Uncovering the toxins in our daily lives

A new book by a lecturer in public health describes what’s safe and what’s not in household products.

By Cathy Shufro

Toxicologist Gary Ginsberg, Ph.D., has good news about the environmental contaminants we encounter in our daily lives. “One of the major myths is that the environment is worse than it’s ever been,” said Ginsberg, the senior toxicologist at the Connecticut Department of Public Health and a lecturer at the Yale School of Public Health. “As a matter of fact, a lot of things are better now than they ever were.”

For instance, pesticides used in farming are less hazardous and less persistent than the banned chemicals of the 1950s, 1960s and 1970s. Paint and gasoline no longer contain lead. Asbestos has been phased out of building materials, and intact asbestos can be safely left in place. And although a staggering number of people are worried about mold in homes and schools, Ginsberg said that humans have lived with mold for millennia, and the fungus is unlikely to cause lung damage. “It’s a crop you don’t want to grow in your house, but it’s something you shouldn’t freak out about.”

Still, research and reporting regularly bring to light serious risks from toxic chemicals, said Ginsberg, “and the headlines don’t answer the specifics of your situation.” To help the public distinguish between major and minor risks, Ginsberg collaborated with health department colleague Brian Toal, M.S.P.H., to write a guide, What’s Toxic, What’s Not, published in 2006.

“Rather than answer questions one phone call at a time, we decided we would try to put it all together in a somewhat encyclopedic but accessible way,” said Ginsberg. He and Toal considered a range of potential hazards: hormones in hamburgers, carcinogens in bubble bath, toxic fumes from overheated Teflon and volatile chemicals in toilet cleansers and drain uncloggers. (Ginsberg said that using harsh cleaners is “like using the atom bomb to clean the bathroom.” He recommends hot water and detergent instead.) The authors discuss power lines, toxic waste dumps and cancer clusters.

Ginsberg cites the top five risks Americans face as radon gas, indoor air pollution, mercury in fish, lead paint and carbon monoxide. The book advises readers to test for carcinogenic radon gas at home and to vent appliances and woodstoves properly, to burn only dry hardwoods and to clean chimneys regularly. Because most fish contain mercury, the book suggests no more than two fish meals per week, with only one containing farmed fish. People living in houses more than 30 years old should watch for chipping paint, especially on windowsills. Occupants of houses built before 1987 should test their drinking water for lead, and all children should get blood tests for lead at ages 1 and 2.

Ginsberg himself buys such products as dish soap and shampoo at the health food store rather than the supermarket. Dangers in supermarket items include volatile organic compounds in cleaning products as well as reproductive toxins and carcinogens in cosmetics. “There’s no gatekeeper at the supermarket, and the Consumer Product Safety Commission doesn’t regulate these things,” Ginsberg said.

With each new headline in the media, Ginsberg gets new questions. For example, consumers have begun worrying about plastic baby bottles and water bottles containing Bisphenol A (BPA), a chemical used since the 1950s to make polycarbonate plastics that was developed in the 1930s as a synthetic estrogen. Recent animal studies have shown that BPA can disrupt the endocrine system. The Canadian government announced in October 2008 that it is banning polycarbonate baby bottles containing BPA. To provide information about such emerging issues, Ginsberg has established a website: whatstoxic.org. He also hosts a radio show, Greener Living with ‘Dr. G,’ which can be heard (locally or on the Internet) on WTIC-AM, Saturdays from 4 to 6 p.m.

Bookshelf focuses on books and authors at the School of Medicine. Send suggestions to Cathy Shufro at cathy.shufro@yale.edu.

Book notes

High Risk Obstetrics: The Requisites in Obstetrics and Gynecology
by Edmund F. Funai, M.D., associate professor of obstetrics, gynecology and reproductive sciences, Mark Evans, M.D., and Charles J. Lockwood, M.D., chair and the Anita O’Keefe Young Professor of Obstetrics, Gynecology and Reproductive Sciences (Elsevier) This volume offers guidance for assessing and managing high-risk pregnancies. The book includes tables that present differential diagnoses and recommendations on lab values and treatments. Case studies and illustrations accompany coverage of antepartum care, medical complications of pregnancy, fetal disorders, fetal surveillance, intrapartum complications and puerperal disorders.

