Toxic Exposures in Pregnancy
2008 - 2009
Environmental Public Health Leadership Institute Fellow:
Thomas Schlenker, MD, MPH
Director of Public Health, Public Health Madison & Dane County
CCB #356
210 Martin Luther King Blvd
Madison, Wisconsin 53703
608-243-0306
608-267-2522
Mentor:
Tim Murphy, Ph.D.
Associate Professor
University of Findlay
2008–2009 Fellow Project
National Environmental Public Health Leadership Institute 370
EXECUTIVE SUMMARY:
Excess infant mortality among African Americans and the longstanding and seemingly irresolvable disparity between black
and white infant mortality rates is one of America’s most egregious social injustices related to health. The magnitude of the problem
and the lack of clarity on underlying causes seem to encourage special-interest-group-linked, pseudo-science. The Center for Public
Integrity’s 2007 publication “Great Lakes Danger Zones,” subtitled “Here’s the report that top officials of the Center for Disease
Control and Prevention thought was too hot for the public to handle-and the story behind it,” implies that increased infant mortality is
associated with living in or near areas contaminated by chemical releases. Such unfounded claims create confusion and cynicism
about the very real dangers of some chemical exposures during pregnancy. Dane County, Wisconsin, which, in contrast to other
Wisconsin metro areas, has experienced very dramatic improvements in black infant mortality in recent years, offers an excellent
opportunity to develop, field test and validate screening methods for environmental exposures that may affect birth outcomes.
The goal of the Toxic Exposures in Pregnancy project is to compose, vet and field test a brief list of chemical exposure-related
questions to be appended to the Pregnancy Risk Assessment Monitoring System (PRAMS) survey instrument. With the expanded
survey 150 African American women recently giving birth in Dane County and 150 in Racine, Wisconsin would be surveyed.
Ecological comparisons between Dane County and Racine will be drawn. The author has completed or will complete the following
steps. 1) Review of medical and environmental literature concerning prematurity and chemical exposures. 2) Identify local and
national individuals and agencies working on the issue. 3) Determine what are the most likely chemical exposures that have
demonstrated risk of adverse birth outcomes. 4) Construct a set of 6-10 questions on specific exposures that can be understood and
answered in a face-to-face interview situation. 5) Get agreement from principal investigators of funded collaborative research project
to include exposure questions 6) Field test and validate questions. 7) Get feedback from national experts on ability of questions
proposed to identify relevant risks. 8) Conduct survey. 9) Analyze results to identify exposures needing verification by biological
and/or environmental monitoring.
Steps 1-5 are essentially completed. Steps 6-8 can reasonably be done during 2009 as part of a three-year, funded
collaborative investigation, of which the author is co-principal investigator, linking the Madison Dane County and Racine public
health departments, the Wisconsin Department of Health Services and the University of Wisconsin School of Medicine and Public
Health, the UW Department of Sociology and Social Work and the UW LaFollette Institute. Step 9 will likely happen during 2010.
Conclusion: screening Women for exposure to chemicals that adversely affect birth outcomes is practical and worth doing.
2008–2009 Fellow Project
National Environmental Public Health Leadership Institute 371
INTRODUCTION/BACKGROUND:
General text
Problem Statement:
The Center for Public Integrity released in late 2007, without authorization, the Agency for Toxic Substances and Disease
Registry (ATSDR) draft report “Selected Information on Chemical Releases within Great Lakes Counties Containing Areas of
Concern (AOC).”(1) The ATSDR draft report compiled and presented previously collected environmental data on 26 AOCs and 54
counties in close geographic proximity. The Center for Public Integrity re-titled the report “Great Lakes Danger Zones” and
commented, “Here’s the report that top officials of the Centers for Disease Control and Prevention thought was too hot for the public
to handle - and the story behind it.” The CPI, in its version of the report, highlighted the fact that elevated rates for infant mortality
were observed in 21 of the 26 AOCs, implying causality. The ATSDR, in the final report issued some months later, stated that “it is
impossible to draw firm conclusions about the threat to human health from critical pollutants” in the Great Lakes study and offered
several convincing reasons why.(2)
Infant mortality and other adverse birth outcomes (congenital defects, premature birth and low birth weight) are plausibly or
implausibly linked to various environmental toxins (pharmaceuticals, alcohol, smoking, mercury, lead, nitrates, manganese, PCBs, the
11 critical pollutants in the above cited study).(3,4,5) Reports of such linkages regularly cause public alarm, especially when viewed
in the context of the large and persistent infant mortality disparities between blacks and whites in the United States. The alarms cause
anxiety and raise serious questions of environmental/social justice. Because of disconnect between environmental science and valid
community-based risk assessment and communication, evidence-based links between environmental toxins, actual exposures and real
life health consequences are lacking, fostering public confusion and distrust of governmental science-based agencies and science in
general.(6)
During recent years in Madison-Dane County, Wisconsin, black infant mortality rates have plummeted such that black/white
parity has been achieved.(7) A public health/academic/ health care provider coalition has formed to thoroughly investigate the
surprising trend. Thus, there is an excellent opportunity to develop and pilot a community-based environmental risk assessment tool
oriented toward adverse birth outcomes that is 1) biologically associated with relevant exposures, 2) well-matched to the
environmental data in space and time and 3) appropriate for use in real life settings.
