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Featured stories in this issue...

The Reactionary Principle: Inaction for Public Health
  This is the clearest introduction to the precautionary principle
  that we have ever seen. It contrasts the precautionary approach with
  the way decisions are currently made in the U.S. -- the reactionary
  principle.
The Precautionary Principle: In Action for Public Health
  This is another good description of the precautionary principle,
  though the vocabulary is academic and somewhat difficult.
France Suspends Planting of GMO Crops
  "I don't want to be in contradiction with EU laws, but I have to
  make a choice. In line of the precautionary principle, I wish [meaning
  "I declare"] that the commercial cultivation of genetically modified
  pesticide GMOs be suspended," said French President Nicolas Sarkozy.
American Academy of Pediatrics Urges Universal Autism Screening
  Because autism spectrum disorder may now be affecting nearly one
  in every 50 boys in the U.S., the American Academy of Pediatrics urges
  a precautionary approach to autism -- universal screening even when
  there is no reason to suspect the disorder will be detected.

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From: Occupational and Environmental Medicine, Sept. 3, 2007
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THE REACTIONARY PRINCIPLE: INACTION FOR PUBLIC HEALTH

By David Kriebel

Martuzzi's commentary on the precautionary principle is welcome and
timely.[1] I will make a few largely supportive comments while perhaps
anticipating and addressing some concerns that readers may have.

The 1998 Wingspread consensus statement characterised the
precautionary principle this way: "when an activity raises threats of
harm to human health or the environment, precautionary measures should
be taken even if some cause and effect relationships are not fully
established scientifically".[2] The statement went on to list four
central components of the precautionary principle:

1. taking preventive action in the face of uncertainty;

2. shifting the burden of proof to the proponents of an activity;

3. exploring a wide range of alternatives to possibly harmful actions;
and

4. increasing public participation in decision-making.

A skeptical reader may ask: isn't this just a fancy new name for what
any responsible public health scientist has always done?

On the contrary, precaution brings important new insights into
occupational and environmental health policy and the science which
informs it. To illustrate this, it may be useful to give a name to the
policy framework in which occupational and environmental health
research currently operates: it is the reactionary principle.[3] Under
this system, anyone is free to introduce a new hazard into the
environment, and governments must wait until an overwhelming body of
evidence is accumulated before intervening. Each new regulatory action
is challenged with the objective of slowing down or stopping public
oversight of production and distribution of chemicals and
technologies. We can see reactionary principle inaction in the
unconscionable delays in regulating a long list of hazards whose risks
were clear long before effective actions were taken to control them:
asbestos, benzene, dioxins and PCBs.[4] While these are "old" hazards,
a reactionary approach is evident as well in many current
controversies in our field, including the potential health risks from:
hexavalent chromium,[5] artificial butter flavouring,[6] and the
antimicrobial agent triclosan.[7]

The reactionary principle operates through these key components
(referring back to the list for precaution may be useful):

1. requiring incontrovertible evidence of harm for each hazard before
taking preventive action;

2. placing the burden on the public (or government agencies) to show
that each chemical, material or technology is harmful;

3. not considering potential health and environmental impacts when
designing new materials and technologies; and

4. discouraging public participation in decision-making about control
of hazards and introduction of new technologies.

Perhaps framing the status quo this way helps the reader to see the
kinds of changes in the science/policy interface which Martuzzi and
others are advocating.

What can be done to shift from reaction to precaution? One important
step would be to reduce the corrupting influence of economic interests
on the evidentiary base of environmental health regulation.[8] Recent
evidence documents how some corporations seek to impede regulation
through the intentional manufacturing of uncertainty about the
hazardousness of their products.[9] Clearly, removing conflicts of
interest and intentional manipulation of data would make it easier to
act in a more precautionary way. But there is more that we can do as
responsible public health scientists.[10] I will mention two examples.

Causal inference is a critical step in the recognition and control of
hazards, and epidemiologists play an important role. We are taught to
distinguish causation from correlation using guidelines like those of
Bradford Hill.[11] A precautionary approach would emphasise that this
judgement is not purely scientific; our public health responsibility
requires that we ask "when do we know enough to act as if something is
causal?" This will depend not only on the strength of evidence but
also on the availability of alternative ways of achieving the same
social good (how essential are artificial butter flavour and
antimicrobial socks?), and on the consequences of inaction or acting
in error.

