Ethical, Legal, and Social Issues: Our Children's Future

Mercury exposure education provided by women's health clinics in Duval County, Florida

Duval County (Jacksonville, FL, USA) has a long history of environmental health hazards, especially prevalent within its urban core, referred to as Health Zone 1. In 2009, the Duval County Health Department conducted a survey of awareness of and actual exposure to methylmercury among women in the county. The survey found that women with more education or higher incomes had a higher awareness of potential mercury exposures. Furthermore, women in the urban core were less aware and had higher exposure than those in more affluent areas. This study assesses the mercury-exposure awareness and education by healthcare providers serving women of child-bearing age. We surveyed 28 women's health clinic offices. Sixty-one percent (17/28) indicated that they provide mercury exposure education to female patients, either written or verbal. Of these, only half (8/17) provide written education materials. Ninety-three percent of the providers indicated that a benefit to providing education on mercury exposure, is having "healthier developing fetuses and young children in the community". Two barriers identified by providers to offering information on mercury exposure and risk were (a) a lack of interest among patients, and (b) a lack of clear, understandable educational materials. The long-term goal of our * -8project is to develop and distribute culturally effective, low literacy materials for distribution by health clinics, to document the increased awareness of mercury exposure risks, and to lessen the adverse health outcomes that may result from mercury exposure among vulnerable population groups in Duval County.

Scientific and policy statements on environmental agents associated with neurodevelopmental disorders

Given established scientific knowledge, protecting children from neurotoxic exposures from the earliest stages of fetal development is clearly an essential public health measure. By reducing environmental factors that may lead to learning and developmental disorders, we will create a healthier environment in which all children can reach and maintain their full potential. (Gilbert, 2008 ).

Monitoring and reducing exposure of infants to pollutants in house dust

The health risks to babies from pollutants in house dust may be 100 times greater than for adults. The young ingest more dust and are up to ten times more vulnerable to such exposures. House dust is the main exposure source for infants to allergens, lead, and PBDEs, as well as a major source of exposure to pesticides, PAHs, Gram-negative bacteria, arsenic, cadmium, chromium, phthalates, phenols, and other EDCs, mutagens, and carcinogens. Median or upper percentile concentrations in house dust of lead and several pesticides and PAHs may exceed health-based standards in North America. Early contact with pollutants among the very young is associated with higher rates of chronic illness such as asthma, loss of intelligence, ADHD, and cancer in children and adults. The potential of infants, who live in areas with soil contaminated by automotive and industrial emissions, can be given more protection by improved home cleaning and hand washing. Babies who live in houses built before 1978 have a prospective need for protection against lead exposures; homes built before 1940 have even higher lead exposure risks. The concentration of pollutants in house dust may be 2-32 times higher than that found in the soil near a house. Reducing infant exposures, at this critical time in their development, may reduce lifetime health costs, improve early learning, and increase adult productivity. Some interventions show a very rapid payback. Two large studies provide evidence that home visits to reduce the exposure of children with poorly controlled asthma triggers may return more than 100% on investment in 1 yr in reduced health costs. The tools provided to families during home visits, designed to reduce dust exposures, included vacuum cleaners with dirt finders and HEPA filtration, allergy control bedding covers, high-quality door mats, and HEPA air filters. Infants receive their highest exposure to pollutants in dust at home, where they spend the most time, and where the family has the most mitigation control. Normal vacuum cleaning allows deep dust to build up in carpets where it can be brought to the surface and become airborne as a result of activity on the carpet. Vacuums with dirt finders allow families to use the three-spot test to monitor deep dust, which can reinforce good cleaning habits. Motivated families that receive home visits from trained outreach workers can monitor and reduce dust exposures by 90% or more in 1 wk. The cost of such visits is low considering the reduction of risks achieved. Improved home cleaning is one of the first results observed among families who receive home visits from MHEs and CHWs. We believe that proven intervention methods can reduce the exposure of infants to pollutants in house dust, while recognizing that much remains to be learned about improving the effectiveness of such methods.

