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#761 - Precautionary Principle: Bearing Witness to and Alleviating Suffering, Part 1, 22-Jan-2003

by Carolyn Raffensperger*

The precautionary principle states that if it is within our
power, we have an ethical imperative to prevent rather than
merely to treat disease, even in the face of scientific
uncertainty. In this paper, I present an overview of what we
know about changing patterns of disease, which provides an
argument for implementing the precautionary principle,
particularly concerning children's environmentally related
developmental disabilities. These statistics are an indicator
of the suffering of the world. Healthcare practitioners have an
opportunity to use the precautionary principle both to bear
witness to suffering and to alleviate suffering.

Status of Environmental Health

Where are we now? Some would argue that the precautionary
principle is unnecessary because in northern countries, high
life expectancy and decreasing child mortality indicate that
human health is improving. However, new patterns of human
disease are emerging that suggest a crucial connection between
an increasingly degraded world and declining human health.

In the past, infectious disease, not chronic disease, was the
significant issue in medical care. Infectious disease is still
a pressing problem, particularly in southern countries. AIDS,
cholera, dengue fever, and malaria continue to plague large
populations of people. Some infectious diseases are of our own
making. For instance, antibiotic resistance, including
multidrug-resistant tuberculosis, is increasingly common.[1]
Some antibiotic resistance may be associated with overuse by
physicians. Some also may be related to the extensive use of
antibiotics in industrial agricultural animal production. Other
infectious diseases, such as West Nile virus, are occurring
over a wider geographic area than in the past as a result of
global climate change, global trade, and increased travel. The
diseases are being homogenized and widely dispersed.

A key health pattern emerging in the United States and other
western countries is the increase in chronic diseases, such as
hypertension, heart disease, cancer, immune dysfunction,
reproductive disorders, and increases in birth defects.

Dr. Ted Schettler has compiled a short list of the chronic
problems that can have an environmental cause[2]:

** Asthma prevalence and severity is sharply increasing
throughout the world and is often of epidemic proportions.

** Depression and other mental health disorders are becoming
new public health threats in many parts of the world, with
profound consequences for individuals, families, and
communities.

** Nearly 12 million children in the U.S. (17%) suffer from one
or more developmental disabilities. Learning disabilities alone
affect 5-10% of children in public schools, and these numbers
are increasing. Attention deficit hyperactivity disorder
affects at least 3-6% of all school children, and the numbers
may be considerably higher. The incidence of autism is
increasing.

** The age-adjusted incidence of melanoma, lung cancer in
women, non-Hodgkins lymphoma, and cancers of the prostate,
liver, testis, thyroid, kidney, breast, brain, esophagus, and
bladder has increased over the past 25 years.

** In the U.S., the incidence of some birth defects, including
hypospadias, cryptorchidism, some forms of congenital heart
disease, and obstructive disorders of the urinary tract is
increasing.

** Sperm density is declining in some parts of the U.S. and
elsewhere in the world.

Societal Consequences of Developmental Disabilities

Some of these problems, such as cancer, depression, and
diabetes, disproportionately affect children. In a statement
drafted at an international conference on the environment and
children's health,[3] the signatories said that a quarter of
the global burden of disease can be attributed to environmental
factors. But more than 40% of environmental diseases affect
children under the age of 5 years, even though that age group
comprises only 10% of the world's population.

Of the many environmental health problems, developmental and
neurobehavioral disabilities merit special attention because
they have exceptional consequences in society. For instance,
according to the 2000 United States census, special-education
enrollment rose twice as fast as overall school enrollment in
the past decade. In addition, a growing number of children
receive federal Social Security payments because they suffer
from serious disabilities.[4] In a study published in 2002,
financial costs were calculated for lead poisoning, asthma,
cancer, and developmental disabilities in U.S. children[5]:

[T]otal annual costs are estimated to be $54.9 billion (range
$48.8-64.8 billion): $43.4 billion for lead poisoning, $2.0
billion for asthma, $0.3 billion for childhood cancer, and $9.2
billion for neurobehavioral disorders. This sum amounts to 2.8
percent of total U.S. health care costs. This estimate is
likely low because it considers only four categories of
illness, incorporates conservative assumptions, ignores costs
of pain and suffering, and does not include late complications
for which etiologic associations are poorly quantified. The
costs of pediatric environmental disease are high, in contrast
with the limited resources directed to research, tracking, and
prevention.