When we continue to study the same known hazards while thousands of
widely dispersed chemicals remain without basic toxicology, we may
inadvertently be promoting inaction by implying that more must be
learned before action can be taken. To avoid this, environmental and
occupational health scientists can learn from colleagues in climate
science. There is now a (nearly) global consensus that human impact on
climate is likely to have serious negative consequences.[12] Climate
scientists have managed to communicate an important yet complex
message: much more needs to be learned about climate AND we know
enough that we cannot remain silent about the need for action. These
scientists have stepped out of their roles as data gatherers and
analysts, and spoken publicly about the need for action.

While striving to do the best science possible, we should be aware of
the potential impact of our research and of our social responsibility
to do science that protects human health and the environment. The
precautionary principle is useful in focusing attention on the need
for this balance.

ACKNOWLEDGEMENTS

I am grateful to Margaret Quinn and Joel Tickner for comments and
suggestions.

FOOTNOTES

Competing interests: None.

REFERENCES

1. Martuzzi M. The precautionary principle: in action for public
health. Occup Environ Med 2007;64:569-70.

2. Raffensperger C, Tickner J, eds. Protecting public health and the
environment: implementing the precautionary principle. Washington,
DC: Island Press, 1999.

3. Kriebel D, Tickner J. Reenergizing public health through
precaution. Am J Public Health 2001;91:1351-5.

4. European Environment Agency. Late lessons from early warnings: the
precautionary principle 1896-2000. Copenhagen: European Environment
Agency, 2001.

5. Michaels D, Monforton C, Lurie P. Selected science: an industry
campaign to undermine an OSHA hexavalent chromium standard. Environ
Health 2006;5:5.

6. Kreiss K, Gomaa A, Kullman G, et al. Clinical bronchiolitis
obliterans in workers at a microwave-popcorn plant. N Engl J Med
2002;347:330-8.

7. Adolfsson-Erici M, Pettersson M, Parkkonen J, et al. Triclosan, a
commonly used bactericide found in human milk and in the aquatic
environment in Sweden. Chemosphere 2002;46:1485-9.

8. Clapp R, Hoppin P, Kriebel D. Erosion of the integrity of public
health science in the USA. Occup Environ Med 2006;63:367-68.

9. Michaels D. Doubt is their product, industry groups are fighting
government regulation by fomenting scientific uncertainty. Sci Am
2005;29:96-101.

10. Kriebel D, Tickner J, Epstein P, et al. The precautionary
principle in environmental science. Environ Health Perspect
2001;109:871-6.

11. Bradford Hill A. The environment and disease: association or
causation? Proc R Soc Med 1965;58:295-300.

12. Houghton J T, Ding Y, Griggs D J, et al, eds. Climate change
2001: The scientific basis. Published for the Intergovernmental Panel
on Climate Change. Cambridge: Cambridge University Press, 2001.

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From: Occupational and Environmental Health, Sept. 9, 2007
[Printer-friendly version]

THE PRECAUTIONARY PRINCIPLE: IN ACTION FOR PUBLIC HEALTH

Better health, better environment, better science: better use the
precautionary principle

By Marco Martuzzi

Article 174 of the Amsterdam Treaty of the European Union says
"Community policy on the environment... shall be based on the
precautionary principle." European law, at its highest level, is
explicit and uncompromising. As promotion and protection of human
health is one of the key motivations of environmental preservation,
the provision of the Treaty is good news for public health too. In
fact the importance and relevance of the precautionary principle in
the health domain has been attracting growing interest.[1] Ministers
of health, together with ministers of environment of the Member States
in the World Health Organization (WHO) European Region (52 of them in
2004) declared: "We reaffirm the importance of the precautionary
principle as a risk management tool, and we therefore recommend that
it should be applied...".[2] These are only two of many acts or laws
where the precautionary principle is referred to. So what is this
principle and why is it important for public health as well as the
environment?

Born in the environmental domain in the 1970s, the precautionary
principle gained political profile in the 1980s and 1990s, and has
attracted the attention of many involved in matters of environmental
protection.[3] Despite its resonance, there is no unanimously agreed
definition of the principle. Quite simply, it is usually taken to
state that lack of scientific certainty must not be used as a reason
to ignore or postpone preventive or remedial action when there are
other good reasons to do so, as has happened many times in the
past.[4]

The prescription to err on the side of caution, the "better safe than
sorry" approach, may seem little more than common sense. Indeed it is
implied by the principles of clinical medicine, in particular by the
principle of non-maleficence, more familiar to the public health
profession. The concept of precaution is deeply rooted in the history
of public health, and environmental health is no exception. Several
established risk factors, such as air, water and soil contaminants,
are known for their adverse effects on human health. The best strategy
for dealing with these is prevention, and some prudence in, for
example, setting protection standards, as when safe levels are divided
by factors of 10 or more to allow for possible inaccuracy in risk
estimates. But this is not the crucial area of application of the
precautionary principle. Prevention applies to known causes;
precaution, strictly speaking, is more relevant for uncertain
determinants, complex scenarios, suspected risk factors, unpredictable
circumstances.

