Air Sick

 Airborne Toxins Take a Toll

 Texas Medicine Logo


 Tex Med. 2012;108(4):16-22.

 By Crystal Conde  
 Associate Editor

As gas prices soar, lawmakers look to alternative energy sources to fuel the future. And, as scientific research strengthens the connection between air pollution and disease, physicians seek ways to restrict the amount of toxins patients breathe.

Wesley Stafford, MD, a Corpus Christi allergy and asthma physician and member of the Texas Medical Association Council on Science and Public Health, regularly sees just how damaging air pollution can be. Dr. Stafford says his patients' respiratory disease symptoms often worsen when the wind blows into town from the city's refinery area, which spans seven miles along its northern border.

"Anyone driving on the north side of town when the winds blow through notices the strong chemical odor from the refinery area. It's likely the air pollution may be causing the exacerbations," he said.

Each year in Texas, Dr. Stafford adds, air pollution from a variety of sources, including coal-fired power plants and diesel engines, triggers heart attacks, asthma attacks, and other lung conditions, causing thousands of hospitalizations and emergency department visits. Coal-fired power plants spew particulate matter air pollution, a mixture of substances including carbon-based particles, dust, and acid aerosols formed in the atmosphere from plant emissions such as volatile organic compounds, sulfur dioxide, and nitrogen oxides.

 The negative effect air pollution can have on Texans, especially the young and elderly, inspired Dr. Stafford, along with the Texas Medical Association, the Nueces County Medical Society, and other physicians and organizations, to urge Las Brisas Energy Center, LLC, to invest in cleaner, more efficient energy alternatives in the proposed construction of a new power plant in Corpus Christi. (See "Medicine Supports Clean Energy.")

Dr. Stafford, a member of TMA's Council on Science and Public Health, says this type of collaboration can make a difference at the state level. He calls on physicians across Texas to continue to work with TMA and other organizations to advocate for policy and legislation to control the sources of air pollution.

 "We can either watch as our patients develop diseases and even die – because of the quality of the air we all breathe – or go public and work to reduce and reverse the progressive deterioration of the environment we all live in. We owe it to our patients, our communities, our children, and ourselves to get involved," Dr. Stafford said.


 Influencing Environmental Policy

Robert Haley, MD, director of the Division of Epidemiology at The University of Texas Southwestern Medical Center at Dallas, says public education is necessary to pass legislation that ensures clean air and energy while stimulating economic growth from clean energy industries.

Dr. Haley was a member of a partnership formed in 2008 that included Texas professionals from business, law, and medicine. Founding members of the partnership include the Dallas County Medical Society (DCMS), Texas Business for Clean Air, and environmental lawyers with the Dallas Bar Association.

The partnership commissioned three studies, ultimately combined into one report, that Dr. Haley says is a primer on environmental health for legislators and policymakers.

The original studies examined:  

  •  The nature and extent of the air pollution problem and the future for sustainable energy in the state;
  •  The effects of current and pending legislation and litigation on air pollution and energy generation in Texas; and
  •  The costs of the energy-generation options for Texas and the economic return in growth and tax revenue.

  The TMA Board of Trustees contributed $5,000 to help fund the studies.

The partnership first circulated the report,  Policy Options for Clean Air and Sustainable Energy in Texas , among lawmakers during the 2009 Texas Legislature.

"Our partnership originally formed to raise funds to complete the study. It formed the first organized source of information – circulated among state legislators and eventually around the country – on how to maintain energy sufficiency while cleaning up the air and the environment," Dr. Haley said.

 Policy Options identifies ozone, particulate matter, mercury, and climate change as challenges to improving public health, meeting federal air quality standards, and attracting new business to Texas.

The report says Houston, Dallas-Fort Worth, Beaumont, San Antonio, Austin, and El Paso exceed U.S. Environmental Protection Agency (EPA) standards for ozone of 75 parts per billion, based on an eight-hour daily average. The EPA says inhaling ozone can prompt chest pain, coughing, throat irritation, and congestion, and can worsen bronchitis, emphysema, and asthma.

