5
Balancing Prevention and Uncertainty
The final day included two sessions. Nsedu Obot Witherspoon, Children’s Environmental Health Network, moderated the first session regarding case examples of science informing policy and public health action. Stephanie Yendell, Minnesota Department of Health, Maida Galvez, New York State Children’s Environmental Health Centers, and Shirlee Tan, Seattle King County Department of Health, presented examples from their respective programs. Heather Patisaul of North Carolina State University moderated the second session, a panel discussion on strategies for acting despite uncertainty. David Levine, the American Sustainable Business Council, Alison Connolly, University of Galway (Ireland), and Wendy E. Wagner, University of Texas School of Law, were panelists. Nsedu Obot Witherspoon provided closing remarks. The workshop ended with a video message from Mari Copeny, Little Miss Flint.
CASE EXAMPLES OF SCIENCE INFORMING POLICY
Minnesota Department of Health Case Examples
Dr. Stephanie Yendell described two examples of science informing policy and public health action in Minnesota: response to contamination near the Water Gremlin site and skin-lightening products.
Water Gremlin produces fishing sinkers, battery terminals, and ammunition components, which generate lead dust that can settle on workers’ clothes and shoes. From January 2018 to September 2019, St. Paul-Ramsey County Public Health notified the state that it had identified 12 children
with elevated blood lead levels (>5 µg/dl), all of whom had a household member who worked at Water Gremlin (Yendell et al., 2022). Department of Health investigators ruled out other sources of lead exposures by testing lead in dust wipe samples of vehicles, entryways used, and shoes worn by these employees in the home.
Water Gremlin also used the toxic solvent trichloroethylene (TCE), which had been around since 1992 but increased around 2000. Following multiple equipment breakdowns at Water Gremlin in late 2018, the Minnesota Pollution Control Agency was made aware that the facility was exceeding air emissions permits for TCE, and use was discontinued in 2019. The agency modeled the potential annual average amount of TCE in the air (exposure range: 2–59 µg/M3). Using the estimated exposure levels from the models, it estimated the likelihood of health effects and determined it was low, but potential effects include risk of certain cancers (kidney and possibly liver and non-Hodgkin’s lymphoma), non-cancer effects to the immune system and kidney, and risk of heart defects during fetal development, said Yendell.
Yendell said that local public health embarked on immediate interventions following the events at Water Gremlin. To respond to TCE, Water Gremlin and the Minnesota Pollution Control Agency entered a stipulation agreement; the company switched to trans-1, 2-dichloroethylene, and increased air and site monitoring activities, including a public health assessment.
Many agencies coordinated so that the state could gain access to the Water Gremlin facility to inspect for lead hazards. The inspections identified many violations of best practices, such as personal protective equipment non-compliance, failure to provide safety trainings in the languages spoken by employees, and locker rooms in the building interior that required walking through lead-contaminated areas after changing out of work clothes (Yendell et al., 2022). The Department of Labor then issued an order temporarily stopping operations, and the Commissioners of Labor and Industry and Health filed a complaint and motion for a preliminary injunction, stating that Water Gremlin had created a public health nuisance, says Yendell. The commissioners asked the court to require Water Gremlin to provide testing and cleanup of worker vehicles and residences, conduct worker training in appropriate languages, make worksite modifications, and hire a third party for monitoring. The court ordered Water Gremlin to complete those activities. The Department of Health also completed public health outreach activities and blood lead testing to evaluate whether the interventions worked (Yendell et al., 2022).
The intervention did not immediately stop exposure to lead. The Minnesota Department of Health found three more children with elevated blood lead levels linked to Water Gremlin, and 90 percent of workers’ cars tested had at least one dust swipe result above the EPA’s clearance standard for residential homes (no standard exists for lead on vehicles). However, on average the interventions were working; workers’ blood lead levels decreased by 4.2 micrograms per deciliter on average after these interventions were put in place, said Yendell.