Caution may be common sense, but such common sense seems to be badly
needed, and in big supply, at times when we are faced with increasing
complexity and uncertainty, when potential health threats can be far-
reaching and irreversible; when technological development and societal
organisation evolve fast enough to outpace, in numerous cases, the
accumulation of data, knowledge and evidence; when the adverse
consequences of policies may be felt at great distances, or by future
generations. In areas such as climate change, chemical safety,
genetically modified organisms and nanotechnologies, to mention just a
few, the potential for health damage is great. The deterioration or
loss of life support systems, the persistence of ubiquitous endocrine-
disrupting chemicals, the cross-breeding of genetically modified
species, the introduction of nanoparticles in human tissues, for
example, may be harmful to health through direct but also indirect
effects; some of these effects can be difficult to detect and measure,
but with serious consequences, perhaps borne by the most vulnerable,
or elsewhere, or tomorrow. Pointing out that many of us live longer
and better than never before is of limited relevance: we are highly
uncertain of what scenarios we might be facing, and we do not know how
likely different outcomes are; furthermore, we do not know what these
outcomes might be at all. Often, we do not know what we do not know.

The precautionary principle, however, is not only about uncertainty,
ignorance and caution, but also about policy and action. Applying
precaution does not result in systematically rejecting new
technologies or in a "zero tolerance" attitude. On the contrary,
despite the lack of a universally accepted definition, several
implications on how to exercise precaution while dealing with
uncertainty emerge in several formulations of the precautionary
principle and can be seen as its distinctive elements: (1) the
principle suggests to adjust the balance of burden of proof from the
need to prove that agents or technologies are harmful before they are
removed or controlled (an onus usually borne by recipients) to the
duty (for the proponents or beneficiaries) to demonstrate that they
can be used safely; (2) it stresses the fundamental importance of
participation, openness and transparency in decision making under
uncertainty, recognising that participatory models of decision-making
are an almost inevitable response to high uncertainty and complexity;
(3) it recommends that, when faced with a possible threat, alternative
courses of action should be considered and explored, preferably before
arriving at the awkward evaluation of acceptable levels of risks,
where one might have, for example, to assign monetary values to life
and death. After all, the precautionary principle was born as the
German Vorsorgeprinzip -- that is, the "foresight" principle, a more
positive concept than precaution, which emphasises a proactive,
anticipatory, imaginative attitude according to which preventing or
bypassing exposures and possible adverse effects is preferable to
mitigating them or analysing whether they are worth the benefits.

What about scientific evidence? Science has a central role to play to
achieve these goals, especially when used critically. Invoking the use
of sound science to support decisions is ambiguous: "evidence-based"
policy, meant to imply "evidence-determined" decisions, is not a
realistic option in modern governance.[5] The direct translation of
evidence into wise decisions is, in fact, fraught with difficulties.
First, defining and framing the policy question is a social process,
not an expert task. Second, the same evidence can have different
implications depending on the underlying ethical viewpoint, especially
when a utilitarian framework clashes with a deontological one.[6]
Third, evidence on the problem may be solid and abundant, while
evidence on the solutions (costs and acceptability of policies, for
example) may be scant. Fourth, the expert-driven process of
identifying optimal decisions in the light of available knowledge is
vulnerable to manipulation by vested interests. And so on.

