UMKC professor, alumni seek prevention and better treatment for an array of ailments.
Finding and evaluating environmental health hazards can seem like a scavenger hunt that has an ever growing and changing list.
Could mold spores from a leaking roof be triggering a patient’s COPD? Can a patient’s ZIP code — situated in the middle of a food desert — be a predictor for diabetes?
There’s evidence for both, and environmental experts say the hunt must go further: Are common household products aff ecting a child’s developing brain? Is local factory pollution causing a teen’s asthma? Is the lead poisoning crisis that grabbed headlines in Flint, Michigan, happening in communities elsewhere?
The range of possible hazards is daunting, but experts think the benefits of addressing toxic environmental exposures could be far more powerful in treating health conditions than any prescription medicine on the market.
“There may be more opportunities for intervention,” said Mark Hoff man, Ph.D., UMKC associate professor of pediatrics and biomedical and health informatics. “The cost of those interventions could be much less than developing a very expensive new drug.”
Doctors have long thought that the air we breathe, the water we drink and the soil where we grow our fruits and vegetables could hold the key to solving many complex medical problems. And never before have so many people, including UMKC alumni and faculty, publicly come together to try to gauge the health effects of environmental hazards.
At UMKC, Hoffman is pioneering an innovative use of electronic data to put valuable environmental information at health care providers’ fingertips. And two UMKC graduates — Bruce Lanphear, M.D. ’86, and Mark A. Mitchell, M.D. ’81 — are part of a nationally recognized group of environmental health experts who joined forces to demand action and policy changes on chemical standards.
Lanphear’s research on lead poisoning put him in the national spotlight when the Flint lead crisis came to light. Mitchell travels across the country educating and empowering minority communities to speak up about pollution.
“You wonder why there are so many disparities in health,” Mitchell said. “One of the contributors in my opinion is the environmental injustice.”
Rolling up their sleeves
Lanphear and Mitchell didn’t know each other at UMKC but came together last year as part of an elite team of environmental health scientists and medical officials known as Project TENDR, for Targeting Environmental NeuroDevelopmental Risks. The advocacy group, calling for a new system to investigate and regulate chemical safety, said it formed because of an “alarming increase in learning and behavioral problems in children.”
“Parents report that 1 in 6 children in the United States, 17 percent more than a decade ago, have a developmental disability including learning disabilities, ADHD, autism and other developmental delays,” the group said in its Consensus Statement, which is on its website at projecttendr.com and was published in the journal Environmental Health Perspectives
Lanphear, Mitchell and their TENDR colleagues spoke up because few others were talking. Though environmental health issues are gaining some traction in the United States, they said, change has been frustratingly slow.
“The only people I heard talking about the link between environment and health were the businesses and industries being regulated, who felt that they were being over-regulated,” Mitchell said. “When in fact from what I saw it was clear that the public was not being protected from the toxic exposures from business and industry.”
The mid-1970s Toxic Substances Control Act, however well-intentioned, made it nearly impossible to ban existing substances and burdensome to evaluate new ones. As a result, the statistics are eye-opening. Less than 7 percent of chemicals on the market have been tested by the Environmental Protection Agency to determine their health effects, Mitchell said, and nearly all of the others are assumed safe.
Mitchell eventually left his position as director of the Hartford Public Health Department, which gave him time to be a stronger voice for policy changes. He founded the Connecticut Coalition for Environmental Justice and Mitchell Environmental Health Associates. His first assignment was to investigate why Hartford children had the highest rate of asthma in Connecticut. State officials weren’t encouraging him to find answers, and Mitchell soon learned why.
He eventually linked poor environmental health indicators — asthma, allergies, headaches and more — in the low-income city of Hartford to a local trash incinerator. It’s the fifth largest incinerator in America.
“It just seems to me that if you’re going to build a trash incinerator that you would want its toxins as far away from people as possible and, in particular, as far away from vulnerable populations such as those that have the highest rates of asthma in the state,” he said. “But in fact, there’s a correlation between the percentage of people of color and the amount of hazards that people are exposed to.
“It’s not just Connecticut,” Mitchell said.
To Flint and back
When the Flint lead crisis came to light, Lanphear’s phone at Simon Fraser University in Vancouver, British Columbia, started ringing. He has dedicated his life to studying the consequences of lead and mercury poisoning in the developing brain. His long-term research goals are to prevent common diseases and disabilities in children including asthma and ADHD.
“The tragedy of Flint is that it was preventable,” Lanphear said.
