"I just don't want them doing that to my food": the backlash against science and its implications for environmental health.Index Case: Raw Milk "It's like they think anything natural has to be better," exclaimed Tom Ward, NEHA Region 7 vice president and public health preparedness coordinator for Union County, North Carolina. Ward was voicing dismay over a small but apparently growing segment of the public who prefer to drink their milk "raw," or unpasteurized, because they consider raw milk nutritionally superior to pasteurized milk (Associated Press, 2008). Or they believe it's an important source of beneficial bacteria. Or they find that pasteurization destroys the flavor. [ILLUSTRATION OMITTED] "I don't understand why someone would put more value on the taste of something than on the potential harm it can cause," commented Terry Pierce, director of the Division of Environmental Health in the North Carolina Department of Environment and Natural Resources. The potential for harm has been well documented. Decades' worth of data show that raw milk has repeatedly been a vehicle of dangerous microbes such as Brucella, Campylobacter, Escherichia coli, Listeria, Salmonella, and Mycobacterium bovis, a rare form of tuberculosis (Aleccia, 2008; Austin et al., 2008; Food and Drug Administration (FDA), 2004; Harrington. Hayward, Archer, Davis, Croft, & Varma, 2004; Holt et al., 2003; Ward, 2008; Weisbecker, A., 2007). M. bovis has cropped up in the San Diego area in association with unpasteurized milk and dairy products (e.g., homemade cheese sold by street vendors), and it is resistant to the antibiotics normally preferred for treatment of tuberculosis (Aleccia). Nevertheless, the issue recently came to the fore in North Carolina. Currently in that state, the sale of raw milk for human consumption is not legal. But advocates approached a state legislator, who has sponsored legislation legalizing "cow shares." Called the "Small Dairy Sustainability" bill, this legislation would allow consumers to collaboratively buy a cow and pay a farmer to care for it, and thus to "own" a portion of the raw milk it produces. As of this writing, in August 2008, the bill is still with the North Carolina Senate Committee on Agriculture, where it was referred on May 29, 2007. Ward called JEH's attention to the very dominant presence that raw-milk advocates have established on the Internet. Their Web sites, he said, often "look scientific," but they abound with fallacies. Indeed, some of the reasoning on these sites is egregious. Under the heading "Raw Milk Safety," for instance, the blog Living the Slow Life in North Carolina, states: The FDA estimates there are 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths per year from foodborne illnesses. ... The majority are caused by contaminated produce, 38%. ... ALL dairy--pasteurized and raw, accounts for less than 1% of these illnesses. (Foster, 2007) Well--to argue the obvious--yes. But then the vast majority of dairy products sold in this country are pasteurized (Headrick et al., 1998). So in what way do FDA's numbers reflect the safety of raw milk? At the request of environmental health professionals in North Carolina, a working group of NEHA members reviewed the issue and composed a position statement opposing the legalization of raw-milk sales, the distribution of raw milk through barter or cow-sharing arrangements, and "any other action that would allow the consumer to obtain a portion of the production of raw, unpasteurized milk from a bovine, ovine, or caprine animal" (NEHA, 2008). This article raises the raw-milk issue not to re-open that debate, but to reflect more broadly on the way the public reacts to the authority of health officials. The issue provides an example of resistance to "the science." And it is a striking example, given how sturdy the evidence is that drinking raw milk is dangerous. It's also important to note, as did Pierce, that most members of the public buy pasteurized milk. They don't think twice about it. But the dissent has gained some traction in the media. And the dislike of technological intervention is echoed in many ways, on many other health issues, in mainstream public discourse. Some Lay Perspectives on Raw Milk To get a sense of how dissenting members of the public might be thinking, JEH contacted 17 acquaintances who had no professional association with environmental health. The selection process was not random. In fact, the respondents were chosen precisely because JEH knew or suspected that they had an interest in "natural" or "alternative" approaches to diet and health. Five people gave in-depth responses: a schoolteacher, a non profit program director, a software developer, a bookseller, and a retiree. Some of these conversations took place over e-mail, some by telephone. The purpose of this exercise was not to conduct a scientific survey, but to provide in-depth access to the voices of some nonscientists in order to more concretely delineate the terms of the discussion. For most respondents, pasteurization was a non-issue. A typical comment came from Dorrie Lieman, a teacher: I'm not ready to drink raw milk. Pasteurized milk--there's long-term evidence of its being okay. Note the reasoning: Acceptance is based on an accumulation of evidence over time. In this, it resembles the public health argument against raw milk. But the emphasis is reversed. Lieman focused on the safety of the intervention, rather than the safety (or lack of it) of the product in its natural state. That distinction is worth keeping in mind in light of the public resistance that is so common when public health officials declare "there is no evidence that" some intervention (pasteurization or fluoridation or vaccination, for instance) causes harm. As Alan Leshner, CEO of the American Association for the Advancement of Science, has argued, scientists have often responded to skepticism by trying to "educate" the public--issue by issue. That approach is not working because "many science skeptics are quite well educated, but they relate more to the risks of science and technology advances than to their benefits" (Leshner, 2003, page 977). Other respondents did the safe thing in practice, but their reasoning might not be entirely reassuring to environmental health professionals: "Unpasteurized milk is a definite health threat unless you know your cows," said Janet Robinson, a retiree. And while no one JEH interviewed was currently consuming raw milk, Michael Bailey, a software developer, did take issue with raw-milk laws on philosophical grounds: "Banning it is kind of overboard. There are more important things to be worried about in public health. Alcohol is dangerous, but prohibition was overturned." Andrea Dupree, program director of a nonprofit organization, said that she would drink raw milk and give it to her children "if it came from a very clean farm"--and that she had in fact done so while traveling in France. The notion of a "clean farm" may sound naive to environmental health ears. As Pierce reminded JEH, cleanliness is an aesthetic characteristic that has no direct bearing on the question of how healthy a cow might be and what microbes are present. But for the lay respondents, phrases like "cleanliness" and "knowing your cows" had more complex connotations. They functioned as shorthand for a small-scale, labor-intensive, artisanal approach to farming: The farmer knows each cow and the state of its health personally. He keeps his animals healthy, as a recent article in Harper's Magazine put it, "by keeping the creeks that run through his farm healthy, by maintaining the stability of his ecosystem" (Johnson, page 75). In other words, the term "cleanliness" incorporates a systemic critique of mass food production. That critique, which underlies much of the gut appeal of the raw-milk movement, runs something like this: When cows are standing shoulder to shoulder knee-deep in feces, eating feed that makes them susceptible to disease, then of course unpasteurized milk is dangerous. In fact, raw-milk advocates argue that it was pasteurization that made possible the development of factory-farm-style dairy production in the first place. The Harper's article quotes the owner of a dairy in California that sells raw milk: "E. coli O157:H7 evolved in grain-fed cattle. It's amazing to me that we've sat by as factory farms feed more than half the antibiotics in the country to animals and breed these antibiotic-resistant bacteria at the same time the food corporations are destroying our immune systems." (Johnson, 2008, page 78) Once again, the point here is not that raw milk should be legal. The point is that effective communication on public health is sues requires an awareness of the meta-argument--the level on which the debate is being conducted by consumers and media. The Meta-Argument Dismay at the state of American food production is cropping up everywhere in mainstream public discourse. Consider, for instance, an impassioned editorial written in response to reports on factory farming that were recently issued by the Pew Charitable Trusts (Pew Commission on Industrial Farm Animal Production, 2008) and the Union of Concerned Scientists (Gurian-Sherman, 2008):
As both of these reports make clear, the so-called efficiency of
industrial animal production is an illusion, made possible by cheap
grain, cheap water and prisonlike confinement systems. ... In short,
animal husbandry has turned into animal abuse. Manure--traditionally
a source of fertilizer--has been turned into toxic waste that fouls
the air and adjacent water bodies. Crowding creates health problems
resulting in the chronic overuse of antibiotics. ("The Worst Way of
Farming," 2008)
