Fall 2003 Newsletter Featured Articles
Pediatric Environmental Health Toolkit
GBPSR and sister chapter San Francisco Bay Area PSR are teaming up on an exciting new project that will bring practical tools on preventing exposures to toxic chemicals to pediatric and family care practices around the country. The Pediatric Environmental Health Toolkit includes laminated desk and pocket reference guides for providers and patient handouts including "Prescription for Prevention" sheets and refrigerator magnets.
We are pleased to have a distinguished group of pediatricians involved in the planning and development group. They include Guenter Hofstadler MD and Brian Linde MD who drafted the initial guidelines, and Mark Miller MD MPH, Lisa Asta MD, Siobhan McNally MD, and David Wallinga MD who are participating in revising and editing and will help oversee the pilot testing of the materials. SF Bay's Program Director Julie Silas JD is another key player, with Maria Valenti and Michelle Gottlieb MEM of GBPSR leading the East Coast team.
Parents, Providers Concerned About Kids Environmental Health
Pediatric Environmental Health is a relatively new field prompted by concerns about such things as pesticide residues on foods, mercury in fish, and arsenic in drinking water and on play structures. Yet, numerous providers have hardly heard of it.
Studies have shown few environmental histories are taken, and that less than one-in-five pediatricians reported having received training in environmental history-taking even though they strongly believe in the importance of environmental exposures in children's health. The issue is a high priority with parents. In a recent paper written by Dr. Sophie Balk, outgoing chair of the American Academy of Pediatrics environment committee and editor of the AAP "Green Book" for pediatricians, "…environmental exposures are among parents' top concerns for their children."
This interest in environment and health issues has also been demonstrated through GBPSR's In Harm's Way trainings for health professionals. Pediatricians have regularly comprised the largest fraction of physician attendees at conferences.
Using "Teachable Moments" During Well-Child Visits
Initial assessment of need for the Toolkit was conducted by surveying participants at In Harm's Way Trainings. Follow-up discussions with practicing pediatricians, and the organization of a pediatric planning group, led us to begin considering the optimum framework for the type of succinct, easily accessible reference materials the physicians told us they wanted. Noted pediatrician T. Berry Brazelton's Touchpoints concept was mentioned repeatedly as a model that could work for the materials, which we began to think of as a multi-part environmental health "toolkit" for both providers and patients.
The beauty of the Touchpoints program is that it makes it quite easy for the practitioner to impart environmental health information during "teachable moments" with patients.
Materials in Development, Soon to be Pilot Tested
The Toolkit materials are currently in development. Early feedback from providers has been extremely positive.
Included in the Toolkit are:
- A 2-sided, laminated provider desk reference card that includes:
- Key concepts and principles in pediatric environmental health A summary of children's unique susceptibilities to toxic substances
- Brief suggested Environmental History
- Brief summaries of major toxicants and their potential health effects
- A 2-sided, laminated pocket reference card containing priority anticipatory guidance keyed to specific developmental stages to use during well-child visits.
- Educational handouts that include:
- "Rx for Prevention" prescription slips keyed to developmental stages
- Magnets with "Tips for Prevention"
- "Out of Harm's Way" fact sheets
Conducting a Pilot Study
One of the primary goals of the project is to test the materials in real practice with pediatric and family practitioners. We are currently in the process of selecting pilot sites around the country that satisfy the strategic objectives needed for proper evaluation, including a good demographic mix to obtain feedback from an economic, cultural, and geographic cross-section of practices.
Many thanks to the Bauman Foundation, the Mitchell Kapor Foundation, and the Alida R. Messinger Charitable Lead Trust for funding the development of this project, and The John Merck Fund for a two-year grant to finalize materials and conduct pilot testing and evaluation.
Outreach on Toxic Threats in Massachusetts
Thanks to a grant from the Massachusetts Environmental Trust's new Human Health and Environment Program, GBPSR is conducting Massachusetts-specific work related to In Harm's Way: Toxic Threats to Child Development (IHW). The primary program goal is to educate more health care providers about the linkages between toxic chemicals and brain development, in order to prevent exposures and pollution.
We are focusing on outreach to health care providers to the most vulnerable populations, including pregnant women and children. We will also concentrate on building capacity within GBPSR to encourage more member and medical student participation in GBPSR programs.
Major project components include the following:
Healthy Mothers, Healthy Babies
GBPSR is working with the statewide Healthy Mothers, Healthy Babies (HMHB) coalition, a collaboration of public and private organizations dedicated to assuring that all children grow up in safe and healthy homes. HMHB of Massachusetts, in conjunction with the multi-disciplinary Partners in Perinatal Health network, has achieved long-standing success providing education on perinatal care. However, information on environment and health issues has not regularly been included. GBPSR will coordinate with HMHB to conduct presentations and provide educational materials to member groups, with an emphasis on training care providers who counsel pregnant women and young children including nurses, lactation consultants, doulas, childbirth educators, and others.