The new tapestry of risk assessment

Neurotoxicology is entering a new phase in how it views and practices risk assessment. Perhaps more than any of the other disciplines that comprise the science of toxicology, it has been compelled to consider a daunting array of factors other than those directly coupled to chemical and dose, and the age and sex of the subject population. In epidemiological investigations, researchers are increasingly cognizant of the problems introduced by allegedly controlling for variables classified as confounders or covariates. In essence, they reason, the consequence is blurring or even concealing interactions of exposure with modifiers such as the individual's social ecology. Other researchers question the traditional practice of relying on values such as NOAELs when they are abstracted from a biological entity that in reality represents a multiplicity of intertwined systems. Although neurotoxicologists have come to recognize the complexities of assessing risk in all its dimensions, they still face the challenge of communicating this view to the health professions at large.

Noninherited risk factors and congenital cardiovascular defects: current knowledge: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young: endorsed by the American Academy of Pediatrics

Prevention of congenital cardiovascular defects has been hampered by a lack of information about modifiable risk factors for abnormalities in cardiac development. Over the past decade, there have been major breakthroughs in the understanding of inherited causes of congenital heart disease, including the identification of specific genetic abnormalities for some types of malformations. Although relatively less information has been available on noninherited modifiable factors that may have an adverse effect on the fetal heart, there is a growing body of epidemiological literature on this topic. This statement summarizes the currently available literature on potential fetal exposures that might alter risk for cardiovascular defects. Information is summarized for periconceptional multivitamin or folic acid intake, which may reduce the risk of cardiac disease in the fetus, and for additional types of potential exposures that may increase the risk, including maternal illnesses, maternal therapeutic and nontherapeutic drug exposures, environmental exposures, and paternal exposures. Information is highlighted regarding definitive risk factors such as maternal rubella; phenylketonuria; pregestational diabetes; exposure to thalidomide, vitamin A cogeners, or retinoids; and indomethacin tocolysis. Caveats regarding interpretation of possible exposure-outcome relationships from case-control studies are given because this type of study has provided most of the available information. Guidelines for prospective parents that could reduce the likelihood that their child will have a major cardiac malformation are given. Issues related to pregnancy monitoring are discussed. Knowledge gaps and future sources of new information on risk factors are described.

Supplementing the traditional institutional review board with an environmental health and community review board

BACKGROUND

Community-based research often involves additional ethical, legal, and social considerations beyond those of the specific individuals involved in the study. The traditional institutional review board (IRB) typically focuses on protecting the rights and ensuring the safety of the individuals involved. For projects involving community members, IRBs should be more sensitive to issues related to the broader community concerns.

OBJECTIVES

The objective of this article is to discuss the concept of community-based participatory research and the shortcomings of the traditional IRBs in dealing with ethical issues associated with broader community concerns such as implications for family members, neighborhood groups, and local businesses. I examine the rationale and benefits for expanding the roles and responsibilities of review boards related to community-based issues.

DISCUSSION

I propose the development of environmental health and community review boards (EHCRBs) that combine the fundamental responsibilities and ethical concept of the traditional review boards with an expanded ethical construct of dignity, veracity, sustainability, and justice, with an added emphasis on community.

CONCLUSIONS

Only by acknowledging the needs of and working with the community can we ensure ethically based and socially responsible research. An EHCRB will allow researchers and community members to more fully address their mutual interest in conducting scientific, ethical, and socially responsible research.

A rationale for lowering the blood lead action level from 10 to 2 microg/dL

Fifteen years ago, in 1991, the U.S. Centers for Disease Control and Prevention (CDC) established 10 microg/dL as the lowest level of concern for children's blood lead levels. This value is extremely important because, historically, policy makers and public health officials generally have acted to remove sources of lead exposure only after the CDC's level of concern had been exceeded. A growing body of evidence, however, reveals that blood lead levels below 10 microg/dL may impair neurobehavioral development. There is now sufficient and compelling scientific evidence for the CDC to lower the blood lead action level in children. This review argues that a level of 2 microg/dL is a useful and feasible replacement. Although it can be argued, in turn, that no threshold for the health effects of lead is demonstrable, analytically a blood level of 2 microg/dL is readily and accurately measured and provides a benchmark for successful prevention. Lowering the level of concern would encourage and accelerate the investments needed to ensure that children are protected from lead exposure in their homes, schools, and play settings. Such a program would also offer economic advantages because of the coupling between lead, educational attainment, earnings and anti-social conduct. By lowering the blood action level, CDC will promote policies and initiatives designed to further reduce children's exposure to this potent developmental neurotoxicant.