Perhaps the most high-profile statement of this theme can be found in Michael Pollan's bestselling books, The Omnivore's Dilemma (2006) and In Defense of Food (2008). Pollan suggests that many contemporary public health problems have their roots in "an agricultural system dedicated to quantity rather than quality" (2006, pages 178-179) and in the profits to be made by foisting processed foods onto the public. In the rise of diet-related heart disease, obesity, and diabetes, he sees "a global pandemic in the making, but a most unusual one, because it involves no virus or bacteria, no microbe of any kind--just a way of eating" (Pollan, 2008, page 136). And he sees the response of the health system as predictably--and perhaps gruesomely--technological: "The mainstream media is full of advertisements for new gadgets and drugs for diabetes, ... and the health care industry is gearing up to meet the surging demand for heart bypass operations ..., dialysis, and kidney transplantation" (Pollan, 2008, page 136). Pollan considers the technological approach to food, which he calls "nutritionism," to be dangerously reductive. He gives example after example of industry and science interfering with traditional food culture, replacing unprocessed foods with mass-produced "food product" (Pollan, 2008, page 149) and having unforeseen negative impacts on public health. Margarine was a technological invention once presented to the public as a healthy alternative to butter; now trans fats are considered so dangerous that some cities are regulating their use. The "lipid hypothesis," under whose aegis many low-fat foods have been marketed, is now "melting" (Pollan, 2008, page 40-61). Carbohydrates turn out to be a bigger factor in obesity than previously thought. Once upon a time, the macronutrients--protein, carbohydrates, and fat--were thought to be the essence of nutrition. But although they are essential, they turned out not to be sufficient--and sailors started coming down with scurvy from lack of vitamin C. Then vitamins were isolated and added to processed foods. More recently, scientists have discovered new micronutrients. Nutritionism keeps thinking it has found the answer, Pollan complains, and packaging that answer as the latest health elixir. And, in the process, sometimes causing harm: Antioxidants taken out of context may actually increase the risk of cancer. By contrast, traditional diets resemble other vernacular creations of culture such as architecture. Through a long, incremental process of trial and error, cultures discover what works--how best to reconcile human needs with whatever nature has to offer us in a particular place. (Pollan, 2008, page 173) The moral of this story is conservative in the classic sense of the word: Respect tradition. Don't assume you have all the answers. The world is complicated, so don't mess with anything you don't have to. That moral un-dergirds what JEH is calling "the meta-argument" about science and health. The meta-argument doubts that the scientists have really thought of everything. It reminds us that they have drawn mistaken conclusions before. It points out that the effects of a technological intervention may not be fully known. In the case of food, it asks what unknown forms of nutrition we might be missing out on, and it points out that contemporary food production is often dirty, dangerous, and distorted by commercial interests. It also insists that "the science" is only one decision-making criterion among many. Other criteria might be personal taste, personal risk-taking preferences, and social and environmental concerns. The meta-argument says, Yes, all right, you have these results from your studies. But they don't trump my doubts about your methods. Sometimes the science itself later vindicates a meta-argument. In the late 1990s, for instance, women were routinely urged to take hormone replacement therapy (HRT) when they reached menopause. It was acknowledged that HRT might slightly increase the risk of breast cancer, but the treatment was thought to provide such important protection against heart disease and osteoporosis that the benefits outweighed the risks. Experts were sometimes heard suggesting that women who resisted such treatment were simply reacting irrationally to the word "cancer." Meanwhile, the resisters said HRT made them "feel" bad. Or they questioned the design of the studies supporting use of HRT. Or they said that between heart disease and cancer, they preferred the former. Or they simply mistrusted "the medical establishment." And in 2002, results from a large-scale clinical study, the largest ever conducted, indicated that HRT was much riskier than previously thought--that in some women it actually increased the risk of heart disease, blood clots, and stroke (National Institutes of Health, 2002). People resort to meta-argument when they suspect that commercial interests are influencing science-based recommendations. Or when they see the field of inquiry as too narrow or when they suspect that a conventional mindset is coloring both the questions posed and the answers reached. Or when they see those who appeal to the authority of science as too certain of themselves. The Lay Voices Sound Off JEH's respondents often echoed Pollan's arguments. (The phrase "shop the outside aisles," which a couple of respondents described as their strategy for healthy eating, paraphrases a recommendation from In Defense of Food.) "The process of modern science," said Bailey, is making a change and finding out later what goes wrong. So having a healthy skepticism of chemicals--you might say of science in general --is reasonable. ... The science says do this or don't do that, or something is okay. Then it changes, and something else is okay. There's no past or future to it. There's no acknowledgment that we've been seeing this happen for years. Lieman told JEH that the rules and reommendations issued by federal agencies might be a factor in her decision making, but they don't trump other sources of information. Thus, when asked if it would affect her thinking on irradiated food to know that FDA said it was safe, she answered swiftly and sharply: "That makes no difference." Then she backed up and qualified: Well, it means something. It holds some clout but ... It seems as bureaucratic as anything else. And conservative. If it's FDA approved, generally that sounds good to me, but there are exceptions. And if there is someone I trust, somebody intelligent, or an intelligent article, the FDA is not the only thing. At the same time, she felt a lack of trusted authorities: "I feel like I could read something to support anything," she said. "That's why it's a gut-level decision." Dupree felt that federal agencies were, in the service of commercial interests, more or less shoving milk from cows treated with rBGH down consumers' throats: "And I know that in Europe--and a lot of parts of the world--that [product] isn't even circulated because they know people would not go for that kind of food." In fact, all the lay interviews expressed the conviction that consumer health and safety were not the main point of government policies promulgated under that rubric. Rational Resistance More subtly, the lay respondents felt bullied. For the most part, the perceived bullying had little to do with the work of environmental health professionals. One might say that environmental health is a mostly innocent victim caught in the rhetorical crossfire. But for that very reason, it's worth being alert to the shootout. On the one hand, arguments like Pollan's are increasingly charging the science with systemic bias. And on the other, arguments from "the science"--or rather, pronouncements that claim a scientific basis--often use statistics to ridicule appeals to personal experience. Or they revel in the triumph of a clever backwards argument over the evidence of the senses, or the subordination of common sense to the counter-intuitive. "Organic Food a Detriment to Public Health" argues Jeff Stier of the American Council on Science and Health (Stier, 2007), while Wired gleefully trumpets, "Surprise! Conventional Agriculture Can Be Easier on the Planet" (Pearlstein, 2008). The penchant of some commentators and cocktail conversationalists--and even some scientists--to prove their intelligence through "science-based" contrarianism has not necessarily served the interests of science or the public health. Of course the senses do sometimes deceive. Common sense is sometimes misguided. But it is not irrational for consumers to be wary. It would be a bad sign if they were not uncomfortable when experts seem to be asking them to discount their senses as a matter of reflex or to assume that the counterintuitive is better, more independent-minded, and more enlightened than the obvious. Some of JEH's respondents suggested that those insisting on "the science" might be blinded by a not entirely rational animus against nontechnological or "natural" solutions--an animus these respondents saw as itself rising to the level of a prejudice. Thus, John Randall, a bookseller, explaining why he had turned to an acupuncturist, wrote, "I was tired of the ANTI-holistic approach of most Western medicine." Resistance as Self-Preservation: The Meta-Argument in Action Several years ago, Dupree was diagnosed with Grave's disease, an autoimmune disorder that attacks the thyroid. The disease causes hyperthyroidism and a variety of dangerous effects, including elevated heart rate. The standard treatment involves destroying the thyroid gland by means of radioactive iodine or surgery. Life-long medication with a replacement thyroid hormone follows. As Dupree told JEH, "I've seen my mother on Synthroid and it's no picnic." So she began reading and asking questions. That led to the following encounter with her doctor: The endocrinologist I used to go to basically said, "You're reading the wrong books." You could tell he's been through this--he's been through these patients who do their own research and he's just had enough of it. He was in his 60s, and he was just tired of it: "Just follow my advice. The only way ... is to nuke your thyroid." And how, JEH asked, did she respond to that? I thanked him for his advice. And then I just stopped going to him. Which probably isn't smart. ... I was scared of him. Every time I tried to bring up a question, you know, something that I'd learned-- I read like five books on Grave's disease, and I was really invested in figuring out what was going on, and I also knew that my daughters are very at risk for autoimmune problems, and I felt like, you know what? I might actually know some things here. Not that you don't-- you've been doing this for 40 years or whatever. But I have some questions. And he just wasn't receptive. I always felt like I was on trial when I went there. Dupree said she did respect the scientific vetting to which Western treatments are subjected. And she had a healthy fear of quacks. Eventually she turned to a combined M.D.