Outreach to Hispanic Community
We are collaborating with the Regional Environmental Council (REC) of Worcester on outreach to the Hispanic community. REC has a history of working with community groups in Worcester, particularly in Hispanic neighborhoods. GBPSR will conduct trainings for health care workers through community health centers, and provide additional training through REC, on the IHW messages about preventing toxic exposures, protecting health, and preventing pollution. In addition, GBPSR will provide educational materials in English and Spanish to REC for distribution through their extensive network of community groups.
If you are interested in scheduling a presentation for health care providers in Massachusetts, please contact email@example.com with your request.
This project is funded by
Massachusetts Envrionmental Trust
SMART Security: PSR's Plan for Preventing Preemptive War
Physicians for Social Responsibility is offering all Presidential candidates and the American people a sensible alternative to the Bush Administration "security" policy that in the name of a war on terrorism has sown chaos, most recently in Iraq, while alienating the community of nations.
The PSR plan is called SMART Security, which stands for "A Sensible, Multilateral, American Response to Terrorism." The plan has been distributed to the staffs of all the Democratic contenders and to the Bush White House. It has also been field-tested among likely Democratic voters in the state of Iowa.
Its platform has three major planks:
- Strengthen international institutions and support the rule of law to prevent acts of terrorism and future wars.
- Reduce the threat and stop the spread of nuclear weapons and other weapons of mass destruction.
- Change budget priorities to reflect SMART Security needs.
Each of these planks contains detailed arguments for a more rational approach to governmental responsibility than has been the case in Washington recently.
In rolling out SMART Security, the PSR Security Committee has written that, "Unfortunately, the Bush administration's go-it-alone reliance on military force is doing more harm than good. It is likely to lead to more anger aimed at the United States - anger that might well lead to more terrorist attacks. And the administration's push for usable nuclear weapons and a policy of targeting other nations for nuclear first-strike attacks is leading countries like North Korea and Iran to seek their own nuclear weapons as a way of 'deterring' the U.S."
Why Preemptive Attacks Foster Terrorism
University of Maryland professor and author Benjamin Barber has coined recently a useful medical metaphor regarding the fight against terrorism. "The harrowing truth," he writes, "is that preventive attacks on 'rogue states' and 'those who sponsor or harbor terrorism' fail because they are premised on a fatal misunderstanding of what terrorism is and how it operates. In operational terms, terrorists are not cancers on the body of a weakened nation-state that die when the state dies. Rather, they are migrating parasites that temporarily occupy hosts (rogue states, weak governments, even transparent democracies). When a given host is destroyed or rendered immune to such parasites, they opportunistically move on to another host - ever ready to reoccupy the earlier host if it is revived as a 'friendly' regime."
Medical Community Uniquely Positioned to Alert Public
Barber's use of a medical analogy also hints at the role PSR members must play in alerting the public to the flawed assumptions that underlie current White House anti-terrorism policy.
As health care workers, PSR members are uniquely positioned to argue for new budget priorities to provide real security for the American people. Our message is, "America needs to invest more at home - on health care for all Americans, rebuilding our schools and education system, creating jobs, and stopping the pollution of our air, land and water."
Help Inform Colleagues, Patients
Over the next few months, PSR chapters will be distributing thousands of SMART Security brochures provided by the Security staff at the PSR national office in Washington. Since "all politics is local," it will be crucial for these several months before the 2004 Presidential election to be used to distribute the PSR plan for SMART Security to our fellow health care workers, our patients and families, and the general public.
In addition, PSR's SMART Security arguments for a more sane and responsible approach to terrorism can form the basis for letters to the editor of local and national newspapers, as well as letters, e-mails, and phone calls to individual political candidates.
John Pastore MD
The GBPSR office will be pleased to send you as many copies of the SMART Security brochure as you can use. For further information about the SMART Security plan, go to http://www.psr.org/smartsecurity.
Environmental Pollutants and the Immune System
OR "It's Not Nice to Fool Mother Nature"
By David H. Sherr PhD, Department of Environmental Health
Boston University School of Public Health
In evolution, surprisingly little is left to chance. Biologic systems, whether composed of millions of liver cells working in concert to detoxify the blood, or white blood cells attempting to defend against foreign microbe invasion, are "designed" with controls, regulators, checks, and balances. The selective value of such biologic oversight is the evolution of systems that, despite their complexity, tend not to fail.
For example, all animal cells are equipped with dozens of proteins that regulate how frequently a cell divides. Should some of the regulatory machinery become defective, cells generally invoke a genetically encoded suicide program.
It actually takes several events to impair both growth regulation and activation of the cell death program, and in that rare instance, a cancer is formed. Even so, most tumors go undetected because they are eliminated quickly by the sentinel immune system.
