Moving from awareness to action on preventing patient exposure to toxic environmental chemicals

Abstract

Related articles, pages 559 and 597 Related articles, pages 559 and 597 A recent headline in The New York Times posed the question, “Are you a toxic waste disposal site?”1Kristof N. Are you a toxic waste disposal site? New York Times. February 13, 2016. Available at: http://www.nytimes.com/2016/02/14/opinion/sunday/are-you-a-toxic-waste-disposal-site.html. Accessed April 18, 2016.Google Scholar A reasonable reply is “yes.” Toxic chemicals are ubiquitous in our homes, workplaces, and communities, consequently in everyone, everyday, everywhere. Two articles in this issue of the American Journal of Obstetrics and Gynecology (AJOG) have brought to the fore how reproductive health professionals are beginning to seize on this immense challenge as an opportunity to benefit the health of all patient populations and future generations. The first article, “Obesogens: an emerging threat to public health” by Janesick and Blumberg2Janesick A.S. Blumberg B. Obesogens: an emerging threat to public health.Am J Obstet Gynecol. 2016; ([Epub ahead of print.])http://dx.doi.org/10.1016/j.ajog.2016.01.182PubMed Google Scholar provides an overview of the burgeoning research that links exposure to endocrine-disrupting chemicals with obesity and recommends that strategies to prevent exposure to endocrine-disrupting chemicals should be discussed routinely by obstetricians with their patients. The second article, “Will my work affect my pregnancy?” by Grajewski et al,3Grajewski B. Rocheleau C.M. Lawson C.C. Johnson C.Y. Will my work affect my pregnancy? Resources for anticipating and answering patients’ questions.Am J Obstet Gynecol. 2016; ([Epub ahead of print.])http://dx.doi.org/10.1016/j.ajog.2016.03.005PubMed Google Scholar which provides resources for anticipating and answering patients’ questions, summarizes queries made to the National Institute for Occupational Safety and Health regarding reproductive hazards that are encountered at work and, importantly, provides invaluable resources to support clinicians in answering patient questions. Publication of these 2 articles by AJOG comes on the cusp of a sea change in awareness and action among reproductive health professionals about exposure to toxic environmental chemicals that have surged over the past 3 years. In 2013, the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine published an opinion that called for “timely action to identify and reduce exposure to toxic environmental agents while addressing the consequences of such exposure.”4American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women, American Society for Reproductive Medicine Practice Committee, The University of California San Francisco Program on Reproductive Health and the EnvironmentExposure to toxic environmental agents: no. 575. The College, Washington (DC)2013Google Scholar, 5American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women, American Society for Reproductive Medicine Practice Committee, The University of California San Francisco, Program on Reproductive Health and the EnvironmentExposure to toxic environmental agents: Committee Opinion no. 575 Companion Piece. The College, Washington (DC)2013Google Scholar On October 1, 2015, this call echoed around the world with publication of a policy statement by the International Federation of Gynecology and Obstetrics (FIGO) on reproductive health impacts of exposure to toxic environmental chemicals.6Di Renzo G.C. Conry J.A. Blake J. et al.International Federation of Gynecology and Obstetrics opinion on reproductive health impacts of exposure to toxic environmental chemicals.Int J Gynaecol Obstet. 2015; 131: 219-225Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar FIGO includes 125 countries/territories and is the leading global voice of reproductive health professionals; its actions have profound resonance. Publication of the FIGO opinion coincided with the FIGO “Summit on Shaping Our Planetary Survival” that was held in conjunction with the XXIII FIGO World Congress in Vancouver, British Columbia. The Summit brought together >50 reproductive health professionals from 25 countries who began to develop a plan of action for the implementation of FIGO’s recommendations.7Program on Reproductive Health and the Environment, FIGO. Summit on shaping our planetary legacy: setting an agenda for reproductive environmental health preconference discussion document. 