2008–2009 Fellow Project
National Environmental Public Health Leadership Institute 372
To develop and test the proposed methodological tool, the investigating collaborators must agree it is a worthwhile endeavor.
The collaborators are Gloria Sarto, UW Women’s Research Institute, Bobbie Wolfe, UW La Follette Institute, Stephanie Robert, UW
Dept Sociology, Laurell Rice, UW Dept Obstetrics, Thomas Schlenker, Public Health Madison Dane County, Janelle Grammer,
Racine Health Department, Sherri Johnson, Wisconsin Public Health. Also, ATSDR, the CDC and EPA would need to review and
endorse pilot of the tool. It is also essential to have buy-in from the Dane County African American community. A plus would be to
have awareness/buy-in from environmental justice advocates.
By identifying actual risks and effectively communicating them, we can marshal political will and resources to tackle priority
problems. We can also pilot a model risk assessment/communication that works on a grass roots level. Conversely, conflicted
scientific leadership, unable to bridge the gap between in vitro and in vivo research creates distrust and erratic, irrational, and
disorganized public concern that is unlikely to lead to improving the environment in which we live and hampers public health practice
in general. The unprecedented disappearance of racial disparity in infant mortality in Madison-Dane County has ignited intense local
interest. ATSDR/CDC should be interested in that it needs to strategically respond to critiques from Center for Public Integrity. By
highlighting the “Great Lakes Danger Zones” study as an example of the need for resolution the role of environmental factors in infant
mortality we would hope to communicate with and link local collaboration with contacts at ATSDR, CDC and EPA. The
disappearance of infant mortality racial disparity in Madison Dane County, the Great Lakes Danger Zone controversy and the PBS
documentary “Unnatural Causes” all provide opportunities to create a very functional bond between local and national public health to
develop and pilot a needed risk assessment/risk communication tool.
2008–2009 Fellow Project
National Environmental Public Health Leadership Institute 373
Causal Loop Diagrams and applicable Archetypes:
Fixes That Backfire: Environmental Alarms
Env. Toxin
Exposure
Alarms
SymptomCorrecting
Process
B
We need to
respond now!
Stonewalling,
Sloppy
Science
Delay
R
Vicious Cycle
Apply
Fix
Alarm and
Confusion
over
Environmental
Toxins
Loss of confidence
and cynicism in
government/science
Apply
Fix
Apply
Fix
Time
(1)
2008–2009 Fellow Project
National Environmental Public Health Leadership Institute 374
10 Essential Environmental Health Services:
The Toxic Exposures in Pregnancy project demonstrates an assessment function of local public health. It is a form of community-based research
in that it responds to community concerns, seeks to elicit information directly from the community and requires community participation in the
form of designing and validating the research tool, conducting out the survey interviews and communicating the results. It is research that aims to
achieve high quality, locally relevant, risk assessment and risk communication.
National Goals Supported
The Toxic Exposures in Pregnancy project supports CDC Health Protection Goals “Health People in Healthy Places” and “Healthy
People in Every Stage of Life” by developing and testing a method for screening for toxic environmental exposures to pregnant
2008–2009 Fellow Project
National Environmental Public Health Leadership Institute 375
women that could adversely impact the fetus and birth outcome. Among the 28 focus areas of Health People 2010, it most directly
addresses Environmental Health and Maternal, Infant and Child Health.
The Toxic Exposures in Pregnancy project supports especially goal 2 of the National Strategy to Revitalize Environmental Public
Health Services, Supporting Research by devising and testing a research tool to be used in response to local concerns, that is
appropriate for use in a unique community but is also, in large part, generalizable.