Stoelting’s Anesthesia and Co-Existing Disease, 5th ed.
by Roberta L. Hines, M.D., HS ’77, chair and the Nicholas M. Greene Professor of Anesthesiology, and Katherine E. Marschall, M.D., assistant professor of anesthesiology (Elsevier) This edition has been updated to reflect the latest information to help clinicians avoid or manage complications stemming from pre-existing medical conditions. Organized by disease, the new edition provides guidance on definition, current pathophysiology and pre-, intra- and postoperative factors of the disease process, anesthetic judgment and management. It provides case studies that exemplify how to overcome a wide range of challenges, and it examines specific anesthesia considerations for special populations, including pediatric and geriatric patients.

Motion Preservation Surgery of the Spine: Advanced Techniques and Controversies
by James J. Yue, M.D., associate professor of orthopaedics and rehabilitation, Rudolph Bertagnoli, M.D., Paul C. McAfee, M.D., and Howard S. An, M.D. (Elsevier) This book provides an introduction to motion preservation surgery and discusses surgical considerations and cervical total disc arthroplasty. The text examines the advantages and disadvantages of the full range of nonfusion technologies and presents step-by-step, illustrated operative guides to achieve optimal outcomes. The book is accompanied by a dvd featuring three hours of surgical video.

Dermatopathology: Diagnosis by First Impression
by Christine J. Ko, M.D., assistant professor of dermatology and pathology, and Ronald J. Barr, M.D. (Wiley-Blackwell) This guide introduces a simple and effective way to approach a slide and focuses on a selection of commonly tested entities, showing low- to high-power views. Major differences among diagnoses that are sometimes confused are emphasized on “Key Differences” pages. The book contains minimal text and should be used as a companion to dermatopathology textbooks and as a pictorial reference and study tool.

The Uncertain Art: Thoughts on a Life in Medicine
by Sherwin B. Nuland, M.D., clinical professor of surgery (gastroenterology) (Random House) This volume is a collection of essays about the mix of expertise, intuition, sound judgment and chance that plays a part in a doctor’s practice and life. Drawing from history and his own experiences, Nuland includes topics ranging from the primitive procedures doctors once practiced with good intentions—such as grave robbing and prescribing cocaine as an anesthetic—to gene therapy, the adoption of Eastern practices like acupuncture and the complex moral and ethical quandaries confronting healers that arise from such innovations as cloning.

Trauma-Centered Group Psychotherapy for Women: A Clinician’s Manual
by Hadar Lubin, M.D., assistant clinical professor of psychiatry, and David R. Johnson, Ph.D., associate clinical professor of psychiatry (Routledge) This manual is a theory-based, field-tested model of group therapy for traumatized women. It includes clinical examples, a session-by-session guide for clinicians and a workbook for clients. Topics include managing traumatic re-enactments, a developmental theory of trauma and post-traumatic stress disorder and guidance in handling difficult treatment and clinical situations. The authors also discuss the use of testimonials and ceremonial structures to heighten the therapeutic impact.

The Marshall Plan: Lessons Learned for the 21st Century
edited by Eliot Sorel, M.D., FW ’75, and Pier Carlo Padoan, M.D. (OECD Publishing) This book examines the historical, diplomatic, economic and strategic aspects of the European Recovery Program—popularly known as the Marshall Plan—that brought Europe out of the chaos, hunger, poverty and desperation of World War II. Contributors address 21st-century applications of lessons learned from the Marshall Plan.

Essential Otolaryngology: Head and Neck Surgery, 9th ed.
by K. J. Lee, M.D., associate clinical professor of surgery (otolaryngology) (McGraw-Hill) This otolaryngology primer delivers the latest critical information to help treat conditions involving the head and neck, such as sinusitis, sensory disorders, cancer and sleep disorders. This edition contains new chapters on cysts and tumors of the jaw, TNM classification in otolaryngology, head and neck surgery, and malignant melanoma.