2015.Google Scholar FIGO has established a Reproductive and Developmental Environmental Health Work Group that will review and address these issues from scientific, social, and political perspectives and will keep this as a central FIGO agenda item for the coming decade. Videos of the presentations at the XXIII FIGO World Congress and other related materials are at the following link: http://prhe.ucsf.edu/prhe/healthnottoxics.html. Thus, reproductive health professional societies in the United States and around the globe now regard the topic of the prevention of exposure to toxic chemicals as their issue. They now officially recognize the science that links exposure to toxic chemicals and adverse health outcomes as informing the practice of reproductive healthcare delivery, have issued a call to action, and have an official work group to bring the plan to fruition. So what does this mean for the practicing health professional? FIGO outlined 4 mutually reinforcing recommendations for action by obstetricians and gynecologists, women’s health nurse practitioners, nurses, and other health professionals. The good news is that obstetricians and gynecologists and other reproductive health professionals can and are acting on each of these recommendations. The unique and powerful voices of reproductive health professionals around the world have become part of the global movement for the prevention of exposure to toxic chemicals. In February 2016, 5 societies of reproductive health professionals (ie, the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, the Endocrine Society, the American Society of Reproductive Professionals, and the Society for Maternal-Fetal Medicine) joined 9 other public and environmental health professional societies in urging the leadership in the US Senate and the US House of Representatives to prioritize public health in their current efforts to reform the Toxic Substances Control Act, which is the outdated regulatory framework for environmental chemicals.8Health Professional Organizations’ Policy Statements Database. Available at: http://prhe.ucsf.edu/prhe/clinical/index.html - ps. Accessed April 1, 2016.Google Scholar Currently, unlike pharmaceuticals, most environmental chemicals enter the marketplace and people with little to no scrutiny of their potential health impacts,9Cranor C. Legally poisoned: how the law puts us at risk from toxicants. Harvard University Press, Cambridge (MA)2011Google Scholar, 10Vogel S.A. Roberts J.A. Why the toxic substances control act needs an overhaul, and how to strengthen oversight of chemicals in the interim.Health Aff (Millwood). 2011; 30: 898-905Crossref PubMed Scopus (46) Google Scholar which is a policy gap likened by Birnbaum,11Birnbaum L.S. When environmental chemicals act like uncontrolled medicine.Trends Endocrinol Metab. 2013; 24: 321-323Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar Director of the National Institute of Environmental Health Sciences, to “…environmental chemicals act[ing] like uncontrolled medicine.” Reproductive and other health professional societies recommended that efforts to reform the Toxic Substances Control Act protect the safety and health of their most vulnerable patients and the public from unsafe chemicals and ensure access to confidential business information by public health and other professionals.8Health Professional Organizations’ Policy Statements Database. Available at: http://prhe.ucsf.edu/prhe/clinical/index.html - ps. Accessed April 1, 2016.Google Scholar Effective public policy is essential to prevent harm, because individuals cannot act on their own behalf to prevent many environmental exposures (ie, chemicals in our air, food, and public drinking water).12Hacker J.S. Pierson P. The real cause of the Flint crisis.The Atlantic. March 7, 2016; (Available at: http://www.theatlantic.com/politics/archive/2016/03/the-real-cause-of-the-flint-crisis/472305/. Accessed April 13, 2016)Google Scholar Likewise, unrecognized or uncontrolled exposures to toxic chemicals at work are not amenable to individual-level action. Grajewski et al3Grajewski B. Rocheleau C.M. Lawson C.C. Johnson C.Y. Will my work affect my pregnancy? Resources for anticipating and answering patients’ questions.Am J Obstet Gynecol. 2016; ([Epub ahead of print.])http://dx.doi.org/10.1016/j.ajog.2016.03.005PubMed Google Scholar point to a long list of urgent policy needs to prevent workplace exposure to reproductive and developmental toxicants among women and men of childbearing age. First and foremost, the authors underscore the need for reliable toxicity data about the chemicals in use so that employers, workers, and health professionals can make informed decisions and the need for policies to prevent discrimination against pregnant workers. Additionally, as Janesick and Blumberg2Janesick A.S. Blumberg B. Obesogens: an emerging threat to public health.Am J Obstet Gynecol. 