Another Victory for Cleaner Air

written by Ted Schetter, MD, MPH
Science Director for CHE and the Science and Environmental Health Network

Ted Schettler, MD, MPHThis month the US Court of Appeals in Washington, DC, upheld EPA’s 2012 decision to tighten air quality standards for fine particulate air pollution (PM 2.5) by lowering the annual average limit from 15 to 12 microgm/m3.[1] The EPA selected the new standard because it is slightly below the lowest long-term average concentration known to cause adverse health effects, including damage to the lungs and cardiovascular system and premature death in people with heart and lung disease.[2] The National Association of Manufacturers, the US Chamber of Commerce, and other industry groups had challenged the scientific basis of this decision, also objecting to EPA’s plan to eliminate the use of spatial averaging in determining compliance and to require near-road monitoring in certain heavily populated urban areas. The court’s affirmation of each of EPA’s decisions was timely since each year the Asthma and Allergy Foundation of America declares May to be “National Asthma and Allergy Awareness Month.”

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Another Cry for Primary Prevention

Elise Miller, MEd
CHE Director

Elise MillerHow many of us have sat with loved ones in the throes of cancer? No doubt way too many. My cousin just passed away two days ago from lung cancer, having never smoked in her life. She joins several other family members and close friends who have died of one form of cancer or another in the last few years. Unfortunately, all of you likely have similar stories to share, and not just about older people in your lives, but about those younger and younger—including those who exercise regularly and have healthy diets.

One would think this untenable situation would catapult our society into action—it would move us to do whatever it takes to implement primary prevention strategies, not just look for cures. But instead the President’s Cancer Panel report on environmental contributors to cancer sits on the proverbial shelf collecting dust. As do other seminal reports that provide clear analyses of the science linking chemical contaminants and other chronic diseases and disorders as well as how to address these issues—such as Endocrine Society’s statement on endocrine disrupting chemicals, the joint opinion issued by the American College of Obstetricians and Gynecologists (ACOG) and the American Society of Reproductive Medicine (ASRM) on environmental chemicals and reproductive health, and the National Academy of Sciences “Science and Decisions” report which offers concrete recommendations to contend with the inadequacies of current risk assessment practices—to name just a few.

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The Primary Prevention of Asthma

written by Ted Schettler, MD, MPH
CHE Science Director
Science Director of the Science and Environmental Health Network
Coordinator of CHE’s Science Working Group 

TedSchettlerAsthma is a complex disorder made up of different subtypes with differing causes, underlying pathology, treatment responses, and natural histories. According to the Centers for Disease Control, about 1 in 12 people in the US have asthma, and the numbers are growing every year. The disorder costs over $56 billion in medical costs, lost school and work days, and early deaths annually.

In 2005, CHE’s Asthma and the Environment Working Group convened a series of conversations to explore our interests in this complex disease and to see if we could identify some aspect of asthma around which we could focus our efforts. We began to wonder about the allocation of asthma research dollars. How much is invested in understanding the origins of asthma and opportunities for primary prevention versus how to reduce the frequency and severity of asthmatic episodes in people who already have the disease?

With that question in mind, we reviewed the research portfolio of the National Heart, Lung, and Blood Institute (NHLBI) at the National Institutes of Health and concluded that less than 10 percent of asthma-related research was devoted to understanding the causes and primary prevention of the disease. Even though this was a rough estimate, based on a review of project descriptions in the NIH database, it seemed to indicate that primary prevention of asthma was underfunded.

Following that review, the working group concluded that convening a workshop to address the causes and primary prevention of asthma would be worthwhile. Published proceedings might attract more funding and help to raise awareness of the urgent need. However, we were initially unable to secure support for the proposed undertaking and the idea languished.

In 2009, CHE partner Polly Hoppin, Research Professor and Program Director of the environmental health program at the Lowell Center for Sustainable Production at the University of Massachusetts, Lowell, seized an opportunity to incorporate the primary prevention of asthma into the first Strategic Plan for Asthma in Massachusetts.

Polly worked with partner organizations in the Massachusetts Asthma Advocacy Partnership to draft a goal in the plan to “develop a Roadmap for better understanding the causes of asthma and the role of primary prevention in Massachusetts.” Its objective was to “develop agreement—’a roadmap’—among experts and other groups on the current evidence on primary prevention, research needed to increase our understanding of prevention of asthma, and evidenced-based strategies that can be currently implemented in Massachusetts.” With the goal of primary prevention of asthma clearly spelled out in the state’s strategic plan, Polly and her colleagues successfully undertook new efforts to find resources to convene a meeting addressing the state of the science, research needs, and capacity to reduce new onset asthma over time.

Polly and Molly Jacobs from UMass Lowell organized and led a planning committee that put considerable effort into preparing for the conference, “The Primary Prevention of Asthma: A Symposium on Current Evidence, Research Needs, and Opportunities for Action”, held at the Massachusetts Medical Society in Waltham, Massachusetts, in April, 2013. See for a description, the agenda, and links to presentations. Participants included invited researchers, clinicians, labor and community representatives, public health professionals, and government leaders from a range of sectors, including housing, education, health, transportation and environment. The symposium was co-sponsored by the Massachusetts Department of Public Health, the National Institute for Environmental Health Sciences, the US Department of Health & Human Services, Region I (New England), the Boston Public Health Commission, the American Lung Association of the Northeast, and Neighborhood Health Plan, with in-kind support from a range of collaborating organizations.