Non-Invasive Management of Gynecologic Disorders
edited by Aydin Arici, M.D. ’50, professor of obstetrics, gynecology and reproductive sciences, and Emre U. Seli, M.D., assistant professor of obstetrics, gynecology and reproductive sciences (Informa Healthcare) This text provides information on currently available options for gynecologic disorders suitable for nonsurgical management. It offers guidance to physicians on how and when to choose more conservative modalities and how to differentiate between the variety of treatment options available. The authors take an evidence-based approach to topics including management of ectopic pregnancy, pregnancy loss and termination, infertility, chronic pelvic pain, endometriosis and dysfunctional uterine bleeding.

How to Think Like a Radiologist: Ordering Imaging Studies
by Tara Marie Catanzano, M.D., assistant professor of diagnostic radiology (Cambridge University Press) This pocket guide provides guidance in choosing which type of imaging study best answers the clinical question posed. The book addresses imaging studies by modality, body region and type of study in bulleted outline format. It discusses general considerations for each modality—including advantages and disadvantages—as well as patient preparation and requirements for each type of examination.

The Nursing Home Guide: A Doctor Reveals What You Need to Know About Long-Term Care
by Joshua D. Schor, M.D. ’85 (Berkley/Penguin) The author guides the reader step by step through the process of placing a loved one in a nursing home or long-term care facility. He covers such topics as questions to ask about medications, meals and activities; deciding whether assisted living may be a viable alternative; determining whether a family member needs long-term or subacute care; and knowing your rights and getting the information you need.
The descriptions are based on information from the publishers.

Send notices of new books by alumni and faculty to Cheryl Violante, Yale Medicine, 300 George Street, Suite 773, New Haven, CT 06511, or via e-mail to cheryl.violante@yale.edu.

In circulation

Library initiative links Third World doctors and researchers to journals

Just seven years ago, clinicians and scientists in the developing world could get hold of—on average—only two international medical journals, according to the World Health Organization (WHO). And in the poorest countries, fewer than half of the doctors and researchers could put their hands on a single journal.

Now, through a WHO program called HINARI, they have electronic access to 6,000. The program makes journals and databases available to health care professionals in 3,600 hospitals, medical schools and other institutions in 108 countries from Afghanistan to Zimbabwe. Subscription rates range from nothing in the poorest countries to $1,000 annually per institution in more affluent countries.

Yale librarians including Kimberly Parker, M.I.L.S., have played crucial roles in developing HINARI. Parker headed the electronics collection for Yale’s library system when the project was conceived in 2001; researchers from resource-poor countries had told who officials that without access to biomedical information they could not be members of the international research community. Within months, several major publishers had agreed to donate access to their journals, and HINARI was launched in January 2002. Last spring Parker took over as program manager of HINARI in Geneva.

Yale librarians continue to contribute. When a researcher in Ecuador peruses a journal, or a gynecologist in Vietnam reads about screening for anemia, each depends upon the support of Yale librarian Daniel Dollar, M.L.S., and his staff, who make sure that links work and add journals and databases to the ever-expanding system. “They actually have access to more journals than we do,” said Dollar.

Because of HINARI, Parker said, more scientists “are contributing to the global conversation in important ways, often on topics the rest of us are ignoring.”

Senegalese urologist Mohamed Jalloh, M.D., depends on HINARI to search the medical literature and find such clinical information as drug dosages. Just three years out of residency, Jalloh says he has had 13 articles published. “It is very important for us to have access to good-quality peer-reviewed publications,” he said.

—Cathy Shufro

In Circulation focuses on activities at the Cushing/Whitney Medical Library. Send suggestions to Cathy Shufro at cathy.shufro@yale.edu.



Curry		Beyrer



Burtness		Friedman Ross

On campus

Connecticut lags in long-term care for elderly and disabled

Connecticut has made inroads into shifting long-term care for the elderly and people with disabilities from institutions to community-based programs, but according to a Yale researcher it lags behind many other states. “Connecticut is making important progress, but there’s a long way to go,” said Leslie Curry, Ph.D., M.P.H., a research scientist at the School of Public Health who spoke at a session in the Aging Research Seminar Series in February.