2016; ([Epub ahead of print.])http://dx.doi.org/10.1016/j.ajog.2016.01.182PubMed Google Scholar point out, we need to act on the findings of well-designed animal studies in the absence of human evidence, much as we do now when deciding whether to proceed to human clinical trials for pharmaceuticals. By the time human studies show harm, prevention has largely failed. Currently, there is tremendous momentum for leveraging the billions of dollars in purchasing power of healthcare institutions to create a healthy food system for all.13Norris T, Howard T. Can hospitals heal America’s communities? Democracy Collaborative 2015.Google Scholar Community and market-based interventions by the healthcare sector are bringing healthier food to diverse and vulnerable populations.14Health Care Without Harm, San Francisco Bay Area Physicians for Social Responsibility. California healthy food in healthy care: harnessing the purchasing power and expertise of the health care sector to build a sustainable food system. In.Google Scholar By aggregating their volume demand for regional, sustainable food products, hospitals are not only helping to increase access to healthy foods but also are building community wealth in workforce development and jobs.13Norris T, Howard T. Can hospitals heal America’s communities? Democracy Collaborative 2015.Google Scholar, 14Health Care Without Harm, San Francisco Bay Area Physicians for Social Responsibility. California healthy food in healthy care: harnessing the purchasing power and expertise of the health care sector to build a sustainable food system. In.Google Scholar For example,•One in 4 hospitals in California participate in the Healthy Food In Health Care Program14Health Care Without Harm, San Francisco Bay Area Physicians for Social Responsibility. California healthy food in healthy care: harnessing the purchasing power and expertise of the health care sector to build a sustainable food system. In.Google Scholar;•Almost one-half of the fresh produce that is purchased for patients at Kaiser Permanente are produced sustainably and/or locally grown15Kaiser and Healthcare without Harm Health Care Food Purchasing Power Infographic. Available at: https://noharm-uscanada.org/sites/default/files/documents-files/3124/Healthy Food System Infographics (Print).pdf. Accessed April 13, 2016.Google Scholar;•Gundersen Lutheran Health System in Wisconsin cofounded a multiple stakeholder–owned Fifth Season Co-op to strengthen the local food economy by building the necessary infrastructure13Norris T, Howard T. Can hospitals heal America’s communities? Democracy Collaborative 2015.Google Scholar; and•In Detroit, an expanding network of healthcare sites are connecting patients with chronic disease, at risk pediatric patients, and food insecure families with local healthy food resources by writing prescriptions for fresh, local fruits and vegetables.15Kaiser and Healthcare without Harm Health Care Food Purchasing Power Infographic. Available at: https://noharm-uscanada.org/sites/default/files/documents-files/3124/Healthy Food System Infographics (Print).pdf. Accessed April 13, 2016.Google Scholar These achievements were supported by over a decade of policy work that was undertaken by health professionals in organizations such as the California Nurses Association and the California Medical Association. In the case of the California Medical Association, early initiatives that raised concerns about pesticide use and health impacts within agricultural areas and schools laid the basis for follow-on comprehensive healthy food policies that were supported, in turn, at the national level by the American Medical Association.8Health Professional Organizations’ Policy Statements Database. Available at: http://prhe.ucsf.edu/prhe/clinical/index.html - ps. Accessed April 1, 2016.Google Scholar All of these preceding examples illustrate how health professionals and their institutions are working for a healthy and equitable food system that is a powerful tool for the prevention of chronic disease. A 2014 survey of US obstetricians found that, although the vast majority believed that asking about exposure to toxic chemicals would benefit their patient’s health, “they equated counseling with ‘opening Pandora’s box’ (ie, they feared broaching the topic of environmental health with patients because they lacked adequate knowledge and understanding to answer patients’ questions about exposures …).16Stotland N. Sutton P. Trowbridge J. et al.Counseling patients on preventing prenatal environmental exposures: a mixed-methods study of obstetricians.PLoS ONE. 2014; 9: e98771Crossref PubMed Scopus (55) Google Scholar The article by Grajewski et al3Grajewski B. Rocheleau C.M. Lawson C.C. Johnson C.Y. Will my work affect my pregnancy? Resources for anticipating and answering patients’ questions.Am J Obstet Gynecol. 