Rachel's Precaution Reporter #96
Wednesday, June 27, 2007

From: Fort Wayne (Indiana) Journal Gazette ...............[This story printer-friendly]
June 24, 2007

LAWYER'S ILLNESS SPOTLIGHTS AN INTERNATIONAL THREAT

[Rachel's introduction: "CDC [federal Centers for Disease Control] is always going to exercise the 'precautionary principle,' that you take protective measures even though you may not be certain how protective they will be, or how much further they may reduce risk," he said.]

By David Brown, Washington Post

The story of Andrew Speaker's infection with "extensively drug- resistant" tuberculosis -- with its weird improbabilities and misunderstood messages -- has provided a crash course in one of the 21st century's least recognized health threats.

The wandering, love-struck and tubercular lawyer accomplished in two weeks what a small army of epidemiologists and advocates has not in a decade: given drug-resistant TB a Paris-Hilton-like spot in the popular consciousness. He has added "XDR-TB" to the vocabulary of American households alongside pandemic flu, anthrax and SARS.

"TB is a weapon of mass destruction, with 2 million deaths a year," said Henry M. Blumberg, a TB expert at Emory University School of Medicine in Atlanta. "It is a huge global public health problem, and it usually gets ignored."

Speaker's story has struck chords that will resonate long after its details are forgotten.

The case marks the latest revision of the world's evolving notion of health risk -- and what to do about it. It illustrates what may be necessary to fight epidemics that, unlike classical plagues of history, can take decades to develop. The federal government's first use of an "order of isolation" since 1963 also showed what a long arm in a white coat is willing to do to prevent infections that probably weren't going to happen anyway -- but would be catastrophic if they did.

Perhaps most important, the case shows what can happen when the affluent precincts of the global village ignore what is happening in the poorer ones.

That last point is the one that Richard E. Chaisson, an expert in drug-resistant tuberculosis at Johns Hopkins University's Bloomberg School of Public Health, hopes will not get lost.

The existence of XDR-TB in the lungs of a young, healthy Atlanta trial lawyer is evidence that the world needs to do a lot better at finding, treating and preventing tuberculosis in poor countries. That is where most of this year's 8.9 million new cases will occur -- 424,000 of them resistant to two drugs (multi-drug-resistant, or MDR) and 27,000 resistant to at least four (extensively drug-resistant, or XDR). They are the direct result of inadequate treatment.

"I am concerned that what will happen is that a lot of money and attention will be spent on homeland security issues, which have little to do with tuberculosis control," Chaisson said. "I am worried that the focus may be on biosecurity rather than on the problem itself."

What's urgently needed, he said, are tools for diagnosing TB and drug resistance that don't require fancy laboratories, as well as drugs both to treat the resistant cases and to make treatment of the regular cases quicker.

The subtleties and contradictions of Speaker's case underscore the challenge of tuberculosis.

The 31-year-old did not have any of the common risk factors for TB. He was not homeless or a recent immigrant. He had not been in prison. He was not poorly nourished or infected with the AIDS virus. Where he caught TB is a mystery. It's possible he was infected last year while visiting hospitals in Vietnam, where he did charity work with the Rotary Club.

Whatever the source, his illness is the result of the unwitting exposure of a healthy person to an ill one -- the very scenario that health authorities in Fulton County, Ga., sought to prevent when they told him not to fly to Europe for his long-planned wedding.

However, it was always a long shot that he would infect anyone else.

His case was "smear-negative" -- no organisms were visible when fluid from his lungs was examined under a microscope (although clearly they were in there because they grew out in lab culture). He felt well and wasn't coughing, which is the way the bacteria spreads in most "pulmonary," or lung-involved, cases. He had not infected his fiancee, family members or co-workers. His physician -- and apparently also the local health authorities -- did not think he needed to be isolated while awaiting treatment.

Nevertheless, people like Speaker aren't harmless. In a study of five years' worth of new TB cases in San Francisco, 17 percent were traced by DNA fingerprinting to a "smear-negative" infected person. The concern about air travel arose from studies in the 1990s showing that TB patients occasionally infect other passengers on long flights, with the people sitting within two rows of them at highest risk.