It's when the balance between growth and death is tipped in the direction of growth, and the immune system is impaired that bad things happen. Our laboratory studies show how several environmental pollutants do exactly that.
Immune System Protects Health
The immune system is responsible for defending its host against invading bacteria, viruses, fungi, and, as noted above, newly formed cancers. Defense against bacteria and fungi is assumed primarily by a system of interacting white blood cells known as the B lymphocyte arm of the immune system. B lymphocytes mass produce proteins (antibodies) which bind to and kill microbes. Each B cell is capable of producing antibody of only one given specificity. The development of millions of B lymphocytes expressing millions of specificities insures that the immune system has the potential to respond to millions of different foreign insults.
The B cells must "learn" their specificities early in their development, must grow enough to constitute the host with a significant mass of B cells of every given specificity, and must learn not to respond to self components. B cells that fail to learn the difference between "self" and "foreign" components are forced to activate the suicide program, sparing the host from autoimmune disease. This education occurs continually in the bone marrow, where all eight kinds of blood cells are produced.
The failure of immature B lymphocytes to learn these lessons results either in an inadequate immune response to foreign microbes, leaving the host susceptible to infection, or to an inappropriate autoimmune reaction to host tissue. Unfortunately, just like babies and young children, bone marrow B cells are more sensitive to environmental pollutants then their more mature counterparts.
Pollutants Can Disrupt Immune System
Our laboratory has shown that two classes of common pollutants, aromatic hydrocarbons and phthalates, disrupt B cell education. Hydrocarbons are ubiquitous and are produced every time something organic is burned - from fossil fuels in our cars and coal in our power plants, to charcoal broiled steaks. Phthalates, which leach from hundreds of common products containing plasticizers (e.g. medical tubing, plastic bags, cosmetics), can also be found throughout our environment.
The effects of these chemicals on immature B lymphocytes are dramatic. Hydrocarbons, many of which are carcinogenic, prematurely induce bone marrow B cells to initiate the cell death program. Notably, the doses of hydrocarbons required to suppress B cell development are significantly lower than those required to induce cancers. Consequently, estimates of hydrocarbon exposure risks, which generally involve cancer as an endpoint, may underestimate the dangers of pollutant exposure.
It has been demonstrated that phthalates similarly induce programmed cell death. Indeed, the strength of the death signal delivered by phthalate-like chemicals is the strongest suicide signal our laboratory has ever seen. At low doses, phthalates spare B cells from the death program but induce them to cease growth.
Research Focusing on Mechanisms of Disruption
A key goal in our laboratory is to define, on a molecular level, how these chemicals invoke aberrant cellular responses. Both hydrocarbons and phthalates are recognized by distinct cellular protein receptors that transmit signals to cell nuclei wherein reside genetic programs for cell suicide and growth regulation. This begs the question of what these receptors evolved to do in the first place; certainly they haven't evolved to recognize by-products of human industry.
We must conclude then that activation of these receptors by environmental chemicals is an unwise practice, one that clearly was not part of mother nature's evolutionary plan. And we all know that it's not nice to fool mother nature.Dr. Sherr holds joint appointments in the Department of Environmental Health and in the Department of Pathology and Laboratory Medicine in the Boston University School of Medicine. He also heads the Sherr laboratory research facility.
GBPSR serves on the Community Advisory Committee of the BU Superfund Basic Research Program (BUSBRP), an EPA-funded program to support research into the possible reproductive and developmental effects of chlorinated and non-chlorinated organic chemicals and substances (dioxins, PCBs, some solvents). We have been working to bring BU research information to our membership through a variety of mechanisms including articles and presentations. We are also participating in an NIEHS-funded project “Community-based Environmental Health Research: Finding Meaning.”
For more information: http://www.bumc.bu.edu/www/sph/eh/superfund/index.html
Issues and Media Training at Harvard Medical School
Amy Kostant (left) of DC-based, nationally known Environmental Media Services, provided a valuable mini media training this Spring to a gathering at Harvard Medical School of physicians, students, nurses and other interested attendees. The event was sponsored by the Harvard Medical Student PSR Chapter. Student co-chairs Nawal Atwan and Abby May helped GBPSR organize the informative evening at which GBPSR Board Chair Ted Schettler MD MPH (right) also spoke on the role of medical professionals in public advocacy and Tom Webster, Professor of Environmental Health at Boston University, shared his latest research projects. The goal of the media training was to provide guidance to health professionals on how to communicate with the press on environmental health issues. In particular Ms. Kostant provided tips on addressing scientific uncertainty, how to stay on message, and how to communicate effectively on television. GBPSR will continue to host such events to both educate health professionals on issues of concern, and help foster a cadre of providers who are comfortable speaking out on environmental health.
(Above) Health professional audience at the Harvard Medical School training.