2016; ([Epub ahead of print.])http://dx.doi.org/10.1016/j.ajog.2016.03.005PubMed Google Scholar demonstrates that healthcare professionals can feel secure in beginning a conversation with their patients about their workplace exposures because the National Institute for Occupational Safety and Health, an agency of the US Centers for Disease Control and Prevention, has resources and experts who can help find evidence-based answers to patient questions. Grajewski et al provide guidance on asking about workplace exposures; environmental and occupational health history forms are available online, along with resources for counseling patients.17University of California San Francisco Program on Reproductive Health and the Environment. Food matters. In. Edited by UCSF Program on Reproductive Health and the Environment, Health Care Without Harm’s Healthy Food in Health Care Initiative, Physicians for Social Responsibility; 2011.Google Scholar, 18SafetyNEST. Available at: http://www.mysafetynest.org/. Accessed April 13, 2016.Google Scholar, 19All that matters series of patient counseling brochures. Available at: http://prhe.ucsf.edu/prhe/allthatmatters.html. Accessed April 13, 2016.Google Scholar Moreover, complementary expertise and resources are available to health professionals regarding nonoccupational exposures through the US Centers for Disease Control and Prevention’s Pediatric Environmental Health Specialty Units (PEHSUs).20Pediatric Environmental Health Specialty Units (PEHSUs). Available at: http://www.cdc.gov/features/pehsu/. Accessed April 13, 2016.Google Scholar The PEHSUs, which are located throughout North America, are ready, willing, and able to respond to the myriad of patient queries (ie, “Should I tell my patients to avoid manicures in pregnancy?” “I ordered a lead level, and it’s high; what should I do?” “Patients are asking me to order hair testing for heavy metals, should I do it?” “My patient is pregnant and renovating an older home; is that a worry?”). The PEHSUs have been serving the pediatric community for the past 15 years; in recognition of the science linking prenatal exposure to environmental chemicals and children’s health, they recently extended their program to support reproductive health professionals. Each PEHSU has a hotline for health professionals who seek answers to patient questions.20Pediatric Environmental Health Specialty Units (PEHSUs). Available at: http://www.cdc.gov/features/pehsu/. Accessed April 13, 2016.Google Scholar Although many challenges to asking patients about their exposure to toxic chemicals remain (ie, time and training),16Stotland N. Sutton P. Trowbridge J. et al.Counseling patients on preventing prenatal environmental exposures: a mixed-methods study of obstetricians.PLoS ONE. 2014; 9: e98771Crossref PubMed Scopus (55) Google Scholar the capacity to overcome these barriers is improving rapidly, and counseling patients about chemicals in their work and home environments is within the reach of practicing reproductive health professionals. Although FIGO’s opinion emphasizes that it should not be a privilege to breathe clean air, eat nutritious food, drink potable water, or have a workplace free of poisons, the discovery and disclosure of the epidemic of lead poisoning from public drinking water in Flint, Michigan, reflects the persistent inequities in exposure to toxic environmental chemicals.21Hanna-Attisha M. LaChance J. Sadler R.C. Champney Schnepp A. Elevated blood lead levels in children associated with the flint drinking water crisis: a spatial analysis of risk and public health response.Am J Public Health. 