Fine particulate matter, a mixture of liquid droplets and particles smaller than 2.5 micrometers in diameter, can trigger cardiovascular and respiratory diseases and cause premature death when it penetrates deeply into the lungs. The report finds levels of fine particulate matter in parts of Houston and Dallas-Fort Worth hover dangerously close to the EPA annual standard of 15 micrograms per cubic meter.

In 2008, the TMA House of Delegates adopted policy urging Texas government leaders to reduce pollution from coal-fired power plants and diesel engines. The resolution lists these steps lawmakers might take to reduce air pollution:  

  •  Require the immediate installation or retrofitting of technology highly efficient in reducing air pollution, including ozone-causing pollutants, particulates, carbon dioxide, and mercury on existing and future coal-fired power plants;
  •  End state subsidies for polluting coal-fired power plants and levy a tax on coal, equivalent to that on natural gas, sufficient to pay future federal levies on pollution damage;
  •  Place a moratorium on approval of old-technology coal-fired power plants; and
  •  Amend the state diesel retrofit program to include particulate controls.  

Since the 2009 session of the legislature, Dr. Haley has worked with DCMS and TMA to develop energy and environmental policy for TMA's House of Delegates and legislators to consider. While he acknowledges that medicine can't transform Texas' environmental landscape overnight, he's encouraged by passage of a 2011 law to help protect the state's water supply.


 Safeguarding Water

Pollutants in the air aren't the only toxins physicians worry about. Last year, the TMA House of Delegates adopted new policy on hydraulic fracturing, commonly referred to as fracking, a natural gas extraction process that involves injecting water, sand, and chemicals thousands of feet underground into rock layers. The resolution asked the legislature, while encouraging natural gas production, to protect water from the risk of fracking by requiring disclosure of fracking fluid components.

Much remains unknown about potential environmental health implications of fracking, says Jeffrey Levin, MD, MSPH, past chair of TMA's Council on Science and Public Health and chair of the Department of Occupational & Environmental Medicine at The University of Texas Health Science Center at Tyler.

Dr. Haley says fracking companies often experiment with chemicals to develop the most effective mixtures to dissolve rock formations. He and many other health professionals worry these chemicals could find their way into the drinking water supply. If that were to occur, there's good reason to worry, they believe.

A 2011 U.S. House of Representatives report on fracking chemicals found that 652 of the 750 compounds in the products contained known or possible human carcinogens regulated under the Safe Drinking Water Act or listed as hazardous air pollutants. Toxic fracking fluids unearthed by the report include diesel, benzene, lead, and methanol. These toxins can cause a number of diseases. Benzene has been linked to cancer, and lead damages the nervous system and can cause brain disorders. To view the report, visit http://bit.ly/gZOn1t.

The report also noted from 2005 to 2009, 279 fracking products contained at least one component listed as "proprietary" or "trade secret" on their Occupational Safety and Health Administration-required Material Safety Data Sheet.

Thanks to the work of organized medicine and advocacy by TMA, the 2011 Texas Legislature passed a law requiring companies applying for fracking permits on or after Feb. 1, 2012, to disclose the chemicals used to extract natural gas.

House Bill 3328 directs the Texas Railroad Commission to require operators of a well undergoing fracking to complete a form posted online. The completed form must include the total volume of water used in the fracking treatment and each chemical ingredient used. To view the commission's rules, click here.

 Because fracking is common in his region of the state, Dr. Haley says, the new law benefits the public's health.

"Oil and gas companies have purchased the mineral rights to drill in many Fort Worth neighborhoods," he said.

"If we see chemicals appearing in a city's water supply or in an aquifer that feeds a large area, we can determine which wells the chemicals came from. We can figure out how the contamination occurred and work to prevent it from happening again. We can also hold the offending company accountable."


 Pollution Affects Kids

Mercury is among the hazardous substances coal-fired power plants emit. A study by researchers at The University of Texas Health Science Center at San Antonio shows a statistically significant relationship between pounds of industrially released mercury and increased autism rates.

In the study, published in the journal Health & Place in 2008, researchers looked at school district data from the Texas Education Agency and industrial mercury release data from EPA.

For every 1,000 pounds of environmentally released mercury, on average, the rate of special education services increased 43 percent, while the autism rate increased 2.6 percent. The study also found that community autism prevalence decreased by 1 percent to 2 percent every 10 miles from the pollution source.