Children with developmental and neurobehavioral disabilities
are more likely than children without disabilities to end up in
prison as they mature and become less likely to function well
in the outside world. A legal memorandum examined the
implications of the Americans With Disabilities Act[6]:

"[A]bout one third of prisoners are unable to perform such
simple job-related tasks as locating an intersection on a
street map, or identifying and entering basic information on an
application. Another one third are unable to perform slightly
more difficult tasks such as writing an explanation of a
billing error or entering information on an automobile
maintenance form. Only about one in twenty can do things such
as use a schedule to determine which bus to take. Young
prisoners with disabilities are among the least likely to have
the skills they need to hold a job."

A Utah survey[7] found that approximately 24% of male inmates
had classic clinical attention-deficit/hyperactivity disorder
(ADHD). According to a physician within the Utah system,[7]

"[O]ther studies and our own experience have led us to believe
that upwards of 40% of our residents in a medium security
prison have findings along the Tourette/ADD spectrum. If you
separate out the nonviolent, impulsive criminals (my basic,
charming and even lovable car thieves and traffic offenders),
the percentage is much greater."

The Evidence

The evidence that environmental health problems have
environmental causes is growing. Landrigan and others[5]
calculated that the fraction of disease attributable to
environmental factors was 100% for lead poisoning, 30% for
asthma, 5% for cancer, and 10% for neurobehavioral disorders.
This suggests that those diseases often may be preventable.

Of course, the link connecting a specific cancer or
neurobehavioral problem to a specific exposure is notoriously
difficult to establish. Yet we know that chemicals such as
neurotoxicants are present in the environment in significant
quantities and in all media-air, water, and soil. A great deal
is known about lead in paint, mercury in tuna, dioxins in
incinerated plastics, and various neurotoxicants in pesticides.
Much of this information, found in the Toxic Release Inventory,
which documents the amounts of some toxic substances released
into the environment annually, gives a sense of the sheer
volume of neurotoxicants (or carcinogens, mutagens, and
teratogens) in the environment. For instance, more than a
billion pounds of neurotoxicants are deposited in the air and
water or on land every year. Is it surprising that with every
breath, every drink, and every bite that human health is being
diminished?

Of course, some of these environmentally linked disorders, such
as cancer or birth defects, have a genetic influence, and some
of the increase may be the result of better detection. But the
authors of the book In Harm's Way say,[8,9]

"We are now certain that complex interactions among genetic and
environmental factors play extremely important roles. It is no
longer in keeping with the state of scientific understanding to
attribute the bulk of these developmental disabilities to
genetic inheritance. Rather we now understand the outcomes are
the result of interacting factors, among which are exposures to
environmental contaminants that are preventable."

Every one of these preventable illnesses represents the
suffering of children and their families.

The Precautionary Principle

The precautionary principle states that it is an ethical
imperative to prevent harms such as developmental disabilities
if it is within our power to do so. The principle is of German
origin. "Precautionary" is a rough translation of a word that
literally means "forecaring," caring for a difficult future. As
codified in several treaties, including the Biosafety Protocol
and the Treaty on Persistent Organic Pollutants, the
precautionary principle always contains 3 elements: scientific
uncertainty, the plausibility of harm, and precautionary
action.

All 3 of these elements are in the Wingspread[10] definition of
the precautionary principle, which states: "When an activity
raises threats of harm to human health or the environment,
precautionary measures should be taken even if some cause and
effect relationships are not fully established scientifically."

The Wingspread statement on the precautionary principle was
written by an international group of academics, scientists, and
environmentalists in 1998 as an implementation process for the
principle that explores those 3 elements of uncertainty, harm,
and action.

There are 4 implementation steps in the Wingspread statement:

First, people have a duty to take anticipatory action to
prevent harm. That is, action must be taken before the harm
occurs.

Second, the burden of proof for a new technology, process,
activity, or chemical lies with the proponents, not with the
public. There are some technologies or activities where the
proponent has more information -- or should have more
information -- about the potential harms, as well as the
uncertainties, and so has a greater obligation to prevent
damage. Such technologies include pharmaceuticals,
nanotechnology, chemicals, and biotechnology. Mechanisms such
as performance bonds posted before a technology is released
onto the market ensure that the polluter pays for damage rather
than externalizing the cost of the damage.

The notion that the burden of proof rests with the proponents
provides a real impetus for proponents to think carefully about
proposed activities before they undertake something hazardous.
Is this activity necessary? Are there other ways to accomplish
the same ends?

Third, implementing the precautionary principle requires
examining "a full range of alternatives"[10] before starting a
new activity, whether it is using a new chemical or a new
technology. If this activity is potentially harmful, it is
necessary to ask if there are other options that are less
destructive.

Fourth, decisions applying the precautionary principle must be
"open, informed, and democratic"[10] and "must include affected
parties."[10] The precautionary principle requires democratic
participation because when we make decisions that are
unresolvable with science, these decisions, by their very
nature, involve ethics and politics. Also, by involving
affected parties, we are more likely to get better science and
a better array of options.