2016; 106: 283-290Crossref PubMed Scopus (649) Google Scholar, 22Bellinger D.C. Lead contamination in Flint: an abject failure to protect public health.N Engl J Med. 2016; 374: 1101-1103Crossref PubMed Scopus (124) Google Scholar The saga of Flint also illustrates how health professionals are championing environmental justice successfully in their own communities. Hanna-Attisha, a pediatrician, played an essential role in supporting the tireless efforts of community members to force action by local, state, and federal officials.22Bellinger D.C. Lead contamination in Flint: an abject failure to protect public health.N Engl J Med. 2016; 374: 1101-1103Crossref PubMed Scopus (124) Google Scholar, 23Gupta S, Tinker B, Hume T. Our mouths were ajar: doctor’s fight to expose Flint’s water crisis [transcript]. CNN. January 22, 2016. Available at: http://edition.cnn.com/2016/01/21/health/flint-water-mona-hanna-attish/. Accessed April 13, 2016.Google Scholar In response to her patient’s concerns about the water, she looked at the lead test data and determined, “We had an ethical, professional, moral responsibility to alert our community (to) what was going on.”23Gupta S, Tinker B, Hume T. Our mouths were ajar: doctor’s fight to expose Flint’s water crisis [transcript]. CNN. January 22, 2016. Available at: http://edition.cnn.com/2016/01/21/health/flint-water-mona-hanna-attish/. Accessed April 13, 2016.Google Scholar Health professionals who work on climate change are at the forefront of action on environmental justice; an editorial in the British Medical Journal put it succinctly, “climate change is about poverty and equity.”24Costello A. Montgomery H. Watts N. Climate change: the challenge for healthcare professionals.BMJ. 2013; 347: f6060Crossref PubMed Scopus (21) Google Scholar The health impacts of climate change disproportionately impact low-income and other vulnerable patient populations in the United States and low-income countries around the world.25Levy B. Patz J. Climate change and public health. Oxford University Press, New York2015Crossref Google Scholar Physicians and medical scientists are working in many arenas to stimulate an urgent response to climate change,26American Congress of Obstetricians and Gynecologists. Position statement: climate change and women’s health. In.: American Congress of Obstetricians and Gynecologists; 2016.Google Scholar and opportunities to “shout from the rooftops that climate change is a health problem”24Costello A. Montgomery H. Watts N. Climate change: the challenge for healthcare professionals.BMJ. 2013; 347: f6060Crossref PubMed Scopus (21) Google Scholar abound. In just 1 example, our medical school at the University of California San Francisco is working to educate faculty members on how to integrate climate change and sustainability themes into existing courses, effectively normalizing environmental health and justice as part of healthcare among the next generation of physicians. In summary, regarding the scope of health professional concerns, these 2 articles in AJOG are a bellwether of the content of medical journals to come. Reproductive health professionals are moving from “awareness of” to “patient-centered action” on the environmental threats to healthy reproduction and development. Indeed, this trajectory of health professional practice offers a powerful opportunity for keeping our families and communities healthy now and across generations. “Will my work affect my pregnancy?” Resources for anticipating and answering patients’ questionsAmerican Journal of Obstetrics & GynecologyVol. 214Issue 5PreviewAuthoritative information on occupational reproductive hazards is scarce and complex because exposure levels vary, multiple exposures may be present, and the reproductive toxicity of many agents remains unknown. For these reasons, women’s health providers may find it challenging to effectively address workplace reproductive health issues with their patients who are pregnant, breast-feeding, or considering pregnancy. Reproductive epidemiologists at the Centers for Disease Control and Prevention National Institute for Occupational Safety and Health answered >200 public requests for occupational reproductive health information during 2009 through 2013. Full-Text PDF Obesogens: an emerging threat to public healthAmerican Journal of Obstetrics & GynecologyVol. 214Issue 5PreviewEndocrine disrupting chemicals (EDCs) are defined as exogenous chemicals, or mixtures of chemicals, that can interfere with any aspect of hormone action. The field of endocrine disruption is historically rooted in wildlife biology and reproductive endocrinology where EDCs are demonstrated contributors to infertility, premature puberty, endometriosis, and other disorders. Recently, EDCs have been implicated in metabolic syndrome and obesity. Adipose tissue is a true endocrine organ and, therefore, an organ that is highly susceptible to disturbance by EDCs. Full-Text PDF