Yendell said that Minnesota recommends but does not require blood level testing for children or pregnant women, so additional children may have been exposed to lead from this facility but not tested. The lead exposures were discovered because Ramsey County was voluntarily investigating blood lead levels of 5–14.9 µg/dl. The state only requires that environmental investigations occur for 15 µg/dl and above. Individual exposures to TCE over time are unknown. Breathing 20 µg/M3 of TCE continuously for a lifetime is estimated to result in no more than one additional cancer event per 10,000 exposed people (EPA, 2011b). In this example, with the approximately 20 years of excess emissions of TCE at varying levels in this population, it is unlikely that measurable increases in cancer above background rates could be detected.
Minnesota has made several policy changes because of this case. The statewide threshold for required lead risk assessments changed from 15 µg/dl to 5 µg/dl for all children less than 18 years old (it was only required for children under 6). Additionally, if a location outside the home is determined to be the original source of exposure, the state or county health department may order the responsible party to perform a lead hazard reduction, giving the assessing agency the ability to reduce exposure without having to go through a district court process. In 2020, the White Bear Area Neighborhood Concerned Citizens Group Ban TCE Act passed and restricted TCE for most uses. A full ban for TCE in Minnesota is now in effect and requires that replacement chemicals must be less toxic.
Yendell described the second case study, skin-lightening products, which often contain mercury. In Minnesota, Hmong and Somali Americans and other communities of color frequently use these because of ideals of colorism (Adawe and Oberg 2013). Though such products with mercury above one part per million are not legal for sale in Minnesota, mercury exposure is not reportable, so it is difficult to know who might be highly exposed. Infant exposures can occur if the products are used during pregnancy and breastfeeding, through breastmilk and inhalation.
Yendell said that the Minnesota Department of Health conducted a biomonitoring study of pregnant women from Asian, East African, Latinx, and White communities. The average urine mercury levels were higher for women who had used skin-lightening cream. Nine of the almost 400 women tested had urine mercury levels above 5 micrograms per liter; they were Hmong and Latina. After voluntary in-home investigations for women who wanted to know where mercury exposure was coming from, skin-lightening products were found in most of the homes.
Investigators also measured mercury in products confiscated from markets in Minnesota and found that about 65 percent of them contained mercury. Steroids were found in about 60 percent, and hydroquinone was detected in a small minority. Levels of mercury varied, but in one example, levels as high as 35,000 parts per million were found.
Minnesota is trying to tackle this issue through legislative efforts. Additionally, a one-time grant program was established for skin-lightening outreach and education. Some are also working to make mercury exposure reportable in Minnesota, which would fill in a large data gap. The Minnesota Health Department is working with local clinics that treat women, particularly women of color, to create clinical guidance on recommending testing for mercury.
New York State Children’s Environmental Health Centers (NYSCHECK)
Dr. Maida Galvez, co-director of the coordinating center for NYSCHECK, described environmental health interventions they have carried out since their founding in 2017. NYSCHECK is a partnership between advocates for children’s environmental health and staff of children’s hospitals in Albany, Buffalo, Syracuse, Rochester, Westchester, New York City, and Long Island. The network is composed of clinicians, allied health professionals, community partners, and state and federal partners working to grow children’s environmental health services for state families and integrating environmental health into clinical practice by connecting clinicians and families to community public health resources. NYSCHECK was conceived by Landrigan and Dr. Robert Amler, who, together with partners, thought, “wouldn’t it be phenomenal if New York State had a network similar to the national Pediatric Environmental Health Specialty Units (PEHSU) model or the Environmental Occupational Medicine Clinics.” Using the foundation of the PEHSU network, NYSCHECK was able to make an intentional shift toward encouraging the integration of environmental health into clinical practice by connecting clinicians and families to community resources. “So [this was] literally connecting the dots between health care, public health agencies, and communities and improving the environment of the families who bear a disproportionate burden of environmental exposures,” said Galvez. For example, at Mount Sinai, Drs. Lauren Zajac, Erin Thanik, and Leora Mogilner are working to integrate environmental health into outpatient well-child visits in the general pediatrics practice. Co-located environmental health services are offered in pediatric allergy, immunology, and pediatric pulmonology practices. Hospitalists are also referring families with children hospitalized with asthma to the environmental team (Galvez et al., 2019).