Implications of the Principle for Healthcare Practitioners

The precautionary principle provides an impetus not only to
bear witness to suffering but to help alleviate suffering.
Healthcare practitioners have a special role in implementing
the precautionary principle and improving the lives of
individuals and their communities. Possibilities abound in both
patient care and policy.

Environmental health is a rapidly developing field, with new
information appearing almost daily about the connections
between human activities and environmental health effects. A
handful of books provides basic information about endocrine
disruptors, reproductive toxicants, and neurotoxicants,[8,9] as
well as the role of biodiversity in human health.[11] The
journal Environmental Health Perspectives, published by the
National Institute of Environmental Health, is a good source of
up-to-date research.

Patient Care

Greater Boston Physicians for Social Responsibility has created
an environmental health medical history form that can be used
to evaluate the environmental component of a patient's health
and disease. It is useful as a beginning guide to thinking
about people within their environmental context.

Where does the patient live vis-a-vis a local incinerator? In
his or her neighborhood, are there enough female plants
co-planted with male plants to attract the pollen and thereby
reduce allergies? How good is the air quality?

Frijtof Capra has said that mapping relationships, not
measuring things, is the ecological future.[12] It is also the
precautionary future, because mapping helps us to understand
connections even when those connections are not certain or
quantifiable. A wonderful example of mapping environmental
health occurred in 1854 during the cholera outbreak in London.
A local physician, John Snow, didn't fully understand the cause
of cholera in London, but he began mapping the outbreaks of
disease and traced them to a single water pump.[13] Snow had
the foresight to take the handle off the pump so that no one
else would catch cholera from the contaminated water.

Fully understanding the environmental context of a patient or
client helps the practitioner prevent disease and promote
health just as John Snow was able to do by taking the handle
off that water pump. [To be continued.] ==========

This article first appeared in the Sept./Oct. issue of
Alternative Therapies in Health and Medicine. Copyright 2002.
Used with permission.

*Carolyn Raffensperger, M.A., J.D., is the executive director
of the Science and Environmental Health Network in Ames, Iowa.

1. Center for Disease Control. Antibiotic resistance. Available
at: http://www.cdc.gov/antibioticresistance/. Accessed July 23,
2002.

2. Schettler T. 2001 Problem statement: why ecological
medicine? [handout]. Presented at: Ecological Medicine
Workshop; February 7-10, 2002; Bolinas, Calif.

3. The Bangkok Statement: a pledge to promote the protection of
children's environmental health. Presented at: International
Conference on Environmental Threats to the Health of Children;
March 3-7, 2002; Bangkok, Thailand. Available at:
http://ehp.niehs.nih.gov/bangkok/. Accessed July 23, 2002.

4. Chon D. Number of children with handicaps grows. San
Francisco Chronicle. July 6, 2002:A3.

5. Landrigan JL, Schechter CB, Lipton JM, Fahs MC, Schwartz J.
Environmental pollutants and disease in American children:
estimates of morbidity, mortality, and costs for lead
poisoning, asthma, cancer, and developmental disabilities.
Environmental Health Perspectives July 2002;110(7).

6. New York State Department of State Counsel's Office. Legal
memorandum LG06: the Americans with Disabilities Act applies to
local jails and prisoners. Available at:
http://www.dos.state.ny.us/cnsl/adajail.html. Accessed July 23,
2002.

7. McCallon TD. If he outgrew it, what is he doing in my
prison? Focus. Fall 1998. Available at:
http://www.add.org/images2/prison.htm. Accessed July 23, 2002.

8. Stein J, Schettler T, Reich F, Valenti M, Palmigiano M,
Watts J. In harm's way: toxic threats to child development
[report]. Cambridge, Mass: Greater Boston Physicians for Social
Responsibility; 2000. Available at:
http://www.igc.org/psr/ihw-report_dwnld.htm#ihwRptDwnld.
Accessed July 24, 2002.

9. Schettler T, Solomon GM, Valenti M, Huddle A. Generations at
Risk: Reproductive Health and the Environment. Cambridge, Mass:
MIT Press; 1999.

10. Raffensperger C, Tickner J, Jackson W. Protecting Public
Health and the Environment: Implementing the Precautionary
Principle. Washington, DC: Island Press; 1999.

11. Grifo F, Rosenthal J. Biodiversity and Human Health.
Washington, DC: Island Press; 1997.

12. Capra F. The Turning Point: Science, Society, and the
Rising Culture. New York, NY: Simon and Schuster; 1982.

13. University of California, Los Angeles. John Snow. Available
at http://www.ph.ucla.edu/epi/snow.html. Accessed July 24,
2002.