The Geopolitical Angle of Public Health

Conflict is never good for public health, though for some commentators that’s such a limp-wristed reason not to fight. The bellicose bloggers such as Ralph Peters and Victor David Hanson reminds one of the bit of apocrypha said of George S. Patton by some, “our blood, his guts” (rendered sardonically by an actor playing a dogfoot in the movie “Patton”). It also brings to mind the saying “amateurs discuss tactics, professionals discuss logistics” (yep, we’re going to be able to mount any sort of meaningful response to Russia’s incursion in Georgia while in the midst of two other conflicts). However, when your mind is in the clouds maneuvering squadrons, fleets and brigades around, there just isn’t time to pay attention to the fallout, such as hunger, dislocation, and epidemics.

Or maybe public health has more of a role in generating conflict than these bush-league Clausewitzs will acknowledge. There are some interesting perspectives on this in a recent article in the Asia Times – actually, there are several interesting perspectives, including the one that all Russian politicians are clever because the stupid ones are dead, whereas we currently have the stupid ones running everything right now. But what drew my attention was Russia’s demographic dilemma and how that might be a cause for its aggressive behavior (though the US and EU trying to extend NATO up to Russia’s doorstep might also have a role. . .).

The article paints a bleak picture demographically for the Russians running things in the country – falling birth rates among ethnically Caucasian Russians, abortion used as a means of birth control, declining life expectancy – and probably a whole host of other issues (I need to take a stroll over to the WHO web site sometime and review the statistics). The geopolitical angle around Russia trying to reclaim its old republics is:

Demographics stand at the center of Putin's calculation, and Russians are the principal interest that the Russian Federation has in its so-called near abroad. The desire of a few hundred thousand Abkhazians and South Ossetians to remain in the Russian Federation rather than Georgia may seem trivial, but Moscow is setting a precedent that will apply to tens of millions of prospective citizens of the Federation - most controversially in Ukraine.

We’ve only explored the fertility angle, and haven’t drilled into other issues of morbidity (caring for the millions made ill from poor diet, alcoholism and smoking), demographic troughs (fewer younger people to care for millions of elderly) or, most speculatively, fertility and neurobehavioral disorders from exposures to persistent organic pollutants and mercury. It may seem presumptuous to elevate pollutant exposures as a significant demographic contributor to geopolitical conflict. However, it’s probably prudent not to neglect them in strategic analysis, given the widespread nature of human exposure to these substances, coupled with the kinds of health effects they might be associated with, along with the uncertainty regarding occurrence and magnitude of those effects.

It’s interesting that we obsess on the resurgent Russia, an energy and geopolitical player on the world stage, and don’t give any consideration that behind the façade is a country full of sick and aging people. It’s both a warning to us, as well as a clue for how to manage Russia’s aggressive tendencies. No word yet on how we manage our aggressive tendencies.

Precaution and Triclosan

The other day I was pointed to an article by Cass Sunstein in the Boston Globe online, about the precautionary principle. I agree with Dr. Sunstein that fundamentally the precautionary principle is incoherent as a risk management tool, at least in the way a lot of the “deep green” people view it. All policy choices entail risks of some form; these may be disparate risks that fall differentially across the population, but we risk making irrational decisions if we don’t try to wrestle with them. Some of his examples are pretty dim, but then again he’s writing for the general audience, who is pretty dim when it comes to making decisions where uncertainty is involved.

In most or nearly all cases where risks are being assessed, you’ll be making a decision based on incomplete information. It may not be prudent to allot the time or resources to do the studies to more fully assess a risk before deciding to act on it. Indeed, the call for more study has become a strategy used by some corporations for deferring action on controlling health risks associated with their products, or with chemical substances that their workers are exposed to. It’s effective too, because, like the general audience, nearly all policy makers are genuinely bad dealing with environmental decisions under uncertainty.

There’s a “strong” version of the precautionary principle, which in effect is to take action to stop something that poses a significant risk until you prove it’s safe. That’s a recipe for either precipitous action or inaction, with Dr. Sunstein’s favorite example being invading Iraq. The more reasonable version of the principle suggests that a lack of decisive evidence of harm should not be grounds for not taking action. For example, the 1992 Rio Declaration, setting out principles for sustainable development, states, "Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation" (see Principle 15).