Despite the improbability of Speaker's infecting anyone else, the consequence of such an event would be extreme, especially when tests revealed his case was not only drug-resistant, but "extensively" so. Only one-third of XDR-TB patients are cured; the rest die.

Such "low-probability/high-consequence" scenarios are among the trickiest in medicine. It appears that Speaker concentrated on the probabilities; public health authorities were more concerned with the consequences.

The latter was dramatically clear when the federal Centers for Disease Control and Prevention tried to stop Speaker during his honeymoon in Italy.

A former CDC tuberculosis specialist working there notified Italian health officials and determined that Spallanzani Hospital in Rome, which has experience treating XDR-TB cases, had an isolation bed available. Simultaneously, a CDC quarantine officer in Atlanta tracked down Speaker and told him by phone to stay put.

Although Speaker's risk to others was almost certainly still small, transmission of the infection at this point would have been unforgivable. So unforgivable that the CDC didn't feel it was safe to send one of its airplanes to get him because none had air-filtering systems that would fully protect the crew.

"You can't be faulted if you take the most conservative approach. I saw this in the anthrax days," said Eddy A. Bresnitz, New Jersey's state epidemiologist, who helped direct the response to the 2001 bioterror attack that caused, among others, six cases of anthrax in New Jersey postal workers.

"CDC is always going to exercise the 'precautionary principle,' that you take protective measures even though you may not be certain how protective they will be, or how much further they may reduce risk," he said.

But extreme caution can have unintended consequences.

The prospect of being hospitalized in Italy for an indeterminate period clearly alarmed Speaker. He and his bride bolted -- back home, where he'd been told he would have the best shot at a cure.

Exactly what was said before they made this decision isn't known. CDC officials say they laid out options for getting him home. Nevertheless, Speaker's action highlights how much the perceptions of single patients can affect the public health.

"It may be that the most effective way to safeguard the health of the public at large is to assure the person who is sick -- or, in this case, the carrier -- that he will not be abandoned," said Johns Hopkins bioethicist Nancy Kass.

Whether it was necessary to slap a detention order on Speaker soon after he reentered the United States has become a subject of debate in public health circles.

Some believe the action violated a principle enunciated in another context by Louisiana State University legal scholar Edward P. Richards: that "the state demonstrate that the action ordered is intended to prevent harm in the future, not to punish for past actions, and that the action is reasonably related to the public health objective." They argue the detention order was punitive, as Speaker agreed to go straight to a New York City hospital when a CDC doctor reached him by phone soon after he reentered the United States via Canada.

Others believe the handling of someone who had twice defied medical advice was justified. Part of the reason, they argue, is that XDR-TB can only be fought one case at a time.

Unlike pandemic flu or SARS, XDR-TB does not emerge explosively. It cannot be stopped by halting or limiting the movement of whole populations. Moreover, there is no vaccine that can be given to masses of adults to prevent infection.

Instead, TB can be controlled only by the meticulous care of individuals, who must take medicine -- often a daily handful of pills -- for at least six months, and sometimes for as long as three years. Those who quit taking the medication once they started feeling better are responsible for the emergence of drug-resistant strains. Stopping a TB epidemic requires the prolonged cooperation -- either willing or enforced -- of every patient.

If every person with XDR-TB acted as Andrew Speaker did, the result would be calamity on a global scale. His detention -- whether that was the intent or not -- sent the world that message.

browndm@washpost.com

Copyright 2007 LexisNexis

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From: Belfast (Ireland) Telegraph .........................[This story printer-friendly]
June 22, 2007

NIE 'TOO CASUAL' OVER RISK FROM INTERCONNECTOR

[Rachel's introduction: "In all spheres of human and animal medicine, there is unanimous agreement that prevention is the best form of cure."]

By Patrick McGinnity, Veterinary Surgeon, Keady

Jim Lennon (Write Back, June 15) is fully justified in raising serious concerns about the proposed NIE [Northern Ireland Electric] cross- border [powerline] interconnector.

I am amazed at the casual dismissal of such fears by NIE, especially in light of a British Medical Journal report highlighting a clear link between overhead power lines and childhood leukaemia (BMJ, Vol. 330, June 4, 2005).