Dr. Haley adds that air pollution harms unborn children.

"It's well known that mercury crosses the placenta and enters the brains of unborn children of mothers exposed to mercury during pregnancy. We know there are greater neurological consequences when exposure occurs in utero as opposed to after birth."

Air pollution can exacerbate asthma. This includes tobacco smoke, indoor and outdoor mold, pet dander, dust mites, cockroach droppings, pollen, smoke, and strong odors.

The Texas Behavioral Risk Factor Surveillance System (BRFSS) includes data for two categories of asthma sufferers: lifetime, which refers to those who have ever been diagnosed with asthma; and current, which refers to those who still suffer from symptoms. According to BRFSS, in 2009, 872,000 children (13.3 percent) had lifetime asthma, and 538,000 (8.2 percent) had current asthma.

Cook Children's Health Care System in Fort Worth has done extensive research on childhood asthma. The 2009 Community-wide Children's Health Assessment and Planning Survey queried more than 7,400 parents in Tarrant, Denton, Hood, Wise, Parker, and Johnson counties.

The study found North Texas children aged 6 to 9 are three times more likely to be diagnosed with asthma than children in the same age group across the state. In the region, more than 120,000 children aged 14 and younger have asthma. The study says the asthma diagnosis rate reaches a peak of 25 percent of the population at age 9 and levels off to about 20 percent in the population of children aged 10 to 14.

Jason Terk, MD, chair of TMA's Council on Science and Public Health and a Keller pediatrician, says environmental risk factors are common triggers for asthma patients. He advises physicians to anticipate an influx of office and even emergency department visits by asthma patients when air quality is poor.

In fact, Nancy Dambro, MD, a pediatric pulmonologist at Cook Children's, sees more patients with aggravated asthma symptoms on high ozone days.

"Physicians need to advise their asthma patients to monitor their exercise and physical activity level on high ozone days. They're more likely to have asthma attacks on high ozone days when they're exerting themselves," Dr. Dambro explained.

While the health impact of high ozone days is evident, she says secondhand smoke is the biggest environmental influence on her young patients.

"Asthma patients exposed to secondhand smoke have more frequent hospitalizations and wheezing exacerbations," she said.

The Centers for Disease Control and Prevention (CDC) says studies show older children whose parents smoke get sick more often and are more likely to contract bronchitis and pneumonia.


 Physician Detective Work

 Dr. Levin says physicians generally receive about four hours of training in occupational and environmental health during medical school. Some specialties require additional education on environmental and occupational health, but overall, Dr. Levin describes training in these areas as "limited and underemphasized." (See "Environmental Health Resources.")

"Determining whether an environmental factor is affecting a patient's health often boils down to detective work – taking a thorough history and asking the right questions. However, I think physicians do not like to deal with occupational and environmental exposures that may contribute to disease, as they are readily frustrated with their relative inability to 'treat' the offending source," he said.

Yet physicians can ask a few simple questions to decide if an environmental factor at work, at school, or in the home is taking a toll on a patient's health. These questions include:  

  •  Where do you work, live, or go to school?
  •  What are your job duties?
  •  Are you exposed to anything at work, school, or at home that may be affecting your health?
  •  Are there places where you spend a lot of your free time that may be affecting your health?   

When diagnosing and treating patients, Dr. Stafford encourages physicians to do some digging.

"Physicians need to be concerned not just with diagnosing illness and prescribing medications but also with the question of why our patients get sick and how we can reduce the frequency and severity of their symptoms beyond the use of medications," he said.

 Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at crystal.conde@texmed.org.  


  SIDEBAR

 Medicine Supports Clean Energy   

In May 2008, Las Brisas Energy Center, LLC, asked the Texas Commission on Environmental Quality (TCEQ) for a permit to build a petroleum coke-fired power plant in Corpus Christi that would power 650,000 homes. Opponents of the plant's construction assert it would emit large amounts of carbon dioxide and other air pollutants, endangering the public's health. TMA, the Nueces County Medical Society (NCMS), and environmental organizations encouraged Las Brisas to invest in cleaner, more efficient energy alternatives.