Flint has understandably received widespread attention, he said, because its problems quickly followed a change in its water supply, made to cut costs but without adequate safeguards. But Lanphear said homes all across the U.S. had lead hazards, mainly from lead-based paint — more than 23 million by one estimate, about 1 in 5 households. As a result, many larger cities such as Chicago and Philadelphia have more cases of lead poisoning than Flint does.
Like Mitchell, Lanphear also decided to speak out more in recent years. His research and professor’s job with Simon Fraser University allows him time to create educational videos and give lectures. Lanphear said he spent half of his time translating existing research work to policy.
“The tragedy of Flint is that it was preventable.”- Bruce Lanphear
It’s a vast change from his research role in the United States. He spent much of his career as a principal investigator working on new areas of study, he said.
“The problem came when all of a sudden we knew what to do and we weren’t translating that,” he said.
According to Lanphear, lead poisoning is a classic example, and tainted water supplies aren’t the only problem. In 1909, a warning went out to keep children away from lead paint, and some European countries outlawed it then. But lead house paint wasn’t banned by the U.S. government till 1978, and Flint pointed out how vigilance also was lacking about lead in some water supplies.
“This is why I started to shift away from the research,” Lanphear said. “At some point it became clear that we actually do know enough to protect people from a lot of these different exposures and yet we’re failing to do so.”
Lanphear and Mitchell said the same thing is happening with chemical companies who have covered up problems with substances including mercury and two chemical classes, BPA and phthalates, that are added to the plastics in hundreds of consumer products.
Though many researchers and environmentalists think regulators should already have enacted more stringent regulations for many pollutants, manufacturers and business groups such as the U.S. Chamber of Commerce are critical of what they see as “politically charged regulations.” The National Petrochemical & Refiners Association called recent moves by the Environmental Protection Agency “overreaching government regulation” and “a clear distortion of current environmental law.”
The EPA generally defends the speed and pace of its actions, saying it can be difficult to turn general mandates for safe products and clean air and water into specific rules.
At UMKC, Hoffman is working on data-driven solutions. He’s creating an electronic system that boils down complex data records to help providers better evaluate their patient’s environmental health needs and risks.
Hoffman spent his career merging computer science with health data. He is constantly asking: “How can we make more effective use of large-scale data and complex analytics to improve health care at all levels?”
Hoffman, who is also the chief research information officer at Children’s Mercy Hospital, has a doctorate in bacteriology but was also the computer guru in the graduate school laboratory. Those skills led him to Cerner Corp., the medical software giant based in Kansas City, where his medical background and software engineering skills allowed him to lead the genomics and public health initiatives.
Hoffman points out that scientists have made tremendous gains by studying the genome (genetic makeup), microbiome (microbes’ genetic makeup), proteome (cells’ expressed proteins) and connectome (neural connections). Why not do the same for environmental factors, Hoffman asked, creating what he calls the envirome.
Envirome takes into account a patient’s exposure to risk factors including air pollution, water contamination and toxic chemicals. It looks at what type of access a patient has to everything from fresh produce and green space to doctors, education and transportation.
Studies have shown that the best life-expectancy predictor is a patient’s ZIP code. By that standard, a patient’s environment could hold the tools to improving public health, Hoffman said. The envirome could, for example, help scientists struggling to learn why thyroid cancer, food allergies and autism are increasing.
“These are not likely to be due to changes within our body but rather changes to the external things we’re exposed to,” he said.
The best part, according to Hoffman, is that a lot of environmental data has already been collected. To get an idea, Hoffman’s UMKC students put 2010 Census data and USDA food desert information into a database that it shared with Children’s Mercy Hospital. It included everything from proximity to grocers to whether someone was more likely to own a home or rent. Another UMKC student created a database of neighborhoods that documented important factors such as whether a roof was leaking. Together, the details could tell doctors a larger story.
Hoffman created a pilot project at Children’s Mercy that alerted doctors about several environmental factors needed in research.
Research helped define Gulf War Illness
GULF WAR ILLNESS, whose often disabling symptoms afflict one in four Desert Storm veterans, for years was misunderstood and dismissed as combat-related stress.
But that’s changing, thanks in part to a medical study co-written by Mary M. Gerkovich, Ph.D., an associate professor at the University of Missouri- Kansas City School of Medicine.
Twenty-six years after the 1990-’91 war known as Operation Desert Storm, the study marks the first time researchers have made a substantial genetic link to Gulf War Illness. The genetic research, published in 2015, found preliminary evidence that veterans with a particular butyrylcholinesterase genotype were 40 times as likely to develop Gulf War Illness after using pyridostigmine bromide pills, which are designed to protect against chemical-warfare nerve agents. The military ordered mass use of the pills in the Gulf War, Gerkovich said.