Of course, matters become more difficult to resolve in practice. A good example is antibacterial soaps containing triclosan. Soaps containing triclosan were no more effective than plain soap at preventing infectious illness symptoms and reducing bacterial levels on the hands. Also, several laboratory studies demonstrated evidence of triclosan-adapted cross-resistance to antibiotics among different species of bacteria. The conclusion of a recent review was:

The lack of an additional health benefit associated with the use of triclosan-containing consumer soaps over regular soap, coupled with laboratory data demonstrating a potential risk of selecting for drug resistance, warrants further evaluation by governmental regulators regarding antibacterial product claims and advertising. Further studies of this issue are encouraged.

Triclosan is used extensively in consumer products, including personal care products, textiles, and plastic kitchenware. The triclosan molecule has some structural similarities to phenols, diphenylethers and polychlorinated biphenyls (PCBs). It is widespread in low levels in waterways throughout the U.S., and has the potential for bioaccumulation in the environment. Biological monitoring performed by the CDC in 2003 and 2004 has detected triclosan in 75 percent of the urine samples collected from a representative sample of the U.S. population. In other words, traces of triclosan are detectable in a large number of people. Finally, triclosan was recently screened using mammalian cell lines for endocrine disrupting potential, and yes, there’s a possibility it’s an endocrine disruptor (potentially interfering with cell signaling that occurs in brain, heart and other cells, according to the UC Davis researchers).

Antibacterial soaps and consumer products have been identified as risk factors for antibiotic resistance. Infections from Methicillin-resistant Staphylococcus Aureus (MRSA) are becoming a growing concern for hospitals and healthcare professionals. Recommendations for managing MRSA in the community aren’t calling yet for getting rid of soaps and products containing triclosan. Noone is calling triclosan a threat to human reproduction yet (for example, CERHR isn’t investigating it).

However, it does raise the question of when action is warranted to reduce exposure to triclosan. There’s limited evidence that it isn’t terribly effective as an antibacterial agent in consumer products, and may contribute to antibiotic resistance. It’s widespread in the environment, bioaccumulative, detectable in humans, and now has emerging evidence of subtle adverse effects that might affect future generations. Absolutely nothing conclusive about any of it, but with the currently regulatory framework and political environment, it could involve decades of study and deliberation before a decision is made that widespread use of triclosan poses a risk or not. Then, if the determination is yes, it poses a risk, several more years would be required before it’s out of the product distribution chain.

This seems like a perfect application for the precautionary principle. However, until the precautionary principle develops some intellectual rigor, and possibly a quantitative framework, it’s going to remain a nice idea without a lot of decision-making punch.

Environmental Health Tools – e.hormone

Wading through the bisphenol-a morass in an effort to tell a coherent story about this substance has taken me into endocrine hormone territory. Hormones are a fascinating but high complex topic, but in the course of my journey, I’ve rediscovered the e.hormone site hosted by the Center for Bioenvironmental Research at Tulane/Xavier Universities. The CBR conducts research on environmental signaling. On the “about” page, they say this about environmental signaling:

Environmental signaling encompasses the many ways plants and animals use chemical signals to communicate life-driving information, to respond to physical or biological stimuli, and to talk to each other. The internal and external signals police interactions within and between cells and organs as well as among individuals and species. Sometimes, certain natural compounds and synthetic chemicals incorrectly trigger signaling mechanisms – turning them on and off at the wrong times or changing signal intensity that may affect reproduction and health.

Endocrine disruption is one of the most studied areas of inadvertent environmental signaling. Endocrine disrupting chemicals (EDCs) – the pesticides, plasticizers, pharmaceuticals, and other pollutants that interfere with estrogen and other hormone system signals – can affect cells to ecosystems and invertebrates to vertebrates. Humans and animals are exposed to EDCs through food, water, and air and can experience health effects ranging from subtle changes in blood hormone levels to overt reproductive abnormalities, infertility, and cancer. Facing the most risk are women of childbearing age, due to increased exposure through lifestyle choices, and infants and children, due to their small size, higher exposure, and fast growth.

EDCs are something that we’re probably going to have to learn to live with, since I don’t see us moving very quickly with reducing exposure to the pesticides, plasticizers, and pharmaceuticals which might be responsible for inadvertent cell signaling. e.hormone (which is also on the blogroll now) is going to be a handy resource for me, and I hope for you too.