In December 2008, Jeffrey Levin, MD, MSPH, then-chair of the TMA Council on Public Health, sent a letter on behalf of TMA to NCMS Executive Director Paulette Shaw. In the letter, Dr. Levin outlined TMA's clean air policy, which focuses on supporting the growth of renewable energy sources while reducing consumption and promoting the use of the latest technologies and allocation of state resources to reduce air pollution.

"TMA policy supports the efforts of NCMS to encourage the use of cleaner technology available to minimize air pollution. On behalf of the Council on Public Health, I wish you much success in this effort," he wrote.

Wesley Stafford, MD, a Corpus Christi allergy and asthma physician and member of the Council on Science and Public Health, says backing by TMA, NCMS, and environmental groups helped build awareness of the Las Brisas project and the detrimental health impact it could have on the area's residents. Dr. Stafford says community physicians opposed the new plant in testimony to the Corpus Christi City Council and TCEQ.

Despite physicians' pleas and a request from the U.S. Environmental Protection Agency (EPA) to withhold the permit until concerns could be resolved, TCEQ approved the Las Brisas facility air permit last January. The project is on hold for now, while EPA reviews the Las Brisas greenhouse gas permit application for the proposed plant. EPA is concerned about the facility's ability to meet new federal standards for nitrogen dioxide and sulfur dioxide and its potential effect on Corpus Christi's smog.

EPA's involvement has drawn criticism from supporters of the plant who say the federal government's actions could cost Texas thousands of jobs and derail a bipartisan effort that has resulted in cleaner air in Texas.

Dr. Stafford would like to see reform within TCEQ and testified to that effect last year before the Sunset Advisory Commission. He wants the TCEQ Board of Commissioners to include representatives of industry, trained environmentalists, experts from the medical community, and interested members of the public. He adds that organizations like TMA need to continue to advocate in favor of legislative efforts to control the sources of air pollution.

"TMA has many policies intended to help reduce the potential impact of the environment on the health of Texas citizens. We need to continue to support Texas physicians when they identify environmental factors that endanger patients," he said.

To read TMA's full policies on clean air, methyl mercury, coal-fired power plants, and diesel emissions, see the association's policy compendium.

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  SIDEBAR

 Environmental Health Resources   

The Centers for Disease Control and Prevention's (CDC's) Agency for Toxic Substances and Disease Registry features comprehensive information about toxins and devotes a page to case studies in environmental medicine geared toward primary care physicians.

For consultations related to toxin exposure, the Texas Poison Control Network is a good resource. The poison control centers collect data and have experts on staff to help physicians diagnose and treat toxin exposure.

Chris Van Deusen, Texas Department of State Health Services (DSHS) assistant press officer, says physicians who see a pattern of patients who may be exposed to similar toxins should contact their local health department or DSHS to determine if a threat to public health exists. Call the DSHS Environmental and Injury Epidemiology and Toxicology Unit at (800) 588-1248, or visit www.dshs.state.tx.us/regions/lhds.shtm for local health department contact information.

In addition, DSHS requires physicians to report all blood lead test results to the Texas Childhood Lead Poisoning Prevention Program for children younger than 15 and the Adult Blood Lead Epidemiology and Surveillance Program for those 15 and older. Forms are available online.

Asthma resources are available, as well.

The American Academy of Pediatrics' (AAP's) Guidelines for the Diagnosis and Management of Asthma – Update on Selected Topics arms clinicians with asthma diagnosis and management recommendations, categorized by four therapy components: measures of assessment and monitoring; control of factors contributing to asthma severity; pharmacologic therapy; and education for a partnership in asthma care. You may access the free guidelines online.

 Pediatric Environmental Health, Third Edition by the AAP Council on Environmental Health helps physicians identify, prevent, and treat pediatric environmental health problems and guides them in answering parents' questions. Chapters address air pollution, mercury, waste sites, environmental tobacco smoke, pesticides, and more.

The publication is available in hard copy for $49.95 and electronically for $39.95.

AAP also offers environmental health-related patient education brochures for purchase in bulk quantities that cover the dangers of secondhand smoke, lead screening, risks of tobacco use, and protecting children from potential environmental hazards. To purchase publications and patient brochures, visit the AAP Online Bookstore or call (866) 843-2271.

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 April 2012 Texas Medicine Contents
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