In all spheres of human and animal medicine, there is unanimous agreement that prevention is the best form of cure.

Hence the precautionary principle was enshrined in the treaty of Maastricht.

The UK Government, as a signatory to this treaty, agreed to incorporate this fundamental principle in its decision making processes.

NIE's stance contravenes everything the precautionary principle set out to achieve.

Their arrogant attitude is that, in the absence of absolute proof of health risks, they should be allowed to erect overhead cables, even though under-grounding is a much safer option. The precautionary principle argues that the onus is on NIE to provide proof that high voltage overhead power lines are absolutely safe and, if they cannot, then it is their responsibility to eliminate the hazard or minimise risk. NIE's attitude is all the more disappointing given that several European neighbours have greater commitment to Maastricht.

If NIE value their customers' health and the picturesque Armagh/Tyrone landscape, they will do the decent thing and put the power lines underground.

Belgium and Denmark have already banned the construction of all new overhead high voltage power lines.

NIE simply don't want to spend the cash on under-grounding. Such penny-pinching is unacceptable where health is concerned.

Instead of working up to a standard like the Swedes, the Belgians and the Danes, NIE seem content to work down to a price.

Copyright Independent News & Media

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From: TheTyee.ca (Vancouver, BC) ..........................[This story printer-friendly]
June 21, 2007

TEMPEST IN A BOTTLE

[Rachel's introduction: Planned water bottling plant stirs fierce opposition in Valemont, British Columbia.]

By Francis Plourde

Residents of a small hamlet near the Alberta border will gather later this month to protest what they say is an environmentally questionable plan to build a second water bottling plant in the region surrounding their town.

Jill Moore and Irvin Leroux approached the Valemount Village council in January, hoping to have a piece of property rezoned for their proposed Shining Mountain Springs bottling plant.

At the time, the two thought their timing was good. The town of about 1400 had recently lost its major employer, a lumber company, and their project could create between 20-60 jobs in the area. What's more, the couple says, their intentions are benevolent.

Moore and Leroux's land is located on a pristine source of water flowing from the nearby Monashee glaciers. The two want to extract groundwater to sell it to third world countries and use the profits to finance water-related humanitarian projects.

"We want to provide water to countries that don't have access to water," said Irvin Leroux in an interview with The Tyee. "We want to be profitable and operate on a minimum amount of profit. And we want to provide good, clean, environmentally-friendly jobs for the area."

But that hasn't convinced local residents, about 100 of whom showed up at a recent meeting to object to the plan. Concerned locals also sent 109 protest form letters to the regional district of Fraser Fort George in the weeks leading up to the meeting.

Most of those who object to the plant are concerned about potential environmental side effects, including the impact on the health of the local aquifer. Valemount already hosts one water bottling company, Monashee Springs. That plant has been around for 17 years and extracts about 38,000 litres of water per day from the ground. But while water quality tests are done on a regular basis, no official evaluation of the aquifer's health has been completed.

Long-time resident John Grogan objects to the planned plant and wants the regional district to use the precautionary principle. "We take precaution about things that we don't know enough about," he said. "This proposal sounds like they are mining water."

Sparse regulations

But regulations governing groundwater in B.C. are sparse, as Chris Wood wrote about last year in The Tyee. So there may be few grounds for Valemount residents to object to the project.

New provisions for groundwater protection were added to the Water Act in 2001. And a Ground Water Protection Regulation was put in place in 2004. The regulation, however, focuses on well construction standards and ground water quality protection. It also only applies to large projects according to a spokesman from the Ministry.

Small projects though, can still be pretty big. Under the current legislation, an individual or a business can extract nearly six and a half million litres of water per day -- or 75 litres per second -- and still be considered "small." By comparison, the limit for a small project in Ontario is just 50,000 litres per day.

The Shining Mountain Springs project has the potential to extract 2.7 million of litres of water per day, or the equivalent of an Olympic- sized swimming pool, according to their website. As a small project then, groundwater regulations would not apply. Nor would the owners have to pay licensing fees.