Rather than determining univocally the preferable course of action,
available evidence and scientific reasoning must be part of the
deliberative process, perhaps on par with the other interests and
values at play. The literature on the precautionary principle has paid
considerable attention to these questions.[7] For a start, the
assumptions and limitations of science must be realised and made
explicit. For example, epidemiological enquiry following the Popperian
scheme of hypothesis generation and testing typically has high
specificity and low sensitivity -- that is, false positives are
penalised more heavily than false negatives.[8] As taught in
textbooks, the recurrent snags of epidemiological studies, such as
measurement error, exposure misclassification and many forms of bias,
push risk estimates towards the null more often that the other way
around; complex questions on broad health determinants are broken down
into workable operational research goals -- an often necessary
reductionist strategy that makes it difficult to re-compose the full
picture. These intrinsic characteristics, per se, are not a good
reason for rejecting the current scientific paradigm (in the Kuhnian
sense), if only because a new paradigm has yet to be articulated.
Nonetheless, enhanced methods are needed for knowing, describing and
dealing with uncertainty. Innovative tools are desirable for more
comprehensive risk assessment and comparison of alternatives, for
studying upstream health determinants, multi-causality, complex
systems. Thus, precaution requires more and better science. As
precaution can also stimulate technological innovation and create new
markets through the development and production of cleaner
alternatives, the precautionary principle is best seen as an
overarching concept,[9,10] which "has relevance to the whole risk
assessment, management and communication process", as declared by
European Ministers in the 4th Ministerial Conference on Environment
and Health.[2]

The debate on these themes is instructive, sometime controversial, but
fascinating, and has been instrumental for reflecting critically about
public health, its environmental determinants, the relevance of
scientific evidence and its use in decision-making -- generally
speaking, about science and society. We hope that the debate continues
and involves more people engaged in public health.[11]

==============

Correspondence to: Dr. M. Martuzzi, WHO European Centre for
Environment and Health, Rome Office, WHO Regional Office for Europe,
Via F Crispi 10, 00187 Rome, Italy; mam@ecr.euro.who.int

ACKNOWLEDGEMENTS

I am grateful to Martin Krayer von Krauss and Joel Tickner for their
comments and suggestions.

FOOTNOTES

Competing interests: None.

REFERENCES

1. Martuzzi M, Tickner J A, eds. The precautionary principle:
protecting public health, the environment and the future of our
children. Copenhagen: WHO, 2004.

2. World Health Organization Regional Office for Europe. Declaration:
Fourth Ministerial Conference on Environment and Health, Budapest,
Hungary, 23-25 June 2004. Copenhagen: WHO, 2004.

3. Jordan A, O'Riordan A. The precautionary principle: a legal and
policy history. In: Martuzzi M, Tickner J, eds. The precautionary
principle: protecting public health, the environment and the future of
our children Copenhagen: WHO, 2004:31-48.

4. European Environment Agency. Late lessons from early warnings: the
precautionary principle 1896-2000. Copenhagen: European Environment
Agency, 2001. 2 Mbyte PDF

5. Martuzzi M. Science, policy, and the protection of human health: a
European perspective. Bioelectromagnetics 2005; (Suppl 7) :S151-6.

6. Coughlin S S. Ethical issues in epidemiologic research and public
health practice. Emerg Themes Epidemiol 2006;3:16.

7. Kriebel D, Tickner J, Epstein P, et al. The precautionary principle
in environmental science. Environ Health Perspect 2001;109:871-6.

8. Grandjean P, Bailar J C, Gee D, et al. Implications of the
Precautionary Principle in research and policy-making. Am J Ind Med
2004;45:382-5.

9. Raffensperger C, Schettler T, Myers N. Precaution: belief,
regulatory system, and overarching principle. Int J Occup Environ
Health 2000;6:266-9.

10. World Health Organization Regional Office for Europe. Dealing with
uncertainty -- how can the precautionary principle help protect the
future of our children? Copenhagen: WHO, 2004.

11. World Health Organization Regional Office for Europe. Dealing with
uncertainty: setting the agenda for the 5th Ministerial Conference on
Environment and Health, 2009. Report of a WHO meeting. Copenhagen,
Denmark, 15-16 December 2005. Copenhagen: WHO, 2006. Available at

Copyright 2007 by the BMJ Publishing Group Ltd.

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From: Planet Ark, Oct. 26, 2007
[Printer-friendly version]

FRANCE SUSPENDS PLANTING OF GMO CROPS

By Sybille de La Hamaide

PARIS -- French President Nicolas Sarkozy said on Thursday he would
suspend the planting of genetically modified (GMO) pest-resistant
crops until the results of an appraisal of the issue later this year
or early in 2008.

Unveiling the country's new environment policy, Sarkozy said no GMO
crops would be planted in France until the government had received the
results of an evaluation by a new authority on GMOs set to be launched
later this year.

"I don't want to be in contradiction with EU laws, but I have to make
a choice. In line of the precautionary principle, I wish that the
commercial cultivation of genetically modified pesticide GMOs be
suspended," he said.