The research team discovered that some veterans with that genotype were slow to metabolize chemical toxicants, said Gerkovich, who works in UMKC’s biomedical and health informatics department.
The study helps explain why veterans with the same exposure had different outcomes. Some remained healthy while others experienced debilitating illness, said the study’s principal investigator, Lea Steele, a neuroepidemiologist and Yudofsky chair in behavioral neuroscience at Baylor College of Medicine in Houston, Texas.
It was a critical point for researchers.
“There are so many kinds of diseases that we don’t know exactly what causes them,” Gerkovich said.
To some extent, Gulf War Illness has always been among those mysterious diseases. But being able to link its onset with underlying genetics “helped refine the understanding of what it is and put it in context.”
Gerkovich was also part of a 2012 published study that sought to determine what environmental links could be traced to Gulf War Illness. Besides pyridostigmine bromide, the study found links to the extensive use of pesticides and proximity to missile explosions.
Few veterans have recovered from Gulf War Illness, whose symptoms include persistent cognitive and neurological problems, widespread pain and respiratory distress not explained by established medical or psychiatric diagnosis.
Gerkovich and Steele worked on a team collecting data from 2000 to 2002 when Gerkovich worked at the Midwest Research Institute. Gerkovich helped design the study, collect blood samples, conduct data analysis and write the results. She has since gone on to other research. Steele has become a world-recognized Gulf War Illness researcher.
They expect the findings to help other researchers and cause the military to think twice before ordering the widespread use of pyridostigmine bromide again.
“If you gauge that without having to dig around for that information, that will structure how you approach your conversation with the patient,” he said.
It could also help epidemiologists pinpoint cancer clusters sooner. It often takes years for scientists to connect geographic areas to cancer risks, Hoffman said. The EPA already provides maps of Superfund sites, some chemical releases and more. What if an oncologist could automatically map a patient’s home and then overlay that map with some of the public resources around chemical releases? The intervention strategies are profound, he said.
“It might not change their diagnosis, but it might help the next person in that neighborhood,” Hoffman said. “If you can make that a relatively simple process through Geographic Information System mapping abilities that are userfriendly, maybe they can trigger a more rigorous investigation that will lead to an earlier intervention at the community level.”
The work is challenging, Hoffman admits. Implementation is a hurdle. Medicine isn’t quick to change, and doctors can get overwhelmed with too much data.
“Then it doesn’t get used,” he said. “You haven’t accomplished anything.” And that’s where the extra efforts by Hoffman and his colleagues can help translate knowledge into action.
Measuring progress hasn’t been easy for environmental health experts. Mitchell is surprised that few physicians advocate for change.
“A lot of the physicians think that somebody else is going to be doing it,” he said.
Mitchell has made it his mission to inform residents about environmental disparities and urge them to speak out.
“One of my hobbies is to visit schools that are built on dumps. Those schools are only built in low-income communities of color,” he said.
It’s not that proposals haven’t come up in wealthy, white communities. But, says Mitchell, the proposals fail when the community learns that dumps produce volatile compounds associated with learning disabilities.
Mitchell admits the work can be frustrating and overwhelming. But there are victories.
In the village of Mossville, Louisiana, he has helped residents battle pollution, which has lingered for decades. More than a dozen chemical plants surround the community. Researchers have measured dioxins — some of the most carcinogenic chemicals — in the fruits residents grow and the dust in their homes. Residents blame the polluters for mercury poisoning, disease and deaths.
Changes are finally taking shape, Mitchell said. A new chemical giant has offered to buy out every homeowner before building a massive facility.
“That was not their intent originally,” Mitchell said. “But the community was organized enough.”
Back in his home city of Hartford, Mitchell successfully advocated for an environmental justice law. It forces polluting facilities to engage community members before building in a low-income community.
The work isn’t lucrative. Mitchell survives mainly on grants and is a consultant with environmental justice organizations around the country. He also works closely with the African American Physicians and the National Medical Association.
“My philosophy is if we work to make things better for the people who are most impacted, it makes things better for everyone,” he said.
Lanphear said the biggest recent changes have come from consumers, who have demanded products such as phthalate-free cosmetics.
“The public no longer trusts us. They’re going out and they’re buying natural cosmetics from smaller companies,” Lanphear said.
Nationally, an update to the Toxic Substances Control Act was signed into law in June. But Lanphear is skeptical that it will improve matters much, though it is supposed to help the EPA test more substances and limit or bar the ones found hazardous to health.
Whether or not the law helps in the short term, Lanphear and Mitchell know this is a long-term battle, often fought community by community.
“Change doesn’t happen overnight, but when it does happen, it tends to be more permanent,” Mitchell said. “And it affects millions of people — not just one patient.”