Spurred by a 1999 U.S. Supreme Court ruling, states have begun to shift long-term care from nursing homes to community-based options, largely because nursing home care is about twice as costly as community-based care and because people prefer community settings. With $56 million in federal grants, Connecticut has increased the proportion of Medicaid clients receiving community-based care from 46 percent in 2002 to 51 percent in 2006, Curry said.

Nationally, though, Connecticut “is not a leader,” and Curry said the state needs to streamline its organization, increase community-based options and enhance consumer-directed models of care in order to reach its goal of having 75 percent of Medicaid recipients who need long-term care in community-based settings by 2025.

—John Dillon

Zimbabwe cholera outbreak has roots in corruption

When cholera struck Zimbabwe last summer, international aid poured into the African country. Despite those resources, however, fatalities increased among those infected. “One in 20 people was dying, and 80 percent of those deaths were preventable,” said Chris Beyrer, M.D., M.P.H., professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health, at a talk at the School of Public Health in February. Beyrer investigated the health care system in Zimbabwe last year on behalf of Physicians for Human Rights.

The reasons for the epidemic and its high mortality rates, Beyrer said, stem from the corruption of President Robert Mugabe’s administration, which enriched itself at the public’s expense. “I have never seen a health care system collapse so extreme,” Beyrer said. Public hospitals and clinics shut their doors, and for political reasons, the government had handed over public water supplies to cronies. As a result, untreated sewage flowed into reservoirs of drinking water.

“If you want to create a cholera epidemic, this is the way to do it,” Beyrer said. “It is very hard to imagine a public health solution to these problems without addressing the politics.”

—John Curtis

Physicians must know how to blow the whistle on torture

Physician complicity in torture at Guantánamo and Abu Ghraib reveals a serious gap in medical education, said former Yale professor Barbara Burtness, M.D., now chief of head and neck medical oncology at Philadelphia’s Fox Chase Cancer Center.

Speaking at the Program for Humanities in Medicine in January, Burtness said that physicians and other health care providers had abetted such tortures as waterboarding, granted medical clearance for harsh interrogations, permitted forced feeding, offered privileged information on prisoners’ phobias, withheld care and falsified death certificates. In Iraq, she said, “they medically approved biopsychosocial interrogation plans.”

“I wondered,” said Burtness, “Were they people I had gone to medical school with, or people I had trained?”

Medical students, she said, should learn standards for treatment of prisoners and understand such ethical codes as the Declaration of Tokyo, which addresses torture. They should recognize signs of torture and understand that, if they participate in abuse, they could be accused of war crimes. Physicians should also know how to blow the whistle: just as they carry notes on how to measure blood gases, she said, they should carry phone numbers for reporting torture.

—Cathy Shufro

Parental consent needed for genetic screening

Most of the 4.3 million babies born in the United States each year are screened without parental consent for up to 50 genetic disorders that may cause such severe conditions as mental retardation. But at a pediatric grand rounds in February, Lainie Friedman Ross, M.D., Ph.D. ’96, the Carolyn and Matthew Bucksbaum Professor of Clinical Medical Ethics at the University of Chicago, argued for changing the recommendations governing parental consent.

“If we had parental consent for these tests it would show respect for parental autonomy in health care decisions for their children, which is required for all other health care, and it would also allow us to enroll the children in research protocols,” Ross said. “That is the only way we will learn the natural history of these very rare diseases, understand who needs to be treated and develop effective treatments for them.”

Ross also questioned the current policies of the American Academy of Pediatrics and the American College of Medical Genetics, which proscribe testing children for adult-onset conditions like breast cancer. Some parents want the information early for psychosocial reasons. While predictive testing should be discouraged, Ross maintained that parents, not physicians, should have the final say in testing children.

—Alix Boyle


			Originally published in Yale Medicine, Spring 2009. Copyright © 2009 Yale University School of Medicine. All rights reserved.