Opening presentations helped to frame the multifactorial, multilevel complexity of asthma, its public health impacts, and the structural and cultural underpinnings of asthma disparities. They were followed by experts who had been asked to review the state of the science linking specific risk factors to asthma onset, for example obesity, air pollution (in particular, traffic proximity), indoor allergens (i.e. dust mites and mold), dietary factors, chemicals, and stress, among others. These experts provided a summary of the literature, their analysis, and concluded with a recommended classification of each risk factor under discussion as known, probably, possibly, or known not to be associated with asthma onset. As necessary, risk factors were considered unclassifiable when data were inconsistent or sparse.

Following presentations of the evidence, conference attendees broke out into subgroups to discuss the various risk factors and decide which were “ready for action” based on the state of the science and considering additional factors such as: (a) the magnitude of the potential public health impact given the strength of the association and/or the scale of potential exposure, (b) additional benefits that could be reasonably expected to come with taking action, (c) the likelihood that taking action would result in serious unintended consequences. For those interested in more detail about the risk factors and conclusions reached at the conference see the conference link (above) and a  CHE partner call summarizing the symposium.

At the conclusion of the symposium attendees concurred that the primary prevention of asthma will require multiple, multilevel interventions. Attendees developed a shared understanding of the relevant science and created components of a 10-12 year roadmap as called for in the state’s Strategic Plan for Asthma. Polly is chairing a new primary prevention committee of the Massachusetts Asthma Advocacy Partnership, which is now working with the Department of Public Health to determine which of the symposium recommendations will be included in the next state strategic plan, currently in the planning stages.

Existing evidence supports the importance of avoiding exposure to tobacco smoke and chemicals that are respiratory tract sensitizers or irritants. Living in close proximity to traffic independently increases risk of developing asthma. Chronic stress is also an independent risk factor for asthma and nearly doubles the risk of asthma onset associated with proximity to traffic-related air pollution. Given the state of the evidence, asthma leaders in Massachusetts are committed to ongoing discussion about opportunities for primary prevention, developing policies to reduce exposure to risk factors, and implementing pilot programs with rigorous evaluation to develop effective interventions. Some actions are achievable within the five-year timeframe of the next strategic plan; others will unfold over the longer term as research on effective interventions strengthens. Finding resources to support an implementation research agenda continues to be a pressing need.

Since the Massachusetts symposium, leaders in other states have expressed interest in pursuing a similar strategy to reduce the burden of asthma over time. Our hope is that the primary prevention of asthma will become a more widely shared goal and ultimate reality.

Primary Prevention Starts with Moms

Elise Miller, MEd

Why would a group of moms from around the country and varied ethnic backgrounds choose to spend almost three days together learning about environmental health science? As one participant in CHE’s new Environmental Health Primary Prevention Training program, put it: “Every mom is already devoted to prevention. We want keep our kids from getting sick and having any health problems. So of course we want to prevent exposures that could hurt our kids and communities. We’re moms—together we can do anything.”

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The Science Behind Unconventional Connections

What do contaminants in cord blood and climate change have in common? One answer: fossil fuels. Last week, a study published in Environmental Science and Technology showed how 87 commonly found chemicals pass efficiently from mother to fetus during pregnancy, and a vast majority of those chemicals are derived from petroleum. Last month, at the UN climate change talks in Cancun, side events sponsored by NGOs highlighted rising health concerns for children and other vulnerable populations related to climate change. Climate change, as scientists have demonstrated repeatedly, has in large part been catalyzed by the widespread development and use of petrochemicals and their by products, which are fast changing the delicate balance of our earth’s systems. In other words, fossil fuels are us, inside and out – with huge economic and social consequences for human and ecological health.

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Obesity and Related Health Conditions: A Call for Primary Prevention Strategies

Elise Miller, MEd

This month is the first-ever National Childhood Obesity Awareness Month. The fact we even have to raise awareness on this debilitating condition is a sad reflection on the current health of our society, particularly our children’s. Even sadder yet is the fact that obesity is associated with a number of other diseases on the rise in younger and younger populations, including diabetes and metabolic syndrome. Nonetheless, children are being sent off for the new school year to try to learn, while continuing to eat foods infused with trans-fats, pesticides and agricultural antibiotics, to imbibe drinks from cans lined with BPA plastic (an endocrine disrupting chemical and likely obesogen – see CHE’s letter to First Lady Michelle Obama), and to sit for hours without adequate recess in classrooms known to have poor ventilation and mold. Not a pretty picture, I know. But I have a 5-year-old starting kindergarten at a public school this week, and believe me, all of these issues are very much on my mind. No doubt many of you as well as countless other parents, grandparents, aunts, uncles and anyone who cares about children’s health and society’s future share these concerns.

Fortunately, a number of innovative thinkers and colleagues in different fields are trying to press for systemic ways to reduce the alarming increase in chronic diseases and disabilities and the resulting escalation in health care costs. Below I list a few events being held this month that are intended to highlight primary prevention and some promising public health interventions. Also feel free to check our online calendar for other webinars, conferences and workshops you may find of interest.

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