-homeopath. What a relief, she said, to be treated by "someone who actually wants to hear your thoughts." Her intake took two and a half hours: They get into everything. That's the big cliche. The "whole picture," the holistic kind of thing. And it's easy to be dismissive of that, but in my experience, it has made a huge difference that they look at context, that they look at other things that could be going on. Within a few months, her bloodwork was normal. She is now officially in remission, albeit with the possibility that the disease could return at menopause. Now, the temptation for proponents of science-based public health might be to point out that post hoc ergo propter hoc is a logical fallacy: Just because one event follows another event doesn't mean that the first event caused the second. We could point out that an anecdote has no statistical validity. Maybe Dupree would have gone into remission anyway. We could suggest the placebo effect. But these arguments would miss the point. The moral of this story is not about the effectiveness of alternative treatments. The moral is that no human being is immune from being too automatic in the application of knowledge. That means scientists too. In fact, the very neutrality of the scientific method can lead to an unwarranted sense of certainty among practitioners who are not constantly monitoring and questioning their conclusions. If Dupree had blindly followed her doctor's counsel, she could have done herself irremediable harm. Instead, she made a meta-argument about the proper role of science. In this case, the meta-argument might be paraphrased as follows: Okay, your evidence says I can't keep my thyroid. But given how high the stakes are, I'm not going to assume there's nothing you've overlooked. Or, as Dupree put it, "I just didn't trust that that was my only option. I guess my philosophy was 'Go try to find another option, and if that doesn't work, go back.' But if I don't have to, it just doesn't make sense." Implications of the Meta-Argument for the Raw-Milk Issue Before looking at how some environmental health professionals are responding to the meta-argument, JEH would like to quote one more voice on the issue of raw milk: Gary Acuff, former president of the International Association for Food Protection (IAFP), who sees "a trend against science in some circles." Acuff warns that as we approach implementation of progressive, scientifically supported steps for consumer protection, we need to be careful to balance science and risk with public perception. It is difficult to know how to proceed in such transitional times, but here are a few things I believe are guaranteed not to work: 1. Tell the consumer that science is the only answer. 2. Promote the myth that we can achieve a "zero risk" food supply. 3. Just throw up our hands and admit that the public is incapable of understanding. 4. Throw facts and data at the consumer until they are forced into an unavoidable logical and compliant opinion. (Acuff, 2007) These "transitional times," as Acuff puts it, pose a two-pronged challenge to environmental health professionals. The first prong is the trend toward skepticism about the findings of science as it is practiced in the contemporary world. The second is a new wariness about a particular line of scientific endeavor, one that has been foundational for environmental health: the war on microbes. In recent years, scientists have been cautiously contemplating the "hygiene hypothesis," which posits that exposure to endotoxins at a young age facilitates development of the immune system and proposes a link between excessively clean environments and an increase in asthma and allergies (Begany, 2003; Gelfand, 2003). In the meantime, the media has been much more loudly questioning the war on microbes. How might environmental health answer these challenges? One could of course say: more education of the public. That answer would not be wrong, although by now, "more education" has been tried and tried, and still the dilemma persists. One reason the answer seems unsatisfactory may be that the rhetorical tools one would use in an education campaign have often been blunted ahead of time by a climate of suspicion and mistrust--and, in the case of raw milk, by the systemic argument that proponents of the product are making. That systemic critique cannot be wished away. Environmental health ignores the meta-argument at its peril. To communicate effectively, at least with the population of respondents in JEH's unscientific survey, one would need to establish some credibility with respect to the meta-argument. And now for the good news. Environmental professionals, perhaps as much as anyone working in the public sector, are well placed to acquire precisely that kind of credibility. Some Environmental Health Voices JEH discussed the meta-argument with six environmental health professionals. Several of them echoed the comments of JEH's lay respondents. In fact, on some issues, they wielded the meta-argument themselves, sounding more like members of the public than members of a public health establishment, although their skepticism was on certain issues precisely targeted. On the general issue of trust in scientific authorities, they tended to say "we" (or use the general "you") when talking about the public and "they" when referring to the public health recommendations of federal agencies. All except one fell that public skepticism was justified, for a number of reasons. (For an account of the exception and a different perspective, see the sidebar at left.) On the Impossibility of Knowing "The latest study always contradicts the study before it," observed Robert Harrington, director of the Casper-Natrona county Health Department in Wyoming. "And what are you going to believe?" said Lawrence Pong, principal inspector and manager of training for San Francisco Environmental Health. "One year coffee's good for you, one year it's bad for you. One year chocolate's good for you, another year--oh, you're going to die from it!" On "I Could Read Something to Support Anything" The environmental health professionals ripped into the state of the discourse on health and science, starting with the evening news, whose sound-byte format virtually ensures that the reports on the latest study will be simplistic and misleading. And they see the Internet as an epistemological disaster area. "Anybody can put out any kind of garbage and tell you anything," Harrington said. "There is no way for the lay person to validate anything on the Internet." "People have a right to be skeptical," said Scott Holmes, division manager of environmental health in Lincoln-Lancaster County, Nebraska, "because of what is out there--if you think about what really credible sources of information there are. When you do a search on Google, you get both sides of the story pretty quick." On "It's as Bureaucratic as Anything Else" On "It's as Bureaucratic as Anything Else" Another factor that Justifies public skepticism, according to Harrington, is that "the official recommendations tend to be unrealistic for normal people. Five to eight servings of vegetables a day? That's absurd. No one's going to do that--unless you are obsessed with nutrition and you sit down and plan your day's meals, counting each calorie and each RDA." Also, the mandated warnings and fine-print food-handling instructions placed on products such as raw meat are difficult to read, he said, "and even more difficult to interpret." Pong noted that when federal agencies talk to the news media, it's often by way of government experts, who aren't particularly flexible communicators; the public knows a canned response when it hears one. Or, as Harrington put it, "The government is a lousy marketer. They can't carry their ideas through, partly because they have to go through so many levels of approval and it gets watered down to the point that it doesn't say anything." Tommye Schneider, director of environmental health for Madison and Dane County, Wisconsin, told JEH that internal disagreement among federal agency experts can vitiate the clarity and consistency of messages; statements by committee aren't terribly informative. Her department once approached a federal agency to get a clear message on a public health issue "and just couldn't." And, even more urgently than the lay respondents, she argued that the public has good reason to mistrust "the science" because of the particular historical moment the country is in: I think part of what you're talking about is the politics of appointing people as heads [of federal agencies] who have a different way of looking at the real science. I think this does cause problems and is a big factor in the mistrust, and probably should be part of your article. On Science as a Tool of Moneyed Interests "If you look just a little below the surface," Harrington said, "there's hardly any independent research anymore. It's all commissioned. Because it's commissioned by a commercial interest, I think there's a lot of pressure there. And I think people recognize that." "Government experts are actually tied into the major industries, the corporations," Pong said. "And people really don't like that." Mark McMillan, supervisor of the Oil and Gas Team in the Colorado Air Pollution Control Division of the Colorado Department of Public Health and Environment, pointed to the 2003 revelation that the management of NIH was allowing its staff to consult for pharmaceutical companies--and perhaps more disturbing--allowing them to sign confidentiality agreements with the companies that kept these arrangements secret from the public (Willman, 2003). (NIH has since changed its policy.) Pong cited the U.S. approach to mad cow disease. In 1997 FDA banned the use of "most mammalian protein" in feed for ruminants. Not until 2004 did it finally expand the ban to cover mammalian blood waste. "That," he said, "is when the entire nation found out that hey, the government had been allowing our ruminants to eat feed made from their own kind. These animals are supposed to be