The only GMO crop grown in the European Union is a maize using the so-
called MON 810 technology developed by US biotech giant Monsanto,
which is designed to resist the European corn borer, a pest that
attacks maize stalks and thrives in warmer climates in southern EU
countries.

Monsanto says the protein contained in its maize has selective
toxicity but is harmless to humans, fish and wildlife.

Just 22,000 hectares -- 1.5 percent of France's cultivated maize land
-- have been sown with GMO maize this year but some farmers have urged
greater use of GMO crops to boost yields.

During a visit to Paris on Wednesday, European Agriculture
Commissioner Mariann Fischer Boel said a full ban on GMO crops would
clearly go against the rules and that France would lose in court if it
implemented such a ban.

RESEARCH TO CONTINUE

The future of GMOs has long been the subject of heated debate in
France and its reluctance, along with other European countries, to use
GMO crops compares starkly with the United States, which has a far
higher take-up of GMO technology.

A ban on GMO maize growing for the coming months would not affect
maize production in France because sowings do not take place until
spring.

Sarkozy stressed that his move did not mean a halt to GMO research.

"This suspension of commercial cultivation of pesticide GMOs does not
mean -- I want to be clear on this -- that we must condemn all GMOs,
notably future GMOs," he said.

During his election campaign last year, Sarkozy said he had "doubts
and reservations" about the commercial use of GMO products which for
him "had little interest", but he stressed that he had wanted research
to continue.

Several European Union countries have dug in their heels on whether
their farmers may grow MON 810 maize, one of Europe's oldest GMO
crops.

Hungary, one of the EU-27's biggest grain producers, outlawed the
planting of MON 810 seed in January 2005.

Germany earlier this year decided that maize produced from MON 810
seeds could only be sold if there was an accompanying monitoring plan
to research its effects on the environment.

And Austria may soon face a third attempt by EU regulators to force it
to lift bans on two GMO maize types, including Monsanto's MON 810 and
T25 maize made by German drugs and chemicals group Bayer.

Copyright Reuters News Service 2007

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From: Physician's First Watch, Oct. 30, 2007
[Printer-friendly version]

AMERICAN ACADEMY OF PEDIATRICS URGES UNIVERSAL AUTISM SCREENING

All children should be formally screened for autism at 18 and 24
months, even if there's no reason to suspect the disorder, according
to new guidelines from the American Academy of Pediatrics.

A clinical report, "Identification and Evaluation of Children With
Autism Spectrum Disorders," was released by the academy online. It
notes several red flags that call for immediate evaluation:

** lack of babbling, pointing, or gesturing by 12 months

** no words by 16 months

** no spontaneous two-word phrases by 24 months

** regression of language or social skills

Physicians are encouraged to look for signs of autism at every well-
child visit and to ask parents open-ended questions about
developmental concerns, such as a child not responding to his or her
name. The report also provides an algorithm for screening children for
autism. The AAP says early diagnosis will help "guide families to
effective interventions, which will ultimately improve the lives of
children with [autism spectrum disorders] and their families."

A second report, "Management of Children With Autism Spectrum
Disorders," reviews therapies and educational strategies. Both reports
will appear in the November issue of Pediatrics.

AAP report on identification and evaluation (Free PDF)

AAP report on autism management (Free PDF)

AAP press release (Free)

Associated Press story (Free)

Helpful autism education site for parents (Free)

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  Rachel's Precaution Reporter offers news, views and practical
  examples of the Precautionary Principle, or Foresight Principle, in
  action. The Precautionary Principle is a modern way of making
  decisions, to minimize harm. Rachel's Precaution Reporter tries to
  answer such questions as, Why do we need the precautionary
  principle? Who is using precaution? Who is opposing precaution?

  We often include attacks on the precautionary principle because we  
  believe it is essential for advocates of precaution to know what
  their adversaries are saying, just as abolitionists in 1830 needed
  to know the arguments used by slaveholders.

  Rachel's Precaution Reporter is published as often as necessary to
  provide readers with up-to-date coverage of the subject.

  As you come across stories that illustrate the precautionary 
  principle -- or the need for the precautionary principle -- 
  please Email them to us at rpr@rachel.org.

  Editors:
  Peter Montague - peter@rachel.org
  Tim Montague   -   tim@rachel.org
  
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  To start your own free Email subscription to Rachel's Precaution
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