The integration between health care, public health, and communities through the NYSCHECK network is building the capacity for clinicians to prescribe healthy home interventions as part of routine well-child visits. NYSCHECK launched an environmental health electronic screener, administered through a questionnaire incorporated into the electronic medical records. The screener targets priority environmental health issues, primarily healthy homes. As concerns are flagged, families are linked to organizations that can provide actionable interventions through a prescription for prevention. These prescriptions for prevention were developed initially by the American Academy of Pediatrics, Physicians for Social Responsibility, and the National PEHSU Network. They have been updated through a National Institute of Environmental Health Services (NIEHS) Inter-Center Collaboration Grant, bringing together NIEHS Community Engagement Cores and PEHSUs in federal regions 1, 2, 3, 5 and 9
to link resources for intervention tailored to the geographic location of use. All seven NYSCHECK centers across the state have implemented these health e-screenings in clinical settings to connect families to actionable prescriptions for prevention and distribute Healthy Home kits (Anderson et al., 2020). NYSCHECK is participating in value-based payment pilot programs led by the New York State Department of Health and New York City Department of Health, and through these programs, is exploring insurance reimbursement with various partner organizations and insurance plans, such as Healthfirst and Empire Blue Cross Blue Shield’s Health Plus. NYSCHECK has provided environmental health clinical services to over 125,000 families, according to Galvez.
NYSCHECK has also provided education to health care and public health professionals and established an interdisciplinary scholars program open to applicants of any background with interest in advancing children’s environmental health throughout the NYSCHECK regions. Scholars include academic pediatricians, postdocs, community organizers, a public health nurse, and a respiratory therapist. These scholars have gone into leadership roles in NYSCHECK (two former scholars are now medical directors), and several Scholar alums created a statewide training program for students focused on team building as a critical component of success in the field of environmental health.
Dr. Galvez encourages others to identify and build upon regional resources and then work with partners to explore how children’s environmental health needs can be better met. She hopes that the NYSCHECK network will serve as a model for future state-based networks, which, together with their regional PEHSU, can work to build capacity further to serve the environmental health needs of families throughout the country.
Strategies to Improve Children’s Environmental Health in King County, WA
King County, Washington, is the most populated county in the state and the 13th most populous county in the United States, with over 2.2 million residents, according to Dr. Shirlee Tan, senior toxicologist with Public Health Seattle—King County. It has about 600,000 children and youth from 0–24 years of age. The residents include about 30 percent of the total population of Washington State, and about half are children of color, with most residing in Seattle or South King County. About 30 percent of all households in the county speak a language other than English at home. The county has a wide variation in income and life expectancy at birth across the different regions, said Tan.
To identify disparities by zip code or census tracts, the state developed its Environmental Health Disparities Mapping Tool. It uses a risk
paradigm that considers risk as a product of threats and vulnerabilities. In this model, threats include indicators that account for pollution burden or a combination of environmental effects (environmental effects) and environmental exposures. Vulnerabilities include socioeconomic factors and sensitive populations for which there is clear evidence of increased susceptibility or vulnerability to an increased pollution burden (in this case, death from cardiovascular disease and low birth weight, which are both associated with exposures). The environmental health disparities risk map for King County shows that South Seattle and South King County are the most affected. This risk map helps Public Health—Seattle & King County know how to best prioritize resources, explained Tan.
To reduce environmental health impacts on a local level, the department focuses on reducing exposures and creating policy change to prevent them for children in communities experiencing the largest inequities. The department has an equity and social justice strategic plan. In addition, the state passed the Healthy Environments for All Act,1 which requires many state agencies to use an environmental justice lens in planning projects. This follows other recent state policies that focus on more upstream chemical legislation, including the Children’s Safe Product Act to limit the use of four priority toxic chemicals (lead, cadmium, phthalates, and flame retardants) and require manufacturers to report if products contain 85 different chemicals from a periodically reviewed list (State of Washington, 2008).