vegetarians." "I think the public understands that agencies are pressured by special interests," Harrington said. "And there is also a sense that at some level, to some degree, the agencies are pressured politically. And the commercial interests pressure the political side of government, and the political side of government pressures the agencies, and around and around we go." On FDA "The government," Harrington said, "really has dropped the ball in terms of its protective function." FDA was originally formed, he pointed out, in response to Upton Sinclair's novel The Jungle, which described abuses in the meat-packing industry. He added: The whole concept of the formation of government regulatory agencies was to protect the public. But over time, that function has become eroded. And they have attempted to become information conduits, and they have--not completely, but to a arge extent--abandoned or very much weakened their protective function. Pong noted that FDA "keeps getting pummeled" in the media over high-profile incidents (e.g., contaminated heparin, contaminated pet food) and added a story of his own: FDA is supposed to monitor what's coming in [into the country]. Well, we knew a long time ago that they're not, because we have all this ceramic eating ware [with lead in it] coming from other countries-- not just China, but Italy and Portugal. We told the FDA about it-- they said they didn't have enough people. Fortunately, the food industry took it seriously and switched to plastic ware. Schneider gave the FDA Food Code as an example. She expressed particular concerns about the requirement for hot-holding temperature; foods can now be held at a lower temperature, "so the safety margin doesn't exist when equipment malfunctions or somebody doesn't do something exactly the way it says in the code." She believes that some of the compromises that have been made to accommodate industry "have gone maybe too far." Food establishments are now permitted to do things that are hard for local health agencies to monitor because they're time oriented. "In the past, we'd go in and say, 'Oh, you're doing this wrong. That was the margin of safety. Now they're allowed to do it, but only for X amount of time. ... It has gotten a lot more difficult for us to know if that food actually has been handled safely or not." She added, "It hasn't just been a bunch of scientists [who made the changes]. It's been industry, too. There's been a lot more industry involvement in recent years than in the early days when the food codes were put together." She concluded with a plea: It would be beneficial to the people doing the day-to-day work [e.g., local health departments] if the research information was compiled in a way that they had easy access to it so that they could really understand why those decisions were made. I wonder if that would help. "The other thing that the government has really failed on is that it allows commercial interests to present their own health messages," Harrington said--and proceeded to mimick a television voiceover: "'Chocolate-frosted sugar bombs are part of a nutritious breakfast, kids!'" He added: "Naturally, they bury the servings of fruit that have to go with the sugar bombs in the fine print. And FDA allows it." That kind of abuse, he believes, gives the public an intensive training in cynicism. JEH invited FDA to respond to the comments reported here and received the following statement from FDA press officer Stephanie Kwis-nek: "The FDA is a regulator)' agency All of our decisions and actions are based on science." On the Half-Life of Mistrust "I'm thinking for example of the Tuskegee syphilis study," McMillan said. "That's an egregious example, but an example none-theless of why citizens should be concerned about the science." In the Tuskegee study, scientists working for the U.S. Public Health Service followed the health status of 399 African-American men with syphilis for a period of 40 years. The men were not informed that they had syphilis. The Tuskegee study started in 1932 and did not stop until 1972, when its practices were exposed in news stories. During this time, effective treatment in the form of antibiotics became available, but it was withheld so that the progress of the disease could be tracked. "When examples like that exist, they plant seeds of distrust in the community that are very difficult to overcome," McMillan commented. Other environmental health respondents traced their personal disillusionment to other decades-old incidents. All these stories were notable for reaching back into history. Tommye Schneider mentioned tests run by the military on people without their knowledge. "When I first heard about it," she said, "I had this naive trust as a child that we were always protected by our government. I think that takes a toll on people when they hear stuff like that." Harrington thinks that for people over 40, Watergate has "really colored our view of our system." He added that because he is "old enough to remember how really terrible that was, I look at everything in Washington with a jaundiced eye." Everyone has formative story, and clearly science has been abused for political and commercial purposes for as long as memory extends. But there was a sense that the contemporary political scene takes the distortions to a new level. Schneider believes the situation on the federal level is going to generate its own crop of formative stories for generations to come. JEH asked her to clarify: "So you're saying the politicization has been so massive that it's going to be hard to recoup." "Yeah." "Even if someone were to go in and clean house--" "Exactly. It will be hard to recoup. That's exactly right." Points of Divergence "The other side of this," said Holmes, "is people like some guy who wrote an email--three pages worth--to one of our city elected officials. It said his conclusion [with respect to the emerging issue to pharmaceuticals in drinking water] was that basically all pharmaceuticals should be banned. He's taking some sort of holistic-medicine courses out of some online university." Certain cultural habits of the American public also seem to be part of the dynamic of mistrust. And here environmental health professionals adopted a more sociological outlook. Interestingly, they still considered themselves part of the public whose attitudes and assumptions they were describing. Expectation of Zero Risk Schneider described it as the expectation of a "sterile" environment. Harrington also used the term: We think USDA gives us sterile meat: 'It's got the purple stamp on it--it must be okay!' We have been led by the regulatory agencies to expect that somebody will always protect us. And at the same time, we have this gnawing suspicion that there's this dark cabal that's willing to sacrifice all of us for a couple of pennies of profit. Thus, the expectation that rules and regulations are promulgated and enforced by what Schneider called "a Godlike creature" sets the public up for a rude experience of disillusionment. She added: We have to do a better job of communicating--among environmental health departments, even--about what is a risk level that is just going to be there. How far can we go to eliminate all the risk that we reasonably can, but yet, what actions do people reasonably have to take to protect themselves because there will always be some level of risk? ... There's a whole movement that needs to happen so that we can do this better." Complacency Contemporary protests against childhood vaccination provide an example of complacency about public health threats: The majority of people who are now raising young children in this country have no personal memory of the diseases prevented by the vaccines the children routinely receive. They may well, though, have had an encounter with autism or have heard vivid accounts in the media of the hardships associated with this apparently non-infectious threat to health. As Pong put it with respect to raw milk: "People will do what they want to do because they think bad things can't happen to them. And when bad things do happen, then they think twice." Individualism "This whole country started up questioning government," Holmes said. "It's in our nature to question government, to question what other people are telling us, because we're very strong on personal rights." On the raw-milk issue, that libertarian sensibility is manifest in the way reporters talk about laws banning the product. They love the irony of milk as contraband, the disproportionate drama of an arrest, the image of a dairy farmer in overalls suddenly clapped into handcuffs. Thus: The agents arrived before dawn. They concealed the squad car and police van behind trees, and there, on the road that runs past Michael Schmidts farm in Durham, Ontario, they waited for the dairyman to make his move. (Johnson, 2008, page 71) Or thus: Cincinnati cops also swooped in to stop Gary Oaks in March 2006, as he unloaded raw milk in the parking lot of a local church. When bewildered residents gathered around, an officer told them to step away from "the white liquid substance." (Johnson, page 71) Or thus: I showed up at the farm in the dark of night. This was not a necessary element to procuring my illicit elixir, but it somehow seemed apropos. ... A black cat scurried across my path, and I mused at the irony. (Nelson, 2007) Anecdotal Decision Making Savvy environmental health professionals understand that, inevitably, criteria that science cannot measure play a role in individuals' health decisions. Prominent among, those criteria is familiarity with one's information. As Dupree put it: "I go very much on gut instinct and a few people who I've trusted telling me things. That's how I inform myself." People trust the stories they hear from friends and family--nonexperts. As Holmes observed, it's probably human nature to do so. It's important to note that while this kind of personal decision making is vulnerable to mistakes (not everyone is a good reader of character, although most people think that they are), it is not intrinsically less rational than decision making based strictly on the data as the data now stand. In fact, it would take a notably irrational mindset for an individual automatically to discount