of phthalate esters is of considerable interest because of their use in many consumer products leading to widespread human exposures and environmental contamination. Of particular concern is their use as plasticizers in medical products and children’s toys made of polyvinyl chloride (PVC). Children chewing on PVC toys are exposed to phthalate plasticizers, and patients receiving intravenous, respiratory, or intestinal therapies from PVC products are exposed to varying amounts of the commonly used plasticizer, di-ethyl hexyl phthalate (DEHP). In Europe and in the US, the Health Care Without Harm coalition is concerned about the potential health impacts of phthalate exposures from medical devices and has been closely following the evolution of scientific understanding of mechanisms of toxicity and identification of individuals who are particularly susceptible to toxic effects … (excerpt)