Project Logic Model:
Activities
Survey literature
Consult with experts
Present to Collaborative
Develop questions
Recruit and train interviewers
Conduct interviews
Analyze results
Outputs
Risk Assessment Tool
# of interviews conducted
Analysis and presentation
Short and Long Term Outcomes, Impacts
Learning
-increased awareness of community exposure to toxins
-increased understanding of pathways and magnitude of exposure
-greater knowledge of how to communicate with community
-appreciation of community-based research
Infrastructure development
-cadre of community outreach workers established
-relationship with UW strengthened
-local public health research capacity demonstrated
2008–2009 Fellow Project
National Environmental Public Health Leadership Institute 376
-partial research grant support to PHMDC staff
-local public health environmentalism legitimacy increased
Behaviors
-greater respect for PHMDC research capacity
-academics seek out PHMDC as partner for community-based research
-African American community is energized on infant mortality issue
-other metro areas adopt our tools and strategies
Results
-infant mortality rates go down state-wide
-Wisconsin becomes model for nation
2008–2009 Fellow Project
National Environmental Public Health Leadership Institute 377
PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:
Program Goal. Develop and test a survey instrument for assessing toxic exposures during
pregnancy.
Health Problem. Persistent excess black infant mortality in the United States
Outcome Objective. Eliminate the black/white infant mortality disparity
Determinant. Infant mortality rate (number of infant deaths/1000 live births)
Impact Objective. Premature birth rate
Contributing Factors. Quality of prenatal care, socio-economic conditions, resilience
Process Objectives. Measures for each of the above
METHODOLOGY:
Through review of literature and consultation with local land national experts, a short list of
questions aimed at determining exposure to toxins with know adverse birth outcomes. The
questions will be vetted for relevance and understandability by community focus groups and
will be tested in the field as part of a community survey.
Next Steps:
1. The vetting and field testing of the environmental toxin exposure questions will be
completed in late 2009.
2. The survey data related to the environmental toxin exposures will be assembled and
analyzed by late 2010.
Expected Outcome:
The validity and practicality of a series of questions relating to exposure to environmental toxins
during pregnancy will be tested and conclusions ready to be drawn by the end of the study.
LEADERSHIP DEVELOPMENT OPPORTUNITIES:
Thomas Schlenker, MD, MPH
2008–2009 Fellow Project
National Environmental Public Health Leadership Institute 378
EPHLI has provided an excellent opportunity to meet and get to know environmental public
health professionals from many different places, with a great variety of skills and interests. Most
helpful has been spending time with big picture thinkers who relate environmental health issues
with the greater universe of public health and life of communties, the nation and world. During
the year I have been able to identify and establish relationships with key partners in local public
health, at the CDC and ATSDR, in academia and at national foundations. I thought the EPHLI
curriculum was, in large part, inadequate. Systems thinking is a valuable concept but
overreliance on a few diagramming tools vulgarized and trivialized the experience. The real
life experience of the Grand Canyon park service team made for worthwhile thought and
discussion, but beyond that little environmental health content or methodology was not
effectively presented. The St. Louis sessions were especially low quality. Small groups led by a
mentor works well and should be continued. Tim Murphy is an interesting and delightful person.
2008–2009 Fellow Project
National Environmental Public Health Leadership Institute 379
ABOUT THE EPHLI FELLOW(s)
Thomas Schlenker, MD, MPH is a pediatrician and Director of Public Health for
Madison and Dane County, Wisconsin. Previously he has been health officer in Salt
Lake, Utah, Milwaukee, Wisconsin and a senior Fulbright fellow at the National Institute
of Public Health in Cuernavaca, Mexico. At the local level, Dr. Schlenker has built and
guided programs in childhood lead poisoning prevention, immunizations, HIV outreach,
drinking water quality assurance and has published research on a variety of
environmental health, infectious disease and public health policy issues. He has served
as advisor and national faculty for the CDC’s lead poisoning prevention training program
for many years.
2008–2009 Fellow Project
National Environmental Public Health Leadership Institute 380
REFERENCES
1. The Center for Public Integrity. Great Lakes Danger Zones 2007.
http://www.publicintergrity.org/Great Lakes/exerpts.htm
2. Agency for Toxic Substances and Disease Registry, Department of Health and
Human Services. Selected Information on Chemical Releases within Great Lakes
Counties Containing Areas of Concern (AOC) (Public Comment Draft 2008).
http://www.atsdr.cdc.gov/grtlakes/2008
3. United States Environmental Protection Agency. A Decade of Children’s
Environmental Health Research, Summary Report 2007. http://www.epa.gov
4. Collaborative on Health and the Environment. Chemical Contaminants and Human
Diseases: A Summary of Evidence. http://www.HealthandEnvironment.org
5. The Role of Environmenbtal Hazards in Premature Birth. The National Academic
Press, Washington, DC 2003. Mattison DR, Wilson S, Coussons C, Gilbert D. editors
6. Rust S, Kissinger M. EPA Drops Ball on Danger of Chemicals to Children.
Milwaukee Journal Sentinel, March 29 2008
7. Schlenker TL, Ndiyai M. Disappearance of Black/White Infant Mortality Gap in
Dane County, Wisconsin 1990-2007. submitted to MMWR
2008–2009 Fellow Project
National Environmental Public Health Leadership Institute 381