Linda Nowlan is the co-author of Eau Canada, a book that assesses the mismanagement of Canadian water. She says stricter regulations on water extraction are needed. "It's a public resource, and private companies are taking groundwater and selling it," she said. "The province is not getting any funding from that, unlike in the forest and mining industries, where there are related fees."

Ontario, for instance, recently passed legislation to charge water bottlers, canning companies and other heavy commercial water users $3.71 per million litres extracted. An environmental assessment would also be required for new projects.

Industry booming

Shining Mountain Springs would be part of a growing trend in Canada. The bottled water industry has doubled here in the last 10 years, earning a $653 million profit in 2005 alone. Water sales today represent six per cent of the beverage industry.

The latest figures for B.C are nearly a decade old, dating back to 1998. But even back then the industry was gulping 163 million litres of H2O per year from the province. B.C. is the third largest producer of bottled water in the country, right after Quebec and Ontario, where regulations have already been put in place.

Michael Austin moved to Valemount about a year ago. He is appalled by the lack of regulations and information on groundwater. "I've been asking what was the impact [of the water bottling plant]. But nobody seems to have this information," he said. "We should obtain more independent information about our aquifer before another water bottling plant is established in town."

Shining Mountains Springs currently has to submit its own hydrogeological report the regional district before starting the project. But Austin wants an independent third party expert to assess and monitor the local aquifer.

"It looks like I could drill some wells, provide some hydrogeological reports and get a license," he said. He adds that the hydrogeological study alone is not enough and should be coupled with geomorphology, ecology and climatology studies to assess the whole impact of the plant in the area.

Regarding Austin's concerns, Leroux says they have to submit to several regulations in terms of quality of the water in addition to the hydrogeological report. He also says he can't meet with the residents until the reports are written. "When we present our project, they'll be able to ask their questions to our independent experts."

Leroux says he follows the Canadian Bottled Water Association's ethics guidelines -- which are stricter than most Canadian legislation -- and considers the storm of protest against his water bottling plant "out of proportion."

The water needs of their plant, he says, will be even less than the needs of the golf courses in the surrounding area. "Besides, I feel there's a number of aquifers that run out the valley through there," he said. "We are based on one of these aquifers. Our water comes from other sources."

But residents fear the impact climate change might have on the aquifer in the long run. Since 1850, some 1300 glaciers have lost 25 to 75 percent of their mass, most of it occurring in the last 50 years.

For Leroux, though, that's no reason to stop his project. "If they are concerned about their water disappearing in Valemount area, the rest of the country has a problem," he said. "It will never dry up, not in our lifetime."

'Excessive withdrawal'

World wide, criticism of the bottled water industry is growing. A recent report by the Washington-based environmental group Worldwatch Institute called the explosion of bottled water sales a "boom to the industry but a bust for the environment."

"Excessive withdrawal of natural mineral or spring water to produce bottled water has threatened local streams and groundwater, and the product consumes significant amounts of energy in production and shipping," wrote the report's authors. "Millions of tons of oil- derived plastics, mostly polyethylene terephthalate (PET), are used to make the water bottles, most of which are not recycled. Each year, about 2 million tons of PET bottles end up in landfills in the United States."

In Canada, too, concern is rising. "It's pulling resources down the drain. And we contribute a cradle of pollution to the environment," said Susan Howatt, national water campaigner at the Council of Canadians.

Moore and Leroux don't share the Council of Canadians' point of view. They say that individuals are responsible for their own water waste. They consider their industry cleaner than many others, and stress they'll use the profits to finance water-related projects in countries that don't have access to water.

The Council of Canadians, however, has a hard time believing their intentions. "I'm cynical enough to say that it's a marketing ploy," said Howatt.

Besides, she adds, Canada has less water than people think. The country is often credited with 20 per cent of the world's drinkable water resources. Yet, official records show that Canada's share is actually much lower, down at 7 per cent.

According to Howatt, it's why there's no political pressure to create a national regulation on water. "Our water is our own apathy. We have this crazy notion that we have all the water in the world. That's tragically false. We are all downstream of everything," she said.

Worried locals

Late last month, Valemount locals Kim and Tore Thorn joined a group of other residents to send a letter to local and national politicians as well as NGOs. In the letter was a call for a moratorium on groundwater exports and a request for official positions on water bottling plants and exports. The regional district says the letters will be considered during the next council meeting. And, in response to the opposition, the council of Valemount recently expressed second thoughts on the project.