personal concerns, personal preferences, Personal circumstances, the evidence of the senses, and the accounts of friends and family in favor of conclusions based on data that may look different when the next round of study results come out. A Difference in Scale Environmental health professionals, whose recommendations affect whole populations, have to play it safe. They cannot indulge hunches that may turn out to be no more than personal prejudice. They cannot cite their friends as sources. They have to follow the best available science, even knowing that new studies may come to different conclusions at some point in the future. But for an individual, a rational calculation of costs and benefits might well take into account the fact that official recommendations change over time. Because the scope of their responsibility is smaller, members of the public can also temper the conclusions of science with other criteria. They might, for instance have personal reasons to fear immune disorders--so much so, that although the immune-system benefits of raw milk are hypothetical and the risks of infectious disease are well documented, they could end up giving more weight to the former than to the latter. A Difference in Timeframe Consumers, like environmental health professionals, weigh many pieces of information, some of uncertain reliability, some contradictory. This weighing takes place both consciously and unconsciously. But in the end, it comes down to yes or no. Each time the food is on the plate, each time the milk is in the glass, the consumer tips yes or no: Irradiated food or no? Raw milk or no? yesterday I had cheese at a restaurant and it probably came from cows that were treated with rBGH, and I'm not feeling any "evidence" of harm, but do I want to compound the exposure with cheese from the supermarket? Yes or no? For the most part, the consumer does not have the option of saying, "Until the science is conclusive, I'm just not going to take a position." One way or another, an action gets taken or avoided. By the time the science has reached a fairly stable verdict, the crucial years of exposure may have passed for the individual. An entire life may have passed. A public health department is not mortal in the way an individual is. And it can sometimes hold off taking a position until data have accumulated. The yes or no of a private individual is thus quite reasonably based on different standards of evidence than that of a public health official making recommendations for populations. Emotion: Signal of Personal Limits An illustration of the ways in which public health and personal health decision making diverge is offered by the comments of Mary Stein, a nutrition education specialist who spoke to JEH both as a public health professional and as a private individual. JEH approached Stein after discovering that she was the author of a public outreach document posted on the Web site of the Montana Department of Public Health & Human Services. The document, whose topic was organic food, intrigued JEH because it displayed a striking awareness of "the meta-argument," acknowledging the range of criteria individuals might apply to personal health decision making (Eat Right Montana, 2006). When JEH reached Stein in her office at the Montana State University Department of Health and Human Development, it became clear why the document had such nuance. Stein had been considering the issue from a variety of perspectives and was familiar with Pollan's work. It was she who alerted JEH to the Harper's article discussed above, "Inside the Raw Milk Underground"--this although she supports NEHA's position on raw milk. She praised Pollan's research, noted some reservation, and suggested that encouraging smaller-scale, more local food production could be a powerful public health intervention whose benefits would include increased food safety. Then, momentarily doffing her public-health-professional cap, she added: This is going to be an emotional thought, but if the animal is not naturally healthy at the time of slaughter, then I don't want to be eating that meat, and I don't want to be feeding that meat to my family. JEH asked if she could define what she meant by "emotional": When I'm talking to folks about food and food quality, I tend to talk mostly about issues that have a scientific basis to them. For example, the U.S. dietary guidelines are science-based public health recommendations. So that's something to really hang your hat on. When it comes to these issues that we don't have the answers to, I guess that's where I see the emotional piece coming in, and I'm less confident giving an absolute recommendation to people. What I'll say is, "You know you've got to consider all your values, your beliefs, and the economic picture as well." By way of example, she noted a position paper by the American Dietetic Association stating that it has found no difference in nutritional value between organic and non-organic food. "So I can support that fully," she said, "but then again, that's only one of the many decision-making pieces that individuals are applying when they go to the grocery store and they're trying to decide between organic and nonorganic." And when it comes to milk from rBGH-treated dairy cows (which FDA has said is chemically indistinguishable from milk from untreated cows), Stein responds as a private citizen: "I'm not willing to make my children the subjects of an ongoing experiment." What about antibiotics and hormones used in meat animals? "I don't like that either." She laughed and added. "you should know that I get my beef from a rancher that is about 3 miles away from me, and I get lamb from a rancher that's about two hours away from me ... I have two growing children, so I don't buy grocery store meat anymore." A vote of no confidence? "Definitely." Implications for Communicating with the Public "This whole area of risk messaging and public health and environmental health needs a lot of work," Schneider said, and that work needs to go "all the way to the top of the profession.'' (See the sidebars above and at right for examples of risk communication challenges.) From a food safety perspective, she believes members of the public should be encouraged to take individual responsibility for their health by understanding their personal circumstances and susceptibilites. If they are immunocompromised, for instance, they should know that eating certain foods may be riskier for them than it is for the general population. In other words, the profession should encourage the public to engage in precisely the kind of individually tailored analysis that JEH's lay respondents were asserting as a right. But here is a key point of divergence: JEH's lay respondents feel that scientists, doctors, and public health agencies often do not recognize such a role for members of the public. "It's really important not to be a bull in the china shop when you approach these things," Stein said. In the case of organic food, "many people are making their decisions based on much more than the nutrient value of the food they're looking at. There is a whole lot to individuals' decisions on the food they purchase." For Example: Food Irradiation On this issue, more than on any of the others that JEH asked respondents about, there was a gap in perception between lay people and public health professionals. The gap was reflected not just in disagreement over the issue (in 1999, NEHA issued a position statement supporting the judicious use of food irradiation, while the lay respondents were with one exception leery of the practice), but also in their understanding of the source of lay resistance. "We have a situation where a lot of people just don't like the idea of using irradiation, period," said Schneider. "They just don't want to be involved with it." Stein mentioned that some people have environmental concerns about the issue of radioactive waste. She also noted that there can be some "off-flavors" and suggested that the technology be used "with foods that aren't going to be compromised in terms of flavor and quality." Certainly some activist groups have expressed concerns about waste and have mentioned off-flavors. But those concerns are not what JEH heard from lay respondents. What JEH heard was a concern that seems to have entirely escaped public health radars. As Bailey put it: I don't have a gut reaction of 'Oh, radiation is dangerous'; I just don't want them doing that to my food. I don't think I would avoid it [irradiated food] categorically, but I would want to know more. I think it [irradiation] might remove some nutrition. In fact, an FDA statement on irradiation discusses loss of nutrients as if this outcome will seem familiar and therefore reassuring to consumers: Irradiation does not make foods radioactive, just as an airport luggage scanner does not make luggage radioactive. Nor does it cause harmful chemical changes. The process may cause a small loss of nutrients but no more so than with other processing methods such as cooking, canning, or heat pasteurization (FDA, 2000). "Ni-ice!" commented Dupree. "That gives you a good feeling." She added: That has to be a deal breaker, especially now that we're hearing that everything we've heard about vitamins might be wrong. I mean, already the word was out: Basically the vitamins just go right through you. And now we're hearing, well, they might actually harm you. So, if you add that to the idea that the food you buy that's supposed to give you those vitamins might not be giving you those vitamins. ... She left the conclusion to the listener. One conclusion a listener might draw is make sure your public health communications address citizens' actual concerns, not just the ones you think they have. Another conclusion: The logical structure of the argument against eating irradiated food--If you can have/do/drink/eat X, why would you choose Y?