King County also has an initiative, Best Starts for Kids, that is community driven, catalyzes strong early starts, and aims to sustain those gains as children progress to adulthood, said Tan. It includes investment areas, such as preventing youth and family homelessness, strengthening communities, child care subsidy program and workforce demonstration project, and capital projects. Public Health—Seattle & King County’s Environmental Health Services Division integrates environmental health into that and similar initiatives. Through the Best Starts for Kids program, it created interventions for toxics reduction and to help improve indoor air quality in child care centers to reduce transmission of COVID-19.
Recently, King County collaborated with Childcare Resources, a community-based organization focused on connecting families to early learning centers and training low-income and immigrant workers in the child care sector to reduce children’s exposures to brominated and organophosphate flame retardants. This work focused on nap mats, an important source (Stubbings et al., 2018). Tan said that it was able to leverage Best Starts for Kids funds to provide flame-retardant-free nap mats (n = 2,400) and nap mat covers (n = 2,800) to child care providers serving low-income and Black
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1https://doh.wa.gov/community-and-environment/health-equity/environmental-justice (accessed November 8, 2022).
and Indigenous people of color families. The program has been successful, and the department is trying to expand to more centers.
To improve indoor air quality and reduce transmission of COVID-19, Tan described how the department has been able to place high-efficiency particulate high-efficiency particulate air (HEPA) filters into child care settings and schools throughout the county. It distributed over 2,000 to small child care centers serving small communities highly impacted by COVID and an additional 1,000 to schools in high-risk areas. The air cleaners will have co-benefits of reducing exposure to wildfire smoke and other indoor allergens.
Tan mentioned that their approach to improving children’s environmental health has been focused on reducing exposure to harmful chemicals. One challenge is that the initiatives require many costs, including staffing time and salary and health burdens experienced by the residents. Tan said a movement toward upstream programs (these prevent environmental hazards from occurring) would benefit child health. Tan stressed that uncertainties often limit actions and that any indication of a possible health effect could lead to action. Finally, Tan emphasized, “Policies that facilitate environmental health are very impactful. At the local level, we often find that we are burdening parents and caregivers to know what to do to avoid harmful exposures to children. [It] is not easy to know all the different hazards that need to be considered, so policies could ensure that children’s environments are healthy, so the burden to avoid harmful chemicals is taken off those caring for our kids.”
PANEL DISCUSSION: STRATEGIES FOR TAKING ACTION DESPITE UNCERTAINTY
Patisaul began by asking Wendy Wagner of the University of Texas, “Some of your work has described what is called a regulatory Catch-22 where policy action depends on scientific evidence, but the evidence regarding risks is driven at least in part by regulatory priorities. So, given that Catch-22, what strategies do you suggest could be used to bring environmental risks to children into sharper focus?”
Wagner replied that evidence is needed to drive policy. The incentives, particularly for manufacturers, are set to calibrate toward ignorance. The burden of proof is on regulators in the United States to determine that a chemical causes harm and a manufacturer would not produce evidence that can be used against it. The “nurtured ignorance” makes it very difficult to get toxicity information, rendering regulations impossible, which is bad for both child and adult health protection. Wagner added that approximately 40,000 chemicals are registered to be sold in commerce in the United States, including mixtures probably triples the estimates. Yet,
very little basic toxicological data exist on most of these chemicals. There is evidence that at least two-thirds of them have insufficient information to assess their toxicology based on standardized tests. For 10,000 of the chemicals, almost no toxicological information is available at all; more than 8,000 of those chemicals (roughly 20 percent) are trade secret protected, meaning that very little is publicly available. The dearth of information leaves policy makers no chance to be anything but reactive (Wagner, 1997).
Next, Patisaul asked Connolly about her work harmonizing exposure data across studies and whether exposure data can reduce uncertainty and improve study comparability to ease the decisions that the science informs.