But the town's mayor, Jeannette Townsend, said that she will wait for the studies to take a decision. "We'll wait until we get all the facts, and we'll take a decision then," she said.

Copyright 2003 -- 2007 thetyee.ca

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From: Milford Daily News (Milford, Mass.) .................[This story printer-friendly]
June 24, 2007

ACTIVISTS: HERBICIDE SPRAYING A RISK

[Rachel's introduction: "There have been studies that have shown that road salt and oil from roads can get into water supplies. Our concern is the same thing could happen with the herbicides. We're sort of practicing a precautionary principle. Is it really a risk they want to take at all if it could get into the water supply and cause all these problems?"]

By Amber Herring, Daily News staff

Bellingham, Mass. -- With toxic herbicide spraying on Interstate 495 scheduled for late summer, state and local officials are weighing in on potential harm to local residents.

"There have been studies that have shown that road salt and oil from roads can get into water supplies," said Dan Dilworth of the Toxics Action Center in Boston. "Our concern is the same thing could happen with the herbicides."

The Toxic Action Center is working to mobilize local groups to stop spraying in their own town, said Dilworth.

The spraying will begin in August in targeted areas of I-495 in Bellingham and Franklin that have been approved by the town's Conservation Commission, said Erik Abell, a spokesman for the Massachusetts Highway Department.

The spray is used to kill weeds on the side of high speed highways, so workers won't be put at risk. Cutting them manually was the sole form of weed control until 2004, said Abell.

"In 2004, they began using herbicides citing the danger that manual labor posed to the workers and also the costs," said Dilworth.

Workers do the spraying from trucks, said Abell.

"The financial part we would just say is not worth the health risks. It's not worth the money saved," said Dilworth.

"We're concerned that eventually they can contaminate the water and if the residents drink the water -- there's all sorts of health problems associated," said Dilworth.

Studies show that exposure to the active ingredient in Roundup, the spray used by MassHighway in the past, can cause eye and skin irritation, headaches, nausea, numbness, elevated blood pressure and heart palpitations, said Dilworth.

Abell said there's a big difference between the amount of road salt and spray used.

"Road salt is applied to far more locations because it's designed to treat the road as a whole. You're dealing with a higher volume there," said Abell.

The herbicides are only used in certain "dangerous areas" -- which adds up to about 1/2 to 1 percent of state roads, said Abell.

The town also knows the danger and reviews the targeted spray areas to make sure it's not near the public water supply, said Conservation Commission Chairman Clifford Matthews.

"They are limited to using this in a particular area where there's no danger of contaminating the public water supply," said Matthews whose board approved the spraying several years ago.

"They came to us saying can we do this or not, and it's our feeling that they're entitled to do it," said Matthews.

MassHighway has sprayed the same areas every year since approval, said Matthews.

If they changed it, the commission would call them back to review the new plan, said Matthews.

"Every few years, we'll touch base with them," said Matthews.

MassHighway also works in a controlled environment when spraying, said Abell.

"If it's too windy outside we won't go out and spray. We operate in a controlled environment so not only is the application done as safely as possible, but we prevent it from drifting into other areas," said Abell.

Toxic Action Center understands the workers are being careful, but it's better to be safe than sorry, said Dilworth.

"We're sort of practicing a precautionary principle. Is it really a risk they want to take at all if it could get into the water supply and cause all these problems?" said Dilworth.

The public comment period held by the Department of Agriculture Resources begins June 25 and closes Aug. 9, said Abell.

Concerned residents could contact the Board of Health or Conservation Commission, said Dilworth.

Amber Herring may be reached at aherring@cnc.com or 508-634-7546.

Copyright 2006-2007 GateHouse Media, Inc.

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From: Risk Policy Report .................................[This story printer-friendly]
June 26, 2007

ACTIVISTS WANT MORE PUBLIC PARTICIPATION IN RISK ASSESSMENTS

[Rachel's introduction: Activists and environmental health experts are stepping up their long-standing demand for more public participation in EPA risk assessment decisions.]