--closely parallels an argument that environmental health professionals make in favor of interventions. If you can do X, why would you do Y? provides, for instance, the logical two-by-fours for the argument against drinking raw milk. As Terry Pierce of the North Carolina Department of Environment and Natural Resources put it: "Why would you not want that added protection of pasteurization? Why would we want to take an unnecessary risk when we have some anecdotal benefits and we know we have a scientifically based substantiated risk associated with drinking raw milk?" The parallels in the logic may be a key point. Does an intervention offer tangible, significant, and empirically supported benefits to consumers? If so, then the logic of If you can do X, why would you do Y? ultimately favors the intervention, despite the growing default preference for products that are "natural," despite suspicion of industry methods and mass production and long supply chains--despite the meta-argument. If the intervention does not offer tangible, significant, and empirically supported benefits to consumers (as opposed to benefits of logistics or convenience or profit to industry), then for the consumer the logic--and it is logic--is likely to work against the intervention. And no amount of science-based evidence showing that the intervention is "not harmful" can trump what is ultimately an argument over priorities. A Meta-Response? The Public Health Paradigm So far, this article has described the "meta-argument" that members of the public often use against scientists. That meta-argument underlies many contemporary discussions about health, food, and the environment. We have also seen that that the small-scale decision making of individuals can paradoxically have a wider frame of reference than the population-based decisions public health routinely makes. And we have argued that environmental health needs to broaden its horizons and increase its ability to communicate by understanding and acknowledging the validity of the "lay" perspective. It is now time to recognize a key strength of public health, especially in relation to the meta-argument. Most of the lay respondents saw the issues JEH discussed with them as private health issues. In their accounts, health seemed to depend almost entirely on personal virtue--choosing the right foods, keeping up with the latest news (they often apologized for not being informed enough), standing up to doctors but not being too stubborn, eating right, having the will power to exercise. Getting it right--always getting it right. The standards of behavior that they held themselves to were striking, as was the extent to which they believed their personal actions were determining their health outcomes. Thus, Randall told JEH: Now I have acupuncture once a month, and it totally keeps some gall bladder problems under control, if I also eat right and exercise and get enough sleep. I've had no colds for the last ten years, and the only year I got the flu was the one year I got flu shots! Interest in one's personal health seems to be ingrained in the American psyche, The desirability of this impulse is apparent; its dark side is perhaps slightly less so. On the dark side we find a tendency to overestimate one's own control over morbidity and mortality--otherwise known as magical thinking. We find inefficiency: Wheels are constantly being reinvented as each individual makes personal accommodations to daily health risks. And we find obliviousness to impacts on others. The libertarian impulse can manifest in profoundly selfish ways: Holmes gave the example of smokers who insist on their "right" to smoke in public places, apparently deaf to mounting evidence of the harm their secondhand smoke does to others. The limitations of private solutions are also manifest in Pollan's work. Granted, he has clearly set out to empower consumers. His books validate culture, tradition, quality-of-life concerns, artisan values, and the intuition of the individual against the more impersonal forces of mega-industry and government. Yet In Defense of Food begins and concludes with three basic recommendations that leave to each individual alone the solution to the massive tangle of problems that his work so eloquently delineates. Tellingly, these recommendations appear in the imperative: "Eat food. Not too much. Mostly plants"; In Defense of Food is essentially a self-help book. Eventually, the three basic recommendations unfold into a longer list of dos and don'ts: "Don't eat anything your great grandmother wouldn't recognize as food" (page 148), "Avoid food products that make health claims" (page 154), "Shop the peripheries of the supermarket," (page 157); "Shake the hand that feeds you [i.e., meet the farmer who grows your food]" (page 160); "Do all your eating at a table"--and "no, a desk is not a table" (page 192); "Cook and, if you can, plant a garden" (page 197); and "Eat less" (page 183). Pollan acknowledges that "eat less" is probably "the most unwelcome advice of all" (page 184). He also acknowledges that many of his recommendations are easier said than done. Indeed, JEH wondered while reading In Defense of Food: Who really is going to adopt the regimen prescribed in this book? Perhaps mostly virtuosos of self-discipline or people who have the time and economic independence to make eating into full-time work. (By contrast, the public health suggestion that Harrington pointed to as unrealistic--five-to-eight servings of fresh fruit or vegetables a day--seems rather modest.) For the majority of overworked, economically squeezed, profoundly stressed Americans, Pollan's solutions may simply add to the modern burden of shoulds and shouldn'ts that they can't quite keep up with: Ah. Guilt. "Yes, shopping this way takes more money and effort," he writes, "but as soon as you begin to treat that expenditure not just as shopping but also as a kind of vote--a vote for health in the largest sense--food no longer seems like the smartest place to economize" (Pollan, 2008, page 161). A bit later he suggests that readers get in touch with the complexity of the food chain and the interconnectedness of personal health and the environment by getting involved "in food production to whatever extent they can, even if that only means planting a few herbs on a sunny windowsill or foraging for edible greens and wild mushrooms in the park." But is the solution really a matter of adjusting one's attitude? Even if every reader could privately muster the will power to stop eating candy bars at his or her desk, would that be sufficient? Will several million individuals making token gestures of participation in the production of food really undo the ill effects of what Pollan elsewhere calls the "vegetable-industrial complex" (Pollan, 2006b)? Herbs on the sunny windowsill do not strike JEH as a solution to the question "How can I be healthier?"--not really. But they do offer a solution to some more guilt-induced questions: "How can I get on the right side of this issue? How can I be a good person?" They slightly change the subject, in other words; they are about virtue rather than health. Thus, while Pollan's work offers a trenchant analysis of a problem that promises to be a central issue in health in the coming decades, the solutions he offers individual consumers do not match the problem. In fairness, perhaps they cannot. Public health--especially environmental health--offers other paradigms. If, as Pollan argues, the "epidemics of obesity, heart disease, and diabetes are among the most urgent health issues of our times," then environmental health can be--should be--at the nexus of the solution, offering systemic interventions. And the profession has, in recent years, been engaging with these issues. It's not easy; neither the problem nor the solution is identifiable or measurable in the way that infectious diseases are. But forward-looking environmental health professionals are looking for ways of influencing the built environment, of facilitating exercise and access to healthy foods, of providing incentives for arrangements like farmer's markets that encourage shorter food supply lines. Or of addressing the complaint articulated by one artisan farmer quoted in The Omnivore's Dilemma, that "one-size-fits-all" food safety regulations "designed to regulate giant slaughterhouses ... are mindlessly applied to small farmers" (Pollan, 2006, page 229). Confronting the meta-argument also means answering consumers' arguments and questions on their own terms. Suppose, for instance, a consumer says: I understand that you think raw milk is dangerous, and I'll take that under advisement, but why should it be against the law? Why should you and your science--which I may or may not trust--have that kind of authority over me? And anyway, who are you to tell me that unproven health benefits should not rank as a factor in my decisions? I can do my own risk-benefit analysis, thank you very much. In this case, a respectful answer would not limit itself to "the science shows that raw milk is dangerous for X, Y, and Z reasons," or to citing the outbreaks raw milk has been associated with, or to enumerating the pathogens it can be contaminated with. To do so would be profoundly nonresponsive. Giving a responsive answer requires acknowledging and taking on the meta-argument--that is, making a philosophical case for legal intervention. Sometimes, particularly in discussions of the raw-milk issue, JEH had trouble getting environmental health professionals to articulate responses on the meta-level. The tendency was to fall back on the scientific record of outbreaks--to quote the data. And yet environmental health, by its very nature as a public health discipline, is in a position to offer a powerful response. After a certain amount of prodding from JEH, Pierce of North Carolina did articulate this thought: History has shown that raw milk has the potential to cause great outbreaks. ... And overtime, regulation has been put in place to protect the public as a whole. And it's for the common good of consumers. At this point, JEH, wanting more, finally capitulated, broke journalistic conventions, and suggested a possible expansion of the statement: The common good means, I assume, protection of people who don't know [about the dangers of drinking raw milk] and protection of children of people who might do something different if it weren't against the law? "I think that would be correct," Pierce said. On Being Local The local environmental health professionals with whom JEH spoke felt that they lack the authority to make paradigm-shifting interventions. JEH was surprised to find that of all the questions posed to environmental health respondents for this article, including questions about the influence of politics and commercial interests on "the science," the one that caused the greatest uneasiness was this one: "In light of the public mood, are there any issues environmental health should revisit?" "That's hard," Harrington said. "The nature of science and the nature of new developments in science necessitate always revisiting issues in environmental health," said Roberts. "I think that's a safe blanket statement." "I think there are probably many issues that could or should be revisited," McMillan said. He, too, hesitated to give specific examples. When pressed, he added, "We could always do more work on our understanding of exposure assessment." "There are environmental health professionals," Pong said, "and then there are environmental health professionals like us. ... We are regulators; we work in a regulatory agency. We do mandatory enforcement of laws and regulations handed to us by the state. There are also environmental health professionals who work in the government agencies, making those public health decisions. They're the ones who are concerned about the public perceptions, and they must respond to the public's mistrust of them. I'm talking about the environmental health professionals in the FDA and USDA and CDC." "I'm local," Holmes said, "and I'm not going to address what CDC should do, or our friends in academia." "We're just here doing our jobs day to day," Schneider said. "We're not out in the research labs seeing how the food impacts people. So we have to rely on FDA." She added: "The food industry changes so fast that we don't know what's coming down the pike. Sometimes there aren't easy answers on whether a technology can be used or not. It's just hard for us to be caught in the middle of that." Harrington clarified: "We need to rely on the large agencies, the FDAs and the EPAs--all the alphabets--for information and guidance." JEH, struck by the unwillingness of local environmental health professionals to venture answers to what seemed to be a fairly abstract and innocuous question, asked Harrington if perhaps people working in local departments feel a bit muzzled. Perhaps they are not completely free agents? "Not completely," Harrington said. "I cannot stand up publicly and announce the things I know are wrong at the federal agencies, because there's some money that flows from those agencies. And I have to present publicly a unified marching-into-the-sunset-together picture. We formally support the official position--we have to." But he also noted that local agencies tend to be more trusted. They are neighbors; they may run into their fellow citizens at the grocery store. By contrast, "The further you get from your hometown, the greater the distrust is--and at the same time, the greater the expectation." In other words, local environmental health practitioners are also local citizens and may be perceived as fellow members of the public. (For more on the way the meta-argument supports a local focus, see sidebar above.) Partly because of this dual status, Harrington sees the possibility for local environmental health professionals, "day to day in our message to the people--and I extend that not only to doing inspections, but also to communicating with local politicians--to quietly continue to have an impact on people's attention and knowledge." He gave the example of "the ever-changing [holding-temperature] recommendations" in the FDA Food Code. We recommend 140[degrees]. We say, "Yeah, the book says 135[degrees], but you know what? 140[degrees] is easier to remember, and it gives you a little bit more margin of safety. And if you're doing small batches anyway, it doesn't make any difference. Why don't you play it safe. Doesn't cost you anything." We do the same thing on cooking temperatures: "Yeah, there's four or five different cooking temperatures for four or five different kinds of meat, and some things have to be reheated to 165[degrees] and some things don't--why don't you pick a temperature that's going to give you a pretty reliable quality product, and stick with it?" "I think," he concluded, "we can be good teachers." Conclusion: Seize the Day In the past few decades, environmental health has suffered from under-recognition and underfunding. The perennial problem of "feeling invisible" has many causes, one of which is that the scope and practice of the profession very so much by locale. But perhaps the local character of environmental health practice itself offers a solution. When JEH shared the results of its interviews with NEHA Executive Director Nelson Fabian, he commented: By virtue of our place in our profession, are we developing an identity we never knew we had? Maybe we're more of an advocate for our local constituencies than we give ourselves credit for. We may have "a brand" that we don't even know we have. The environmental health professionals interviewed for this article often think and feel like outsiders. Perhaps that is a strength. They experience the same doubts lay people do about the way the science is being practiced. They have the same worries about the way food is being produced and distributed. They are fundamentally in sympathy with " the meta-argument." Perhaps that convergence constitutes a significant opportunity. Perhaps it even suggests the faint outlines of a map for the future. 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Putting meat on the table: Industrial farm animal production in America. Pew Charitable Trusts & Johns Hopkins Bloomberg School of Public Health. Retrieved August 29, 2008, from www.ncifap.org/_images/PCIFAPFin.pdf. Pollan, M. (2006a). The omnivore's dilemma: A natural history of four meals. New York, Penguin: 2006. Pollan, M. (2006b, October 15). The vegetable-industrial complex. New York Time Magazine. Retrieved September 4, 2008, from www.michaelpollan.com/article.php?id = 84. Pollan, M. (2008). In defense of food: An eater's manifesto. New York, Penguin: 2008. Stier, J. (2007, April 24). Organic food a detriment to public health. Huffington Post. Retrived August 30, 2008, from http://www.huffingtonpost.com/jeff-stier/organic-food-a-detriment-_b_46751.html. National Institutes of Health, National Heart, Lung, and Blood Institute. (2002, rev. 2005). Facts about menopausal hormone therapy (NIH Publication No. 05-5200). Retrieved September 2, 2008, from http://www.nhlbi.nih.gov/health/women/pht_facts.pdf. Ward, T. (2008). Daniel Boone, Yogi Berra, the tsunami, and raw milk. Journal of Environmental Health, 70(8), 42-43. Weisbecker, A. (2007). A legal history of raw milk in the United States. Journal of Environmental Health, 69(8), 62-63. Willman, D. (2003, December 7). Stealth merger: Drug companies and governmental research. Los Angeles Times. Retrieved July 16, 2008, from http://articles.latimes.com/2003/dec/07/nation/na-nih7. The Worst Way of Farming [Editorial]. (2008, May31). New York Times, Retrieved August 29, 2008, from www.nytimes.com/2008/05/31/opinion/31 sat 4.html?scp = l &sq = industrial%20animal%20 production&st = cse. Editor's note: NEHA is committed to providing its members with information specific to the profession of environmental health. To this end, Rebecca Berg, our staff reporter, will occasionally write in-depth reports on trends and events in the field and offers insights into the profession. These reports are designed to encourage discussion of controversies. challenges, and big-picture issues facing the profession. Readers are invited to participate in these discussions through letters to the editor: Please send your responses, opinions, or comments to Kim Clapper, Content Editor, kclapper@neha.org RELATED ARTICLE: When the Science Contradicts Itself--Or Is It Just the Appearance of a Contradiction? Welford Roberts, NEHA's president-elect, argued that the problem is not with science. It's a public-education problem: The problem is that the public doesn't understand how science works. He remembers being taught in elementary school that science is the study of facts. "But it's not. It's not. The issues that we deal with, especially with respect to the toxic effects of chemical, biological, and physical agents are not facts. They are given in terms of probabilities. The results of scientific studies report the probability of something being harmful at a particular level or concentration." Findings that drugs or life style choices can influence disease processes are often reported prematurely, he added, and the attendant uncertainties and variabilities don't get mentioned. "It gets reported more or less as an absolute fact." X does Y. "Exactly." But then, JEH asked, doesn't educating the public to understand how science works mean, precisely, educating them to be more skeptical of claims that are said to be based on science? "I don't think 'skeptical' is the right word," Roberts said. "The proper way of putting it is to understand context, to understand the uncertainty there is in science. Science is not certain." JEH would add to that: Science is a method. Strictly speaking, it cannot be "wrong." Strictly speaking, it does not "contradict itself." It simply puts hypotheses to the test. The varying results of various studies are "more evolutionary," as Roberts put it, than contradictory. But "strictly speaking" breaks down when the discussion moves out of the abstract realm and into the practical. At some point, someone has to decide that the probabilities are high enough to warrant action--or lack of action. That decision can be highly fraught. Yet once the decision is made--once, say, an emissions standard is set--regulatory agencies tend to insist on the authority of science. "The science" functions as a synonym for precisely the concept Roberts wants to problematize: "fact." In the practical world, there is a temptation, in other words, to try to have it both ways: to ask the public to adopt a sophisticated understanding of uncertainly and variability involved in science, and, at the same time, to accept science as firm grounds for regulatory authority. To a lay person's ears, this dual requirement can sound like special pleading. Science, the chosen