Connolly described her work with the International Society of Exposure Science to harmonize studies for comparable data across studies and terminologies to improve and have a more appropriate and aligned interpretation for a common understanding. Terms across the field vary, as do meaning and interpretation. Other advancements include ensuring qualified exposure scientists are available to interpret the data. Risk assessments are more rigorous when the people conducting them are trained in the appropriate educational programs. Connolly is contributing resources for developing appropriate training and educational courses within Europe to align exposure science education to ensure graduates have appropriate skills for these positions. Europe has made a tremendous effort to harmonize how exposure studies are executed in terms of data collection and analysis. The Human Biomonitoring for Europe Initiative (HBM4EU) has made great progress in advancing biomonitoring, and the main goal is to provide evidence for chemical policy making. The efforts include trying to standardize questionnaires used in research and how the data are analyzed. The laboratories involved have also gone through quality assurance and quality control interlaboratory studies to ensure the limits of quantification and detection are low enough to detect these environmental exposures.
Another European initiative is the Scientific Committee on Health Environment and Emerging Risks (SCHEER). The goal is to identify emerging risks early and alert the EU commission. It is a protective and preemptive way of thinking about hazards. To Connolly, it is important to ensure a minimum standard requirement for conducting studies and that studies are aligned to ensure comparability, which will result in assisting regulatory agencies in interpreting the results.
Next, Patisaul asked, “Mr. Levine, much of our discussion at this workshop has dealt with the relationship between science and policy. However, we all know that commercial interests are also at play here. In your experience, what kinds of incentives can help shift the market away from products that pose risks to children? In your experience, does the private sector need a higher level of certainty regarding the risks their products pose to make changes?”
Levine described that business is not monolithic, although many industry groups suggest otherwise. Therefore, he formed the American Sustainable Business Council because it was important for a responsible, just, and stakeholder-driven economy to be represented by a set of businesses that were actually practicing that. Several incentives helped to move toward a more just economy; Coming Clean (a nonprofit environmental health collective) and the Environmental Justice Health Justice Alliance Campaign for Chemical Policy Reform is helping improve consumer consciousness and the business community. Levine also sees opportunities in some federal programs that recognize companies and their products, such as the EPA’s Safer Choice program. Those make creating safer chemicals a business incentive. The broader community of businesses that are trying to do the right thing can be allies, working across sectors and driving policy to obtain results that better protect children.
CLOSING REMARKS
Dr. Nsedu Witherspoon of the Children’s Environmental Health Network summarized the workshop. The workshop highlighted several areas of need, including investment in children through social services and education, policy changes, improving risk assessment, the continued threat of climate change, community investment and engagement, and several opportunities, such as the new authorities that the TSCA amendments give the EPA.
Witherspoon highlighted unifying themes that could help improve children’s health protection at the EPA. Several speakers (e.g., Perera, Galvez, and Bernstein) noted that working with key community partners is vital, and these partnerships can help expand existing programs, informing individuals about resources to help protect vulnerable communities. Many participants also highlighted a need for prevention even during uncertainty (e.g., Tanguay, Birnbaum, Burke). Witherspoon emphasized that the way to achieve equity is by treating everyone not equally but justly according to their circumstances, and this can be widely applied in the field of children’s environmental health. She encouraged attendees, speakers, panelists, and the Office of Children’s Health Protection to continue to think about how justice and equity and protecting the most vulnerable children drive their work. She added that it is always important to visualize the children they are trying to protect, and she thanked all participants.
LITTLE MISS FLINT VIDEO
The workshop ended with a video of Mari Copeny, also known as “Little Miss Flint.” In the video, Hanna-Attisha has Ms. Copeny introduce
herself, letting the attendees know that she is a Flint activist and a clean water, environmental health, and justice activist. Ms. Copeny goes on to describe the annual backpack drive that she created; she donates backpacks with school supplies to other children whose families cannot afford such items. Hanna-Attisha emphasized that this is only one of many activities that Ms. Copeny is involved with and reminded the attendees that as this was a children’s environmental health workshop, it was important to hear from children as well. The video ended with Ms. Copeny asking workshop attendees to remember to think about children in their work, as they are important.
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