Activists and environmental health experts are stepping up their long- standing demand for more public participation in EPA risk assessment decisions, urging a National Academy of Sciences (NAS) panel that is developing a report on improving risk assessment practices to include a strong recommendation for enhancing the affected public's role in agency risk assessment and mitigation decisions.

Among other changes activists seek is EPA involving the public early in the processes of deciding what issues should be addressed in agency site-specific risk assessments.

The latest call for more public participation in risk decisions echoes recommendations made in a 1996 NAS report, Understanding Risk: Informing Decisions in a Democratic Society, which found that implementing risk decisions can be difficult if federal agencies do not involve stakeholders in the process. For instance, the report noted that chemical producers can be relied on to participate in risk assessment processes and debates, but "representatives of the more general public or [activist] groups cannot, perhaps because of lack of resources or limited expertise." The report concluded, "Ways to broaden participation in these exercises should be explored."

That suggestion is being aggressively touted by environmentalists and academic experts as the current NAS panel continues its work. For instance, at a June 11 meeting of the panel in Washington, DC, Jennifer Sass of the Natural Resources Defense Council said following the 1996 recommendation "would go a long way" toward restoring public confidence in EPA risk assessment and regulatory decisions, which she argued has eroded over the years.

"Communities hate risk assessment" as it is currently practiced at EPA, she told the panel, citing as an example a New York City group called West Harlem Action whose representatives argued at a public forum earlier this year that "communities feel there are really smart technical people out there who don't come and breathe the air in Harlem or drink the water.... They look at mice instead of people." Communities resist "having to live with regulatory decisions" without ever meeting or consulting with risk assessors or regulators, she said.

A West Harlem Action source did not respond to requests for comment.

At the meeting, panel chair Thomas Burke of Johns Hopkins University asked Sass whether risk assessment "is running the risk of being irrelevant" to real-world environmental health issues and how it could respond to that potential problem. Sass said her concern is that "this panel gets it" on the need for public participation, just as the 1996 panel ultimately promoted the idea in its report, "but how will EPA implement it?" She argued the agency "has failed almost willfully to engage public participation," for instance on assessing the risks of organophosphate pesticides.

Sass' comments closely track with presentations to the panel earlier this year by Amy Kyle of the University of California (UC) at Berkeley and Nicholas Ashford of the Massachusetts Institute of Technology (Risk Policy Report, April 24, p1). For instance, Kyle said EPA's definition of risk assessment should encompass potential risks to whole communities.

"Risk assessment needs to be informed by a public problem paradigm, not just using the same [study] model every time," Kyle said at the April 17 meeting. "The audience isn't just agencies" but includes the public being protected by regulations, she said, adding that such work could, for instance, support decisions by communities as well as individuals "on safer, less toxic products."

She argued that "at the heart of this is the 'My way or the highway' attitude from the risk assessment community, the idea that if you don't do it my way nothing else you do is scientific."

NAS panel member Thomas McKone, also of UC Berkeley, asked Kyle at that meeting whether EPA would be the right agency to do the kind of work she proposed. "I'm not saying EPA can do all of this," she responded, "but thinking about how to do it could be beneficial." Ashford agreed with Kyle's assessment, saying, "When you talk to a community you tell them about risk assessment and uncertainty and so on and then someone [from the community] says, 'Does that plant need to be there? Does it need to do what it's doing the way it's doing it?' Well, that's an embarrassing question." It is also a question toxicologists aren't equipped to answer, Ashford said.

Sass said at the June 11 meeting that more complete public participation in risk decisions is desirable for the scientific community and would not result in anti-industry bias. "People in fenceline communities [near industrial sites] don't want those businesses shut down. They work at the sites they live near," she said. She pointed out, however, that occupational exposures "are some of the highest" of any scenario and urged the panel to consider that factor in making its recommendations.

Panel member Adam Finkel of the University of Medicine and Dentistry of New Jersey concurred, saying, "One place where not a lot of data is gathered is the workplace, and it's not going to happen if you rely on" the Occupational Safety & Health Administration or the National Institute of Occupational Safety & Health. "EPA could lend a helping hand," he said.

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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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