method, is never at fault; the problem is always it's how it's communicated or how it's received. How it's interpreted, how it's misinterpreted. The problem is always elsewhere. RELATED ARTICLE: When the Science Contradicts the Senses One issue over which local health departments have often encountered citizen mistrust is outdoor air quality. The stories are myriad. They follow a pattern that JEH's readers will probably recognize, an archetype of a pattern. For instance: Once upon a time, a local industry was emitting smoke over a neighborhood in Madison, Wisconsin. The health department received many complaints, Director of Environmental Health Tommye Schneider told JEH: "What am I breathing? I can smell that. What is that? My throat hurts. My eyes are burning." The department had "a three-to-five-year exchange" with residents, who kept calling and asking for different kinds of action. "We did as much as we could," Schneider said. But there were limits to what her department could do. Its investigations, for instance, determined that the emissions met U.S. EPA standards. That raised another question: Were the U.S. EPA standards really protective? Part of the problem, Schneider believes, is that environmental health science is not as developed with respect to chemical exposures as it is with respect to biological exposures. "We just don't know in many cases what the effects of emissions are on humans," she said. "I think that's an area where there's a lot of mistrust." And, she added: Even though there were people who were sure there were cancers in the neighborhood caused by this, the studies we did showed that, well, there was nothing unusual going on as far as the number of cancers. ... And we just didn't have evidence of people becoming chronically ill or dying from this--but then those kind of studies would take years and years and years, and I don't think we [the local department] even have the tools to do those studies. At the same, time, as she observed, "Who wants to be breathing this stuff that's coming out of that smoke stack, no matter what level it is?" But when people complained of sore throats or burning eyes, the department could only say, "Well, yes, that probably can happen once in a while, depending on how the wind is blowing. ... But it's still in compliance with emissions standards. And because you have a burning throat or burning eyes doesn't mean that's enough to allow us to take some significant action and shut the plant down." This kind of situation can place the health department at odds with people's direct sensory impressions. In this context, the statement "There's no evidence of harm," which even under the best of circumstances is not the same as "There's evidence of no harm," can be particularly hard for affected members of the public to swallow. Schneider's department worked with the Centers for Disease Control and Prevention (CDC) and issued a report, but she feels that she was never quite able to give the people of the neighborhood satisfaction--although "we were able to stop them screaming at us," she added with a slight laugh. "And I think some people were okay; other people never would be okay. A couple people moved out of the neighborhood because they'd had it." For local departments whose work is often circumscribed by state or federal edicts, is there any way out of this bind? Is there any way to fully address the public's concerns without simply abandoning science as a basis for action? The answer will vary according to the individual situation, of course. But for one new approach that seems to have slightly shifted the traditional dynamic, see the sidebar on the facing page, "When the Science Draws on the Senses." RELATED ARTICLE: When the Science Draws on the Senses One way to increase public acceptance of study results--and to provide a little science education along the way--is to involve the public in the investigation. When JEH spoke with Mark McMillan of the Air Pollution Control Division at the Colorado Department of Public Health and Environment, his team was wrapping up an air quality study in Garfield County, Colorado, the location of numerous oil and gas operations. The purpose of the study was to "understand air quality issues in that part of the state," McMillan said. Although the study was prompted in part by citizen complaints, it was mainly undertaken because the department knew that a suite of pollutants, including benzene and formaldehyde, have traditionally occurred with such operations, as well as with associated truck and auto traffic. An important part of the methodology, McMillan said, was "knowing that there were specific individuals who were being impacted and really empowering them to help us understand what the issues were." Odor complaints can be tricky. They are subjective. Typically, to verify them and to identify a source, someone needs to go to the site and take an air sample. Sometimes, by the time environmental health staff arrive, the odor has weakened or the wind has shifted. Then the department has no science-based evidence of a problem, which makes action difficult to justify--which in turn frustrates citizens. McMillan's team treated the complainers as resources. "A big part of it," he said, "was recognizing that those individuals who are being affected are on site and are experiencing it in real time. And so they can capture that info for us." His program provided citizens with summa canisters that allowed them to take samples. If an individual smelled something, he or she could put out a device that would capture air and then McMillan's laboratory could analyze the sample. Citizens could take anything from a 15-minute grab sample to a 24-hour sample. Under this arrangement, the public learns about the science. The process is transparent. If it results in words of reassurance from the health department, those might be expected to be greeted with less suspicion. But perhaps not surprisingly, McMillan told JEH that "some of these grab samples--citizen-recorded samples--are recording some of the highest values." Benzene was at actionable levels; the values were high enough that "it moved the dialogue forward. It had individuals, agencies, and local governments saying, 'Okay, we believe there is an issue out here. What do we need to do?'" Some companies have made some voluntary reductions in emissions. Some new rules went into effect for volatile organic compounds (VOCs) in 2008. And as of this writing (August 2008), the Colorado Oil and Gas Conservation Commission has provisionally approved a number of proposed changes to statewide rules for the oil and gas industry ("Most Oil, Gas Rules Approved," 2008). RELATED ARTICLE: The Meta-Argument and Food Safety: Go Local? The essence of the meta-argument: there has got to be another way. "European hamburger probably comes from a steer that's fairly local, was killed in the past couple of days, possibly even comes from one animal--instead of four or five hundred animals, and they swept the trimmings up off the floor," remarked Bob Harrington, director of the Casper-Natrona County Health Department. Mary Stein, a nutrition education specialist at Montana State University, told JEH that "the way we are mass producing our meat products is a catastrophe waiting to happen. And it has happened a couple of times. With such centralized production, if you have a contamination issue, it ends up being a widespread contamination issue." She made a similar point about the 2006 spinach-associated E. coli outbreak: "That was out of a food-processing facility that provided spinach for the majority of the country." "You don't see the phrase 'berries in season' anymore," Harrington added. "Berries are available 12 months a year, because they're hauled in from all over the world." Stein also argued that with smaller operations there's "more ability to control the various food safety parameters." She believes that a return to more local food supply systems--or at least regionally based systems--is crucial to prevention of the large outbreaks that have followed one after another in recent years. Meanwhile, FDA seems to be heading in the opposite direction, apparently fulfilling the bitter prediction of a small farmer quoted in The Omnivore's Dilemma: '"You would think ... they'd want to decentralize the food system, especially after 9/11. But no! They'd much rather just irradiate everything instead'" (Pollan, 2006, page 230). On August 22 of this year, responding to a petition from the Grocery Manufacturers' Association, FDA published a rule allowing irradiation of fresh iceberg lettuce and fresh spinach. This is the first time the agency has permitted irradiation of fresh produce at levels high enough to kill bacteria. Previous rules allowed irradiation of certain kinds of produce only at levels sufficient to kill insects or to slow spoilage. They also allowed irradiation of meat, poultry, mollusks, and spices (FDA, 2008a, 2008b). In its public announcement of the new rule, FDA stated that irradiation of other foods is still under consideration: Although this announcement only applies to fresh iceberg lettuce and fresh spinach, other fresh produce, such as tomatoes or peppers, are included in the GMA petition and remain under review. The FDA continues to evaluate the safe use of irradiation in additional foods (FDA, 2008c). Neither Harrington nor Stein, by the way, expressed concerns about irradiation of food. And really, is another way possible? Is it realistic to expect consumers to return to a seasonal diet? What about people who live in northern climates with short growing seasons? "I don't think we're going to go back to that," Stein said. "It doesn't have to be all or nothing. People like having tomatoes in the middle of the winter." She also acknowledged that without economies of scale, local operations might have trouble providing meat "at the price points you can get it to now." But, she said, "if we can move a little bit more in the direction of producing and processing food more regionally, we can do a better job of keeping the food supply safe--and," she added, "supporting the economic development